Sleep interventions for adults admitted to psychiatric inpatient settings: A systematic scoping review.

Sleep disturbances are common, affecting over half of adults with a mental disorder. For those admitted to a psychiatric ward, difficulties with sleep, particularly insomnia, are compounded by factors relating to the inpatient setting. We conducted a scoping review of sleep intervention studies involving adults admitted to psychiatric settings. We categorised the different types of sleep interventions and identified the effects on sleep and other mental and physical health outcomes. Instruments used to measure sleep were also examined. The search strategy yielded 4780 studies, of which 28 met the inclusion criteria. There was evidence of more non-pharmacological than pharmacological interventions having been tested in inpatient settings. Results indicated that non-pharmacological interventions based on cognitive behaviour therapy for insomnia improve sleep and may improve mental and physical health. Several distinct sleep measures were used in the studies. Gaps in the literature were identified, highlighting the importance of research into a wider range of sleep interventions tested against robust controls, using validated measures of sleep with evaluation of additional mental and physical health outcomes among a large sample size of adults in the psychiatric inpatient settings.

Co-production and adaptation of a prison-based problem-solving workbook to support the mental health of patients housed within a medium- and low-secure forensic service.

INTRODUCTION: Problem-solving skills (PSS) help to provide a systematic approach to dealing with and managing complex problems. The overall aim of this study was to assess the acceptability and feasibility of developing and adapting a prison-based PSS  workbook for adults within a medium- and low-secure hospital. METHOD: We used the Medical Research Council framework in our participatory mixed methods study incorporating an adapted survey (to identify what types of problems people experience in secure hospitals), a series of three interactive workshops (to co-produce two case study examples for a workbook) and we gathered feedback from patients and hospital staff on the acceptability and feasibility of the workbook. Data from the survey were used to inform the case study examples, and the feedback from patients and hospital staff was descriptively summarised and the results consolidated. RESULTS: In total, 82 (51%) patients took part in the survey; 22 patients and 49 hospital staff provided feedback on the workbook. The survey results indicated that patients regularly experience problems while in the hospital. Patients reported problems relating to restrictions of freedom and boredom. The workshops produced two case studies for the workbooks, with mainly positive patient and staff feedback. More work is required to improve the visual representation of the characters in the case studies, the amount and content of the language and the mechanism of the intervention delivery. CONCLUSION: The adaptation process proved acceptable and feasible to both patients and staff. The co-production methodology for the workbook and feedback from patients and staff was an effective way of iteratively refining the materials to ensure that they were both meaningful and acceptable to staff and patients. Subsequent work is required to develop the workbook and evaluate the feasibility of the intervention delivery, recruitment rates, uptake and adherence to the PSS using a randomised controlled trial. PATIENT OR PUBLIC CONTRIBUTION: At each stage of the project consultation with patients and/or hospital staff was involved.

Effects of interventions on depression and anxiety in older people with physical health problems in the criminal justice system: a systematic review.

The demand for health care in older people involved in the criminal justice system is high. The prevalence of mental and physical health conditions for people living in prison is greater than in community populations. After systematically searching 21 databases, we found no targeted interventions to support depression or anxiety for this group of people. 24 studies (including interventions of yoga, creative-arts-based programmes, positive psychology, or mindfulness-based interventions and psychotherapy) did contain people older than 50 years, but this only represented a minority (10%) of the overall study population. No single study reported outcomes of physical health. Future interventions need to consider the needs and views of this vulnerable group. Specific gendered and coproduced interventions are required to enhance the implementation, feasibility, and acceptability of interventions that are delivered in prisons.

Cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour: a cross-sectional survey using an Ecological Validity Model.

OBJECTIVE: To complete a cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour. DESIGN: A cross-sectional survey participatory design using an Ecological Validity Model. SETTING: The study was a collaboration between: the Academy of Justice, in Warsaw, the University of Lodz, two Polish prisons (ZK Raciborz and ZK Klodzko) and the University of York (UK). METHODS: The adaptation process included an examination of the use of language, metaphors and content (ie, culturally appropriate and syntonic language), the changing of case study scenarios (relevance and acceptability) and maintenance of the theoretical underpinning of the problem-solving model (intervention comprehensibility and completeness). Four stages used: (1) a targeted demonstration for Polish prison staff, (2) a wider audit of the skills with Polish prison staff and students, (3) forward and back-translation of the adapted package, and (4) two iterative consultations with participants from stages (1) and (2) and prison officers from two Polish prisons. PARTICIPANTS: Self-selecting volunteer participants included: targeted prison staff (n=10), prison staff from the wider Polish penitentiary system (n=39), students from the University of Lodz (n=28) and prison officers from two Polish prisons (n=12). MAIN OUTCOMES AND MEASURES: Acceptability and feasibility of the training package, reported in a series of knowledge user surveys. RESULTS: The recognised benefits of using the skills within the training package included: enhancing communication, reflective development, collaborative working, changing behaviour, empowering decision-making, relevance to crisis management situations and use of open-ended questions. The skills were endorsed to be used as part of future penitentiary training for prison officers in Poland. CONCLUSIONS: The skills had widespread appeal for use across the Polish penitentiary system. The materials were deemed relevant while adhering to the comprehensibility of the intervention. Further evaluation of the intervention should be explored using a randomised controlled trial design.

Effectiveness of psychological interventions in prison to reduce recidivism: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Repeat offending, also known as criminal recidivism, in people released from prison has remained high over many decades. To address this, psychological treatments have been increasingly used in criminal justice settings; however, there is little evidence about their effectiveness. We aimed to evaluate the effectiveness of interventions in prison to reduce recidivism after release. METHODS: For this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, Embase, Global Health, MEDLINE, PsycINFO, and Google Scholar for articles published from database inception to Feb 17, 2021, without any language restrictions. We searched for randomised controlled trials (RCTs) that evaluated the effect of psychological interventions, delivered to adolescents and adults during incarceration, on recidivism outcomes after release. We excluded studies of solely pharmacological interventions and of participants in secure psychiatric hospitals or special residential units, or attending therapies mainly delivered outside of the prison setting. We extracted summary estimates from eligible RCTs. Data were extracted and appraised according to a prespecified protocol, with effect sizes converted to odds ratios. We used a standardised form to extract the effects of interventions on recidivism and estimated risk of bias for each RCT. Planned sensitivity analyses were done by removing studies with fewer than 50 participants. Our primary outcome was recidivism. Data from individual RCTs were combined in a random-effects meta-analysis as pooled odds ratios (ORs) and we explored sources of heterogeneity by comparing effect sizes by study size, control group, and intervention type. The protocol was pre-registered with PROSPERO, CRD42020167228. FINDINGS: Of 6345 articles retrieved, 29 RCTs (9443 participants, 1104 [11·7%] females, 8111 [85·9%] males, and 228 [2·4%] unknown) met the inclusion criteria for the primary outcome. Mean ages were 31·4 years (SD 4·9, range 24·5-41·5) for adult participants and 17·5 years (SD 1·9; range 14·6-20·2) for adolescent participants. Race or ethnicity data were not sufficiently reported to be aggregated. If including all 29 RCTs, psychological interventions were associated with reduced reoffending outcomes (OR 0·72, 95% CI 0·56-0·92). However, after excluding smaller studies (<50 participants in the intervention group), there was no significant reduction in recidivism (OR 0.87, 95% CI 0·68-1·11). Based on two studies, therapeutic communities were associated with decreased rates of recidivism (OR 0·64, 95% CI 0·46-0·91). These risk estimates did not significantly differ by type of control group and other study characteristics. INTERPRETATION: Widely implemented psychological interventions for people in prison to reduce offending after release need improvement. Publication bias and small-study effects appear to have overestimated the reported modest effects of such interventions, which were no longer present when only larger studies were included in analyses. Findings suggest that therapeutic communities and interventions that ensure continuity of care in community settings should be prioritised for future research. Developing new treatments should focus on addressing modifiable risk factors for reoffending. FUNDING: Wellcome Trust, Fonds de recherche du Québec - Santé.

The effect of a peer-led problem-support mentor intervention on self-harm and violence in prison: An interrupted time series analysis using routinely collected prison data.

BACKGROUND: Levels of mental disorder, self-harm and violent behaviour are higher in prisons than in the community. The purpose of this study was to determine whether a brief peer-led problem-support mentor intervention could reduce the incidence of self-harm and violence in an English prison. METHODS: An existing intervention was adapted using a theory of change model and eligible prisoners were trained to become problem-support mentors. Delivery of the intervention took two forms: (i) promotion of the intervention to fellow prisoners, offering support and raising awareness of the intervention but not delivering the skills and (ii) delivery of the problem-solving therapy skills to selected individual prisoners. Training and intervention adherence was measured using mentor log books. We used an Interrupted Time Series (ITS) design utilizing prison data over a 31 month period. Three ITS models and sensitivity analyses were used to address the impact across the whole prison and in the two groups by intervention delivery. Outcomes included self-harm and violent behaviour. Routine data were collected at monthly intervals 16 months pre-, 10 months during and six months post-intervention. Qualitative data measured the acceptability, feasibility, impact and sustainability of the intervention. A matched case-control study followed people after release to assess the feasibility of formal evaluation of the impact on re-offending up to 16 months. FINDINGS: Our causal map identified that mental health and wellbeing in the prison were associated with environmental and social factors. We found a significant reduction in the incidence of self-harm for those receiving the full problem-solving therapy skills. No significant reduction was found for incidence of violent behaviour. INTERPRETATION: Universal prison-wide strategies should consider a series of multi-level interventions to address mental health and well-being in prisons. FUNDING: Research Champions Fund and the Economic and Social Research Council Impact Acceleration Account Fund, University of York, UK.

Sleep interventions for adults admitted to psychiatric inpatient settings: a scoping review protocol.

OBJECTIVE: The scoping review aims to identify how sleep is measured and what sleep interventions are used effectively in psychiatric inpatient settings. Potential barriers to measuring sleep in inpatient settings will be classified. INTRODUCTION: Polysomnography has shown that poor sleep is associated with emotional, cognitive, and somatic changes, as well as increased risks in suicide ideation and aggression. People with mental illness often experience sleep disturbances and believe the psychiatric inpatient environment contributes to sleep problems. The use of sleep interventions has been studied widely in general inpatient wards; less is known of similar interventions in psychiatric inpatient settings. INCLUSION CRITERIA: The review will include studies that focus on the effectiveness of sleep interventions for adults in any psychiatric inpatient setting. Studies that focus solely on sleep apnea, parasomnias, or restless legs syndrome will be excluded. METHODS: A literature search of PsycINFO, Web of Science, MEDLINE, and Google Scholar will be conducted. Studies identified will be screened and examined against the eligibility criteria. Only studies published in English will be considered, and there will be no date limitation applied to the search. Eligible studies will be assessed for risk of bias and relevant data will be extracted to answer the review questions. Extracted data will be presented in narrative and tabular formats.

Assessing vulnerability to risk of suicide and self-harm in prisoners: a Rasch analysis of the suicide concerns for offenders in the prison environment (SCOPE-2).

BACKGROUND: With increasing levels of suicide and self-harm behaviour in the criminal justice system professionals would benefit from a tool that can identify individuals who may be at risk of self-harm and/or suicidal behaviour. METHOD: The Suicide Concerns for Offenders in the Prison Environment (SCOPE) tool was originally devised and validated in six UK prisons between 2003 and 2004. The goal of this study is to re-evaluate the SCOPE using Rasch methodology to produce a psychometrically robust instrument. Data were presented from 1051 SCOPE assessments of male and female offenders. RESULTS: The analysis produced a revised SCOPE-2 tool reducing the tool from a 27 to a 19 items and simplifying the categorical six point scale to a four item scale. CONCLUSIONS: Further validation of the new SCOPE-2 tool is required in samples of male and female prisoners to assess different cut-off points for clinical and policy use.

Interventions for female drug-using offenders.

BACKGROUND: This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. OBJECTIVES: To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS: We searched 12 electronic bibliographic databases up to February 2019. SELECTION CRITERIA: We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'. In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence). One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported. One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence). One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence. One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence. One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence. One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence). One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence. One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence. One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence. One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported. AUTHORS' CONCLUSIONS: The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.

Interventions for drug-using offenders with co-occurring mental health problems.

BACKGROUND: This review represents one from a family of three reviews focusing on interventions for drug-using offenders. Many people under the care of the criminal justice system have co-occurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population. OBJECTIVES: To assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems in reducing criminal activity or drug use, or both.This review addresses the following questions.• Does any treatment for drug-using offenders with co-occurring mental health problems reduce drug use?• Does any treatment for drug-using offenders with co-occurring mental health problems reduce criminal activity?• Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)?• Does the type of treatment affect treatment outcome(s)? SEARCH METHODS: We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information. SELECTION CRITERIA: We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drug-using offenders with co-occurring mental health problems. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane . MAIN RESULTS: We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias.Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderate-certainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitive-behavioural therapy (one study; 314 participants), reporting no significant reduction in self-reported drug use (RR 0.78, 95% CI 0.46 to 1.32), re-arrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drug-related crime (RR 0.87, 95% CI 0.56 to 1.36), yielding low-certainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderate-certainty evidence.One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' follow-up on an Addictive Severity Index (ASI) self-report of drug use (mean difference (MD) 0.00, 95% CI -0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or re-incarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing low-certainty evidence.Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at three-month follow-up assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderate-certainty evidence. In comparison to a waiting list control, one study reported no significant reduction in self-reported drug use based on the ASI (MD -0.04, 95% CI -0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting low-certainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD -1.05, 95% CI -2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI -0.12 to 1.86), along with a small reduction in frequency of re-arrest (MD -0.66, 95% CI -1.31 to -0.01) up to 36 months, yielding low-certainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD -0.7, 95% CI -3.5 to 2.1), providing very low-certainty evidence.Two studies reported on the use of multi-systemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD -0.22, 95% CI -2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing low-certainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in re-arrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on low-certainty evidence.One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in self-reported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very low-certainty evidence. The final study (29 participants) compared legal defence service and wrap-around social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very low-certainty evidence. AUTHORS' CONCLUSIONS: Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multi-systemic therapy, legal defence wrap-around services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes.

Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm.

BACKGROUND: Social problem-solving is one technique used to help reduce incidence of self-harm. Our study evaluated the feasibility and acceptability of the adaptation and implementation of a brief Problem-Solving Training (PST) intervention to reduce self-harm in prisons. METHODS: The process involved i) adaptation of the training materials using focus groups with prison staff and prisoners, ii) training frontline prison staff to use the skills, and iii) implementation of the skills with prisoners at risk of self-harm. Qualitative interviews were conducted with prison staff, prisoners and field researchers and were analysed using a thematic framework to produce a model of the barriers and facilitators to the process. RESULTS: We conducted 43 interviews across three prison sites. The interviews included 19 prison staff, 18 prisoners and six field researcher meetings. The adaptation to the training and intervention materials were well received. The findings identified the need to support training using a collaborative and flexible approach. Prisoner engagement was affected by their own personal circumstances and by a range of contextual issues relating to the prison environment. Implementation of the skills by prison staff were hindered by resource constraints, the prison environment and staff attitudes. CONCLUSIONS: We found that it was feasible to adapt an existing intervention and contextualise it within the prison environment. Although we could train large numbers of staff it was deemed unfeasible for staff to implement the problem-solving skills to prisoners at risk of self-harm. Prisoners who engaged with the intervention reported a range of benefits. Alternative implementation mechanisms to tackle the contextual barriers proposed by staff and prisoners included delivery of the intervention using an educational setting and/or use of a prisoner peer-led scheme.

Interventions for drug-using offenders with co-occurring mental health problems: a systematic review and economic appraisal.

BACKGROUND: Drug-using offenders with co-occurring mental health problems are common in the criminal justice system. A combination of drug use and mental health problems makes people more likely to be arrested for criminal involvement after release compared to offenders without a mental health problem. Previous research has evaluated interventions aimed broadly at those with a drug problem but rarely with drug use and mental health problems. This systematic review considers the effectiveness of interventions for drug-using offenders with co-occurring mental health problems. METHODS: We searched 14 electronic bibliographic databases up to May 2014 and five Internet resources. The review included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and/or criminal activity. Data were reported on drug and crime outcomes, the identification of mental health problems, diagnoses and resource information using the Drummond checklist. The systematic review used standard methodological procedures as prescribed by the Cochrane collaboration. RESULTS: Eight trials with 2058 participants met the inclusion criteria. These evaluated: case management (RR, 1.05, 95 % CI 0.90 to 1.22, 235 participants), motivational interviewing and cognitive skills, (MD-7.42, 95 % CI-0.20.12 to 5.28, 162 participants) and interpersonal psychotherapy (RR 0.67, 95 % CI 0.3 to 1.5, 38 participants). None of these trials reported significant reductions in self-report drug misuse or crime. Four trials evaluating differing therapeutic community models showed reductions in re-incarceration (RR 0.28, 95 % CI 0.13 to 0.63, 139 participants) but not re-arrest (RR 1.65, 95 % CI 0.83 to 3.28, 370 participants) or self-report drug use (RR 0.73, 95 % CI 0.53 to 1.01, 370 participants). Mental health problems were identified across the eight trials and 17 different diagnoses were described. Two trials reported some resource information suggesting a cost-beneficial saving when comparing therapeutic communities to a prison alternative. CONCLUSIONS: Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. Specifically, tailored interventions are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Are Non-Pharmacological Interventions Effective in Reducing Drug Use and Criminality? A Systematic and Meta-Analytical Review with an Economic Appraisal of These Interventions.

Background: The numbers of incarcerated people suffering from drug dependence has steadily risen since the 1980s and only a small proportion of these receive appropriate treatment. A systematic review to evaluate the effectiveness and economic evidence of non-pharmacological interventions for drug using offenders was conducted. Methods: Cochrane Collaboration criteria were used to identify trials across 14 databases between 2004 and 2014. A series of meta-analyses and an economic appraisal were conducted. Results: 43 trials were identified showing to have limited effect in reducing re-arrests RR 0.97 (95% CI 0.89-1.07) and drug use RR 0.90 (95% CI 0.80-1.00) but were found to significantly reduce re-incarceration RR 0.70 (95% CI 0.57-0.85). Therapeutic community programs were found to significantly reduce the number of re-arrests RR 0.70 (95% CI 0.56-0.87). 10 papers contained economic information. One paper presented a cost-benefit analysis and two reported on the cost and cost effectiveness of the intervention. Conclusions: We suggest that therapeutic community interventions have some benefit in reducing subsequent re-arrest. We recommend that economic evaluations should form part of standard trial protocols.

Screening for depression in primary care: a Rasch analysis of the PHQ-9.

Aims and method To explore the modern psychometric properties of the Patient Health Questionnaire (PHQ-9), we used the Rasch analysis in a sample of 767 primary care patients with depression. Results The analysis highlighted dependency issues between items 1 and 2 ('Little interest or pleasure in doing things' and 'Feeling down, depressed, or hopeless'), and items 3 and 4 ('Trouble falling or staying asleep, or sleeping too much' and 'Feeling tired or having little energy'). Items 1 and 2 displayed an over-discrimination, suggesting their potential redundancy within the complete item set. Clinical implications In its current format the PHQ-9 displays some problems with regard to its measurement structure among a sample of primary care patients. These problems can be addressed by removing potentially redundant items to deliver a stable screening tool. The results also lend support for the PHQ-2 to be used as a screening tool in a primary care setting.

Interventions for drug-using offenders with co-occurring mental illness.

BACKGROUND: This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness. OBJECTIVES: To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both. SEARCH METHODS: We searched 14 electronic bibliographic databases up to May 2014 and 5 Internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information. SELECTION CRITERIA: We included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and criminal activity, or both in drug-using offenders with co-occurring mental illness. We also reported data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Eight trials with 2058 participants met the inclusion criteria. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most 'Risk of bias' items, we rated the majority of studies as unclear. Overall, we could not statistically combine the results due to the heterogenous nature of the different study interventions and comparison groups. A narrative summary of the findings identified that the interventions reported limited success with reducing self report drug use, but did have some impact on re-incarceration rates, but not re-arrest. In the single comparisons, we found moderate-quality evidence that therapeutic communities determine a reduction in re-incarceration but reported less success for outcomes of re-arrest, moderate quality of evidence and self report drug use. Three single studies evaluating case management via a mental health drug court (very low quality of evidence), motivational interviewing and cognitive skills (low and very low quality of evidence) and interpersonal psychotherapy (very low quality of evidence) did not report significant reductions in criminal activity and self report drug use respectively. Quality of evidence for these three types of interventions was low to very low. The trials reported some cost information, but it was not sufficient to be able to evaluate the cost-effectiveness of the interventions. AUTHORS' CONCLUSIONS: Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Pharmacological interventions for drug-using offenders.

BACKGROUND: The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders. OBJECTIVES: To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both. SEARCH METHODS: We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information. SELECTION CRITERIA: We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74). AUTHORS' CONCLUSIONS: When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.

Interventions for female drug-using offenders.

BACKGROUND: This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders. OBJECTIVES: To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS: We searched 14 electronic bibliographic databases up to May 2014 and five additional Website resources (between 2004 and November 2011). We contacted experts in the field for further information. SELECTION CRITERIA: We included randomised controlled trials (RCTs) designed to reduce, eliminate or prevent relapse of drug use or criminal activity in female drug-using offenders. We also reported data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Nine trials with 1792 participants met the inclusion criteria. Trial quality and risks of bias varied across each study. We rated the majority of studies as being at 'unclear' risk of bias due to a lack of descriptive information. We divided the studies into different categories for the purpose of meta-analyses: for any psychosocial treatments in comparison to treatment as usual we found low quality evidence that there were no significant differences in arrest rates, (two studies; 489 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.45 to 1.52) or drug use (one study; 77 participants; RR 0.65, 95% CI 0.20 to 2.12), but we found moderate quality evidence that there was a significant reduction in reincarceration, (three studies; 630 participants; RR 0.46, 95% CI 0.34 to 0.64). Pharmacological intervention using buprenorphine in comparison to a placebo did not significantly reduce self reported drug use (one study; 36 participants; RR 0.58, 95% CI 0.25 to 1.35). No cost or cost-effectiveness evidence was reported in the studies. AUTHORS' CONCLUSIONS: Three of the nine trials show a positive trend towards the use of any psychosocial treatment in comparison to treatment as usual showing an overall significant reduction in subsequent reincarceration, but not arrest rates or drug use. Pharmacological interventions in comparison to a placebo did not significantly reduce drug use and did not measure criminal activity. Four different treatment comparisons showed varying results and were not combined due to differences in the intervention and comparison groups. The studies overall showed a high degree of heterogeneity for types of comparisons and outcome measures assessed, which limited the possibility to pool the data. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the precision of confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.