مرور سیستماتیک و متا آنالیز مداخلات مربوط به مجرمین جوان با اختلالات خلقی، اختلالات اضطرابی و یا خودآسیبی

Abstract Background Mood and anxiety disorders, and problems with self-harm are significant and serious issues that are common in young people in the Criminal Justice System. Aims To examine whether interventions relevant to young offenders with mood or anxiety disorders, or problems with self-harm are effective. Method Systematic review and meta-analysis of data from randomised controlled trials relevant to young offenders experiencing these problems.

Introduction Numerous studies have demonstrated that young offenders experience high levels of mental health problems (e.g. Chitsabesan et al., 2006 and Vermeiren, 2003). Depression, anxiety disorders, and self-harm occur particularly frequently in this population (Ahrens and Rexford, 2002, Callaghan et al., 2003, Carswell et al., 2004, Dixon et al., 2004, Stallard et al., 2003, Sukhodolsky and Ruchkin, 2006 and Vermeiren, 2003) and with high levels of comorbidity (Axelson & Birmaher, 2001). Moreover, there is considerable evidence that young offenders, both incarcerated and in the community, do not receive the referrals and interventions for mood and anxiety disorders, and self-harm that they need (Callaghan et al., 2003, Carswell et al., 2004, Chitsabesan et al., 2006, Gunn et al., 1991 and Stallard et al., 2003), and that such problems predict offending status – the more psychiatric diagnoses a youngster has, the more likely they are to be an offender (Dixon et al., 2004). In order to identify which interventions should be recommended for young offenders experiencing problems with mood or anxiety disorders, or self-harm, we have conducted a systematic review of trials of interventions using Cochrane Collaboration methods (Higgins & Green, 2008). A systematic review is a scientific and robust methodology which aims to provide a synthesis of data which is as free from bias as possible (Khan, Kunz, Kleijnen, & Antes, 2003). In particular, it is important that clinical and policy related decisions are made using the highest quality evidence and the systematic review is seen as the gold standard in evidence-based research (Egger, Davey Smith, & Altman, 2001). Moreover, evidence-based research and practice helps to ensure that public money is not wasted on interventions which have exaggerated effect sizes due to biases (Schulz, Chalmers, & Hayes, 1995), or on interventions which may do more harm than good. This is particularly crucial in the domain of mental health, especially when working with a vulnerable group like young offenders. It is crucial that decision-making in relation to health services and treatments for this group are based on current best evidence. The main objective of the review was to determine what interventions are relevant to, and effective in, alleviating the symptoms and behaviours associated with mood and anxiety disorders and self-harm. Where possible we wished to determine whether specific interventions are effective for different types of disorder.

Results We identified 708 papers for potential inclusion in this review. Of these, 10 studies reported in 12 papers were evaluated as suitable for inclusion in this review. The flow of trials in this review is shown in the Quorum Diagram in Fig. 2. This diagram describes how trials identified in the searches are handled through the review process with the aim of using review methods that are transparent and reproducible Moher, Cook, Eastwood, Olkin, Rennie, and Stroup (1999). Quorum diagram detailing flow of papers into this review. Fig. 2. Quorum diagram detailing flow of papers into this review. Figure options Interventions A range of interventions were examined in the studies included in this review. Some studies focussed on young offenders with a diagnosis of a particular mental health problem (e.g. PTSD), whilst others did not impose diagnostic inclusion criteria. Brief details about the participants, settings and interventions of each of the studies included in this review are shown in Table 1 and Table 2. In this review we have included outcomes relating to each of the mental health problems under investigation. It should be noted that a range of other outcomes (e.g. recidivism) were also reported in trials which are not included here as our focus in this review is on mental health outcomes. Quality assessment A key aspect of trial quality is the adequacy of the allocation of participants to treatment groups. Allocation concealment ensures that a researcher cannot influence which arm of a trial a given participant is allocated to. An example of adequate concealment would be the use of an off-site trial unit which generates the allocation sequence independent of the research team. Where a trial is found to have used inadequate allocation concealment (e.g. alternation) effect sizes are found to be considerably inflated (Schulz et al., 1995). We used Cochrane Collaboration criteria to evaluate the allocation concealment methods used in the studies included in this review (Higgins & Green, 2008). In two trials additional pre-existing control groups were reported as a second control group (Rohde et al., 2004 and Taylor, 1967), but because participants were not randomised to these groups they were excluded from the review. We contacted the authors of trials where allocation concealment was unclear in the report of the trial. In one case this changed the allocation score from ‘unclear’ to ‘adequate’ (Rohde, Clarke, & Mace, 2004) (randomisation had been carried out by a data analyst who had no contact with any of the participants in the trials). However, in one case (Biggam & Power, 2002) the further information provided did not clarify the adequacy of allocation concealment. The assessment of quality of concealment of allocation resulted in four trials (40%) being rated as ‘A’ quality (the highest rating – for adequate concealment), five trials (50%) being rated as B (for unclear concealment), and one trial (10%) being rated as C (inadequate concealment). The quality scores in terms of allocation concealment, blinding of assessors, withdrawals after randomisation and length of follow-up period may be viewed in Table 3 (summarized as per Khan et al, 2003). Table 3. Summary of results of quality assessments performed in this review. Author Randomisation (concealment) Blinding of assessors Description of withdrawals Outcome 1-year long follow-up Rank* Gleser et al. (1965) Unclear Inadequate Adequate Inadequate 6 Taylor (1967) Adequatea Inadequate Adequate Inadequate 4 Jesness (1975) Adequate Unclear Adequate Inadequate 2 = Reardon and Tosi (1977) Inadequate Unclear Unclear Inadequate 10 Shivrattan (1988) Unclear Inadequate Inadequate Inadequate 9 Ahrens and Rexford (2002) Unclear Unclear Unclear Inadequate 7 = Biggam and Power (2002) Unclear Unclear Unclear Inadequate 7 = Nakaya et al. (2004) Unclear Unclear Adequate Inadequate 5 Rohde, Jorgensen et al. (2004) Adequate Unclear Adequate Inadequate 2 = Rohde, Clarke et al. (2004) Adequate Inadequate Adequate Adequate 1 * Based on proportion of total items they comply with (after Khan et al., 2003). Studies with deficiencies in areas with increased bias (e.g. lack of concealment allocation) were ranked lower than studies with deficiencies in other areas (e.g. lack of information about withdrawals). a Based on the two groups that were randomised (with adequate concealment) in this trial. An additional pre-existing, non-randomised control group was included in this trial but was excluded from this review. Table options Effectiveness of the interventions included in this review Effectiveness in individual studies Here we report the results of the effectiveness of each trial in terms of the descriptive statistics and significance levels as reported in the original trials (see Table 4). As is standard practice in systematic reviews we selected the longest follow-up point from each trial (Higgins & Green, 2008). In the eight trials in which depression was measured as an outcome, significant improvements in depressive symptoms were seen in those receiving experimental interventions as compared to control groups in five trials (see Table 4). In the six trials that measured anxiety outcomes, significant improvements in anxiety symptoms were seen in those randomised to experimental interventions as compared to those in control groups in three trials (see Table 4). Only one trial measured self-harm as an outcome and reported no significant reduction in the experimental group as compared to a control group (Rohde, Jorgensen et al., 2004). Table 4. Effectiveness of interventions examined in studies included in this reviewa Study/Outcome measure Experimental group outcomes Mean (SD), N Control group outcomes Mean (SD), N Statistical significance Gleser et al. (1965) Anxiety – from verbal sample 1.78 (NS), 21 2.22 (NS), 24 p = 0.08 IPAT Anxiety 37.47 (NS), 21 38.28 (NS), 24 Not significant (ns) Taylor (1967)b Depression (MMPI scale 2) 59.97 (7.01), 98 62.27 (3.77), 11 p < 0.05 Jesness (1975) Withdrawal-depression (JI) 48.70 (NS), NS 50.60 (NS), NS p < 0.05 Social Anxiety (JI) 41.30 (NS), NS 50.60 (NS), NS p < 0.01 Reardon and Tosi (1977)b Ex 1) RSDI Ex 2) RSDT Con 1) Placebo Con 2) No treatment Depression (MAACL) 6.63 (NS), 8 13.38 (NS), 8 15.00 (NS), 8 18.38 (NS), 8 p < 0.01 c Anxiety (MAACL) 4.63 (NS), 8 7.25 (NS), 8 8.38 (NS), 8 8.75 (NS), 8 ns Shivrattan (1988)b Ex1) Social skills training Ex 2) Stress management Depression (MMPI scale 2) 59.03 (NS), 14 59.72 (NS), 14 56.63 (NS), 15 ns Ahrens and Rexford (2002)b Depression (BDI) 6.88 (7.14), 19 17.94 (8.22), 19 p = 0.002 PTSD symptoms 7.82 (10.00), 19 20.38 (10.46), 19 p = 0.0001 Impact of Events 23.41 (6.88), 19 33.50 (6.29), 19 p = 0.0001 Biggam and Power (2002) Depression (HADS) 5.10 (2.90), 23 8.40 (3.60), 23 p < 0.05 Anxiety (HADS) 6.90 (3.10), 23 9.60 (3.50), 23 p < 0.05 Rohde Jorgenson et al. (2004) Suicide ideation/behaviour 0.8 (2.2), 46 1.5 (3.0), 30 p = 0.254 Nakaya et al. (2004): Depression (Psychological Stress Response Scale (PSRS)) 8.4 (8.3), 8 4.5 (4.1), 8 ns Anxiety (PSRS) 8.0 (7.1), 8 5.9 (6.1), 8 ns Rohde, Clarke et al. (2004) Depression: BDI-II 9.9 (1.04), 41 7.5 (8.00), 46 p = 0.821 Depression: Hamilton 5.6 (6.40), 41 4.1 (5.10), 46 p = 0.594 n/N (%) n/N (%) Depression: MDD (K-SADS) 15/41 (36.6) 17/46 (37.8) ns Conduct Disorder: (K-SADS) 24/41 (58.5) 28/46 (62.2) ns a Descriptive statistics (and significance level) from original papers are reported. Where data were missing from the original report this is indicated by ‘NS’ (Not stated). b N = Original number randomised (precise number available for analysis not stated in report). c RSDI was significantly different to each of the other groups. Table options It is interesting to note that in the Rohde, Clarke et al.,(2004) study some significant differences were found between treatment groups immediately post-treatment, leading the authors to conclude that their group-based CBT intervention is a useful acute treatment for the youth offending population. Data aggregation and meta-analysis We aggregated data from three trials included here with respect to the outcome of depression as they had each examined a group-based CBT intervention. Ahrens and Rexford (2002) had examined Cognitive Processing Therapy (CPT) with young offenders with PTSD. Biggam and Power (2002) examined group problem solving with vulnerable young offenders, and Rohde, Clarke et al. (2004) investigated group Cognitive Behavioural Therapy (CBT) with young offenders with Major Depressive Disorder (MDD) and Conduct Disorder (CD). Two of the trials examined depression with the Beck Depression Inventory (BDI) (Beck, Steer, & Brown, 1996) and one used the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). Previous meta-analyses have demonstrated that it is feasible to combine these measures using Standardised Mean Difference (SMD) calculations (Townsend et al., 2001). The SMD is a measure of effect size for continuous data and is used when trials have used different scales to measure the same outcome (Khan et al., 2003). Fig. 3 shows the outcome of this analysis, which demonstrates that outcomes for depression were improved in participants who received group-based CBT as compared to those in the control groups [SMD = 0.38 (−0.69, −0.07)]. Effectiveness of CBT group-based interventions in young offenders (with any ... Fig. 3. Effectiveness of CBT group-based interventions in young offenders (with any disorder) with respect to depression. Figure options Insufficient data were available to permit full intention-to-treat analyses of outcome data. We were, however, able to obtain sufficient information to permit an available case analysis (Higgins & Green, 2008). Available case analyses: “Include data on only those whose results are known, using as a denominator the total number of people who had data recorded for the particular outcome in question” (Higgins & Green, 2008, Chapter 16, section 2.2).We have included proportion of participants in each study who did not provide outcome data in Table 2 where this information was provided. Assessment of heterogeneity Examination of the forest plot (which shows measure of effect sizes and confidence intervals for individual studies and data aggregated via meta-analysis (Lewis & Clarke, 2001)) in Fig. 3 reveals a degree of heterogeneity with respect to the effectiveness for group CBT interventions for young offenders with any type of mental health problem. There are a number of potential sources of heterogeneity. First, the studies focussed on young offenders with differing mental health problems (CD/MDD, PTSD and DSH). Secondly, there were differences in quality of the studies in terms of the adequacy of allocation concealment. Only one of the studies was found to have adequately concealed the allocation to groups (Rohde, Clarke et al, 2004). The heterogeneity (I2) for this meta-analysis (which is a measure that quantifies inconsistency) was substantial and significant (see Fig. 3). Hence, we conducted a random effects analysis (which assumes that included studies estimate intervention effects which are different, but related in some important way) (Higgins & Green, 2008). This type of analysis is commonly used to explore any observed heterogeneity (Higgins & Green, 2008), and revealed a non-significant overall effect for group-based CBT [SMD = −0.69 (−1.18, 0.37)].