Interventions for drug‐using offenders with co‐occurring mental illness
Abstract
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.
PICOs
Plain language summary
Interventions for drug‐using offenders with co‐occurring mental illness
Background
A number of policy directives are aimed at enabling people with drug problems to live healthy, crime‐free lives. Drug‐using offenders with co‐occurring mental health problems represent a group who access treatment for a variety of different reasons. The complexity of the two problems makes the treatment and rehabilitation of this group particularly challenging.
Study characteristics
The review authors searched scientific databases and Internet resources to identify randomised controlled trials (where participants are allocated at random to one of two or more treatment groups) of interventions to reduce, eliminate, or prevent relapse or criminal activity of drug‐using offenders with co‐occurring mental illness. We included people of any gender, age, or ethnicity.
Key results
We identified eight trials evaluating treatments for drug‐using offenders with co‐occurring mental illness. The interventions included case management via a mental health court: a therapeutic community; an evaluation of motivational interviewing techniques and cognitive skills (a person's ability to process thoughts) in comparison to relaxation training; and an evaluation of interpersonal psychotherapy in comparison to a psycho‐educational intervention. Overall, the interventions reported limited success with reducing self report drug use, but did report some success with reducing re‐incarceration rates, but not re‐arrest. The therapeutic community studies reported a reduction in re‐incarceration but were shown to be less effective for re‐arrest and self report drug use. Three single studies evaluating case management via a mental health drug court, motivational interviewing and cognitive skills, and interpersonal psychotherapy did not report significant reductions in criminal activity and self report drug use respectively. Some information is provided on the costs and cost‐effectiveness of such interventions and trial evaluations focusing specifically on the needs of drug‐using offenders with co‐occurring mental illness are required.
Quality of the evidence
This review was limited by the lack of information reported in this group of trials. The quality of the evidence was moderate for therapeutic community and low to very low for the other types of intervention. The evidence is current to May 2014.
Authors' conclusions
Summary of findings
| Therapeutic community for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Therapeutic community | |||||
| Criminal activity ‐ Re‐arrests | 117/340 (34.4%) | 167/458 (36.5%) | 1st study: 1.65 [0.83, 3.28] 2nd study:0.96 [0.82, 1.13] | 798 | ⊕⊕⊕⊝ | ‐‐ |
| Criminal activity ‐ Re‐incarceration | 71/283 (25.1%) | 47/353 (13.3%) | 1st study:0.28 [0.13, 0.63] 2nd study:0.73 [0.45, 1.19] 3rd study:0.49 [0.27, 0.89] | 636 | ⊕⊕⊕⊝ | ‐‐ |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 Across the 2 studies, 13 of the 18 'Risk of bias' items in total were rated as unclear risk; 2 of the 18 were rated as high risk. | ||||||
| Mental health court for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Mental health court | |||||
| Self report dichotomous criminal activity | Study population | RR 1.05 | 208 | ⊕⊝⊝⊝ | ‐‐ | |
| 724 per 1000 | 761 per 1000 | |||||
| Moderate | ||||||
| 725 per 1000 | 761 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 4 of the 9 items were rated as high risk; 4 of the 9 items were rated as unclear risk. | ||||||
| Motivational interviewing and cognitive skills for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Motivational interviewing and cognitive skills | |||||
| Self report drug use continuous | ‐‐ | The mean self report drug use continuous in the intervention groups was | ‐‐ | 162 | ⊕⊕⊝⊝ | ‐‐ |
| Self report drug use dichotomous | Study population | RR 0.92 | 41 | ⊕⊝⊝⊝ | ‐‐ | |
| 364 per 1000 | 335 per 1000 | |||||
| Moderate | ||||||
| 364 per 1000 | 335 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 1 of 9 items judged as high risk; 7 of 9 items judged as unclear risk. | ||||||
| Interpersonal psychotherapy for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Interpersonal psychotherapy | |||||
| Self report drug use dichotomous | Study population | RR 0.67 | 38 | ⊕⊝⊝⊝ | ||
| 474 per 1000 | 317 per 1000 | |||||
| Moderate | ||||||
| 474 per 1000 | 318 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 2 of 9 items rated as high risk; 2 of 9 items rated as unclear risk. | ||||||
Background
This review is part of a family of four reviews providing a close examination of what works in reducing drug use and criminal activity in drug‐using offenders. Overall, the four reviews contain over 100 trials, generating a number of publications and numerous comparisons (Perry 2013a; Perry 2013b; Perry 2013c). The four reviews represent a specific interest in pharmacological interventions, non‐pharmacological interventions, female offenders, and offenders with co‐occurring mental illness. All four reviews stem from an updated previous Cochrane systematic review (Perry 2006). In this set of four reviews, we consider not only the effectiveness of interventions based on two key outcomes but also analyse the impact of setting and intervention type. We have presented here the revised methodology for this individual review focusing on the impact of interventions for drug‐using offenders with co‐occurring mental illness.
Description of the condition
Mental health issues in offenders are common, with over half (64%) of jail inmates in the US reporting a serious mental illness (Glase 2006). In the US, individuals incarcerated to jails are generally on remand awaiting trial, while those in prison have been sentenced within the criminal justice system. One study of mental illness in jails found that more women than men (31% and 14.5%, respectively) have a serious mental illness (Steadman 2009). Other studies have reported that a greater proportion of mentally ill people are arrested compared with the general population (Lamb 1998). Factors cited as causes include a lack of support in the community, problems accessing treatment, and the attitudes of police and society. A systematic review evaluating 62 surveys from 12 countries accounting for 23,000 prisoners. They found that prisoners were several times more likely to have psychosis or major depression and 10 times more likely to have an antisocial personality disorder than the general population. It is unknown how well the prison service is addressing these problems (Fazel 2002).
In the UK, renewed emphasis from Clarke's green paper, Breaking the Cycle, recognises that the justice system is not always the best place to manage the problems of less serious offenders, where their criminal behaviour is related to their mental health problems (Clarke 2010). As a result, several diversionary schemes have been established (Ministry of Justice 2010). The use of diversionary schemes have been supported by previous systematic reviews and meta‐analytical techniques that have evaluated diversion programmes (for example mental health courts) providing a mechanism for diverting individuals with severe mental illness into treatment programmes instead of the prison system (Sarteschi 2011). Findings from such studies generally show positive improvements on a small number of clinical outcomes. However, the conclusions are often limited by the research design (that is quasi‐experimental studies), introducing potential bias about the relative effectiveness of such schemes. Evidence from one systematic review of serious mentally disordered adult offenders identified seven trials, but the evidence was insufficient to draw conclusions. The authors called for more comparative trials to increase their confidence in the findings (Fontanarosa 2013).
Description of the intervention
Many different treatments for substance misuse (for example detoxification and therapeutic communities) have been adopted for use in the criminal justice system. This review included any intervention that was designed to reduce, eliminate, or prevent relapse to drug use or criminal activity, or both. This resulted in the inclusion of a wide range of treatments focusing on: case management via a mental health drug court, therapeutic communities, and motivational interviewing (MI) with cognitive skills in comparison to relaxation training. The evidence to support the effectiveness of these interventions differs and is dependent upon the quality of the experimental evaluations employed to assess whether they are successful in reducing drug use or criminal activity, or both.
Case management evolved traditionally to address the needs of prisoner re‐entry programmes covering employment, education, health, housing, and family support via assessment and connecting clients with the appropriate services (Austin 1994). Case management in the US has been applied in Treatment Accountability for Safer Communities programmes (Marlowe 2003b), and has shown initial effectiveness but without systematic evidence in support of the process.
Previous meta‐analyses and systematic reviews have shown therapeutic community interventions specifically with aftercare to have modest effects in the reduction of recidivism and drug use (Mitchell 2012a; Pearson 1999).
Cognitive behavioural approaches, including self monitoring, goal setting, self control training, interpersonal skills training, relapse prevention, group work, and lifestyle modification, have shown signs of success with offenders generally (Lipsey 2007), but the evidence is based on systematic reviews that have excluded evaluations focusing specifically on the needs of drug‐using offenders. Two previous systematic reviews found that motivational interviewing can lead to improved retention in treatment, enhanced motivation to change, and reduced offending, although there are variations across studies (McMurran 2009; Smedslund 2011).
Interpersonal psychotherapy has been used in the community with proven effectiveness in non‐criminal justice settings. Such studies have not found interpersonal psychotherapy to be superior to other treatments (Johnson 2012).
Policy interests have also placed an increasing demand on knowing more about the cost and cost‐effectiveness of such interventions. We can draw some evidence from systematic reviews completed in the area. However, despite growing knowledge about the effectiveness of treatment programmes for offenders, there is no recent systematic review evidence focusing on the effectiveness of treatment for offenders with drug misuse and co‐occurring mental health problems.
How the intervention might work
Interventions delivered to drug‐using offenders under the care of the criminal justice system have varied over time. Case management is a problematic term that has been used to describe what amounts to a range of diverse practices and supervision models spanning several different services, including probation. These are generally used to co‐ordinate and integrate all aspects of community supervision, from the initial offender needs assessment, through to programme delivery and the intended completion of the order or sentencing requirement (Partridge 2004).
In the US since the 1960s therapeutic community interventions have been used in combination with work release programmes to rehabilitate offenders via a supportive environment over a relatively long period. This usually encompasses the transition between the prison and working within the community (Prendergast 2011). The ethos of a therapeutic community intervention is to focus on treatment on the whole self (and not on the drug abuse per se) and the underlying symptomatic problems, where the residents are instrumental in running the therapeutic community (Mitchell 2012a).
Cognitive behavioural approaches using programmes based on psychological theory have been employed to try to help people address their offending behaviour and generally have good support from the literature in their reduction of recidivism, but have previously excluded drug‐using offenders (Andrews 1990; Lipsey 1998; Lipsey 2007).
Miller and Rollnick developed motivational interviewing as a process to motivate change in substance abusers (Miller 1991). The technique uses different strategies such as expressing empathy, avoiding arguing for change, and working on ambivalence to strengthen commitment to change. Meta‐analyses evidence supports the use of motivational interviewing as a stand‐alone treatment and in combination with more intensive programmes (Vasilaki 2006).
Why it is important to do this review
Many people under the care of the criminal justice system have co‐occurring mental illness and drug‐misuse problems. While previous research has evaluated treatment programmes for offenders more broadly, we know little about the challenges, treatment, and rehabilitation opportunities for offenders with co‐occurring mental health and drug‐misuse problems. We therefore believe that an evaluation of existing evidence on the impact of interventions for drug‐using offenders with co‐occurring mental illness might be helpful in identifying treatments for reducing drug use and criminal activity in this vulnerable population. Where possible, the review will also report descriptively on the costs of such treatment programmes.
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.
The review addressed the following questions:
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Does any treatment for drug‐using offenders with co‐occurring mental illness reduce drug use?
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Does any treatment for drug‐using offenders with co‐occurring mental illness reduce criminal activity?
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Does the treatment setting (court, community, prison/secure establishment) affect the intervention outcome(s)?
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Does the type of treatment affect the outcome(s)?
Additionally, this review aimed to report on the cost and cost‐effectiveness of interventions.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs).
Types of participants
We included drug‐using offenders with co‐occurring mental illness regardless of gender, age, or ethnicity. Drug misuse included any study that referred to participants who used occasionally, were dependent, or were known to abuse drugs. We defined offenders as participants who were involved in the criminal justice system. We judged offenders to have co‐occurring mental illness where the paper explicitly stated this. We used several different mechanisms to identify study samples with mental health problems including:
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use of diagnostic gold‐standard tests such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD‐10) criteria; or
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the nature of the intervention (e.g. mental health court); or
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where the study described the participant demographic as having a "history of psychiatric illness" or "serious mental disorder" with a co‐occurring substance misuse.
Types of interventions
Included interventions were designed, wholly or in part, to eliminate or prevent relapse to drug use or criminal activity, or both, among participants. We defined 'relapse' as participants who may have returned to an incarcerated setting or were subsequently arrested, or who had relapsed back into drug misuse, or both. We included a range of different types of interventions in the review.
Experimental interventions included in the review
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Any pharmacological intervention (e.g. buprenorphine, methadone)
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Any psychosocial intervention (e.g. therapeutic community, case management, cognitive behavioural therapy, interpersonal psychotherapy, motivational interviewing)
Control interventions included in the review
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No treatment
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Minimal treatment
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Waiting list
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Treatment as usual
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Other treatment
Types of outcome measures
Primary outcomes
For the purpose of this review, we categorised our primary outcomes into those relating to dichotomous and continuous drug use or criminal activity, or both. Where papers reported a number of different follow‐up periods, we reported the longest period, as we felt this measure was the most conservative estimate of effectiveness.
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Drug use measures reported as:
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self report drug use (unspecified drug, specific drug use not including alcohol, Addiction Severity Index composite scores);
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biological drug use (measured by drugs testing by either urine or hair analysis).
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Criminal activity as measured by:
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self report or official report of criminal activity (including arrest for any offence, drug offences, re‐incarceration, convictions, charges, and recidivism).
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Secondary outcomes
Our secondary outcome reported on cost or cost‐effectiveness information. We used a descriptive narrative to describe these findings. We undertook a full critical appraisal based on the Drummond 1997 checklist for studies presenting sufficient information.
Search methods for identification of studies
Electronic searches
The update searches identified records from 2004 to May 2014.
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CENTRAL (issue 5, 2014) (Appendix 1)
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MEDLINE (1966 to May 2014) (Appendix 2)
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EMBASE (1980 to May 2014) (Appendix 3)
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PsycINFO (1978 to April 2014) (Appendix 4)
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PASCAL (1973 to November 2004)a (Appendix 5)
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SciSearch (Science Citation Index) (1974 to April 2014) (Appendix 5)
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Social SciSearch (Social Science Citation Index) (1972 to April 2014) (Appendix 5)
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ASSIA (1987 to April 2014) (Appendix 6)
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Wilson Applied Science and Technology Abstracts (1983 to October 2004)a
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Inside Conferences (1993 to November 2004)a
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Dissertation Abstracts (1961 to October 2004)a
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NTIS (1964 to April 2014)
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Sociological Abstracts (1963 to April 2014) (Appendix 7)
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HMIC (2004 to April 2014) (Appendix 8)
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PAIS (1972 to April 2014) (Appendix 9)
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SIGLE (1980 to June 2004)b (Appendix 10)
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Criminal Justice Abstracts (1968 to April 2014) (Appendix 11)
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LILACS (2004 to April 2014)
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National Research Register (March 2004)c (Appendix 12)
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Current Controlled Trials (December 2009)
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DrugScope (February 2004) ‐ unable to access
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SPECTRA (March 2004)d (Appendix 13)
aUnable to access further to 2004 search.
bDatabase not updated since original 2004 search.
cNo longer exists.
dNow Campbell Collaboration searched online.
In our update of the original review we restricted the search strategy to studies that were published or unpublished from 2004 onwards (Perry 2006). We did not search several of the original databases for this update (indicated by the key at the end of the database list). We did not search PASCAL, ASSIA, Wilson Applied Science and Technology Abstracts, Inside Conferences, and Dissertation Abstracts, as these databases were available only via the fee‐charging Dialog online host service, and we did not have the required resources. The National Research Register no longer exists, and SIGLE has not been updated since 2005. DrugScope is available only to subscribing members. The original searches were undertaken by DrugScope employees.
We developed search strategies for each database to employ the search engine most effectively and to make use of any controlled vocabulary. We designed search strategies to restrict the results to RCTs and placed no language restrictions. We included methodological search filters designed to identify trials. Whenever possible, we used filters retrieved from the InterTASC Information Specialists' Sub‐Group Search Filter Resource site (www.york.ac.uk/inst/crd/intertasc/). If filters were unavailable from this site, we used search terms based on existing filters instead.
In addition to the electronic databases, we searched relevant websites (Home Office, National Institute of Drug Abuse, and European Association of Libraries and Information Services on Alcohol and Other Drugs). We searched directory websites up to November 2011. We placed no language restrictions on identification and inclusion of studies in the review.
We have listed details of the update search strategies and results and websites searched in Appendix 1; Appendix 2; Appendix 3; Appendix 4; Appendix 5; Appendix 6; Appendix 7; Appendix 8; Appendix 9; Appendix 10; Appendix 11; Appendix 12; Appendix 13.
Searching other resources
Reference checking
We scrutinised the reference lists of all retrieved articles for additional references and searched the catalogues of relevant organisations.
Personal communication
We sought out experts for their knowledge of other published or unpublished studies relevant to the review.
Data collection and analysis
Selection of studies
Two review authors independently inspected titles and abstracts identified by the search strategy. We obtained each potentially relevant study as a full article, and two review authors independently assessed these for inclusion. In the case of discordance, a third review author arbitrated. One review author undertook translation of articles not written in the English language.
We divided the screening process into two key phases. Phase one used the initial eight key questions reported in the original review (Perry 2006).
Phase one pre‐screening criteria:
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Is the document an empirical study? [If no, exclude document]
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Does the study evaluate an intervention, a component of which is designed to reduce, eliminate, or prevent relapse in drug‐using offenders?
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Are the participants referred by the criminal justice system at baseline?
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Does the study report pre‐ and post‐programme measures of drug use?
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Does the study report pre‐ and post‐programme measures of criminal behaviour?
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Is the study an RCT?
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Do the outcome measures refer to the same length of follow‐up for two groups?
Following identification of relevant papers from phase one, we sought in phase two screening to identify those papers describing offenders with a mental illness. This information was primarily obtained from the participant description and the type of intervention (for example mental health drug court).
Phase two pre‐screening:
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Is the study population comprised wholly of participants with diagnosed mental illness using DSM‐IV or ICD‐10 diagnostic criteria? [if yes, include document]
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Is the study population comprised wholly of participants identified on screening to have a mental health problem(s) based on intervention eligibility (e.g. mental health court)? [if yes, include document]
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Where the full study population is not comprised of offenders with diagnosed or presumed mental illness, are separate results given for those participants with mental illness? [if no, exclude document]
Drug‐using interventions were implied if the programme was targeted at reducing drug use in a group of individuals or could be ascertained from the background characteristics of the group. Offenders were individuals residing in special hospitals, prisons, the community, or who were diverted from court or placed on arrest referral schemes for treatment. We did accept papers in the review where the entire sample were not using drugs, but reported pre and post measures needed to be the same at both time points. The study setting could change throughout the process of the study. For example, offenders could begin in prison but progress through a work release project into a community setting. Finally, studies did not need to report both drug and criminal activity outcomes. If either of these were reported, we included the study in the review.
Data extraction and management
We used data extraction forms to standardise the reporting of data from all studies obtained as potentially relevant. Two review authors independently extracted data and subsequently checked them for agreement.
Assessment of risk of bias in included studies
Three review authors (AEP, MMSJ, RW) independently assessed risk of bias of all included studies using the 'Risk of bias' assessment criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
The recommended approach for assessing risk of bias in studies included in Cochrane reviews is a two‐part tool, addressing seven specific domains, namely sequence generation and allocation concealment (selection bias), blinding of participants and providers (performance bias), blinding of outcome assessor (detection bias), incomplete outcome data (attrition bias), selective outcome reporting (reporting bias), and other source of bias. The first part of the tool involves describing what was reported to have happened in the study. The second part of the tool involves assigning a judgement relating to the risk of bias for that entry, in terms of low, high, or unclear risk. To make these judgements, we used the criteria indicated by the Cochrane Handbook for Systematic Reviews of Interventions adapted to the addiction field. See Appendix 14 for details.
The domains of sequence generation and allocation concealment (avoidance of selection bias) were addressed in the tool by a single entry for each study.
Blinding of participants, personnel, and outcome assessor (avoidance of performance bias and detection bias) were considered separately for objective outcomes (for example drop‐out, use of substance of abuse measured by urine analysis, participants relapsed at the end of follow‐up, participants engaged in further treatments) and subjective outcomes (for example duration and severity of signs and symptoms of withdrawal, participant self reported use of substance, side effects, social functioning as integration at school or at work, family relationship).
Incomplete outcome data (avoidance of attrition bias) was considered for all outcomes except for drop‐out from the treatment, which is very often the primary outcome measure in trials on addiction.
For studies identified in the search, the review authors attempted to contact study authors to establish whether a study protocol was available.
Measures of treatment effect
The mean differences (MD) were used for outcomes measured on the same scale and the standardised mean difference (SMD) was used for outcomes measured on different scales. Higher scores for continuous measures are representative of greater harm. We presented dichotomous outcomes as risk ratios (RR), with 95% confidence intervals (CIs).
Unit of analysis issues
To avoid double counting of outcome measures (for example arrest and parole violation) and follow‐up time periods (for example 12, 18 months), we checked all trials to ensure that multiple studies reporting the same evaluation did not contribute towards multiple estimates of program effectiveness. We followed Cochrane guidance, and where appropriate we combined intervention and control groups to create a single pair‐wise comparison. Where this was not appropriate, we selected one treatment arm and excluded the others.
Dealing with missing data
We attempted to contact study authors via email where missing data occurred in the original publication.
Assessment of heterogeneity
We assessed heterogeneity using the I² statistic and Chi² statistic (Higgins 2011).
Data synthesis
We planned to use the RevMan software package to perform a series of meta‐analyses for continuous and dichotomous outcome measures (RevMan 2012). We planned to use a random‐effects model to account for the fact that participants did not come from a single underlying population. Because of the high heterogeneity of included studies for types of intervention compared, no meta‐analysis were performed. The narrative tables included a presentation of the study details (for example author, year of publication, and country of study origin), study methods (for example random assignment), participants (for example number in sample, age, gender, ethnicity, age, mental health status), interventions (for example description, duration, intensity, and setting), outcomes (for example description, follow‐up period, and reporting mechanism), resource and cost information and resource savings (for example number of staff, intervention delivery, estimated costs, and estimated savings) and notes (for example methodological and quality assessment information).
Subgroup analysis and investigation of heterogeneity
We had planned to conduct sensitivity analyses to assess the impact of studies at high risk of bias compared with those at low or unclear risk of bias. Because of the overall high risk of bias of the included studies, this analysis was not possible.
Results
Description of studies
Results of the search
Original review
The original searches spanned from database inception to October 2004. They identified a total of 8217 records after duplication. We acquired a total of 90 full‐text papers for assessment and excluded 36 papers, bringing 24 trials to the review (see Figure 1).
Study flow diagram of paper selection process: Original Review
First update
The updated searches spanned from October 2004 until March 2013. These identified a total of 3896 records after duplication. We acquired a total of 109 full‐text papers for assessment and excluded 104 papers, bringing 5 new trials to the review (see Figure 2).
Study flow diagram of paper selection process: First update
Second update
The updated searches spanned from March 2013 until April 2014. These identified a total of 2092 records after duplication. We acquired a total of 72 full‐text papers for assessment and excluded 69 papers, bringing 3 new trials to the review, making a total of 14 publications represented by 8 trials (see Figure 3).
Study flow diagram of paper selection process: Second update
Included studies
Fourteen publications represented eight trials published between 1999 and 2014. The eight trials consisted of three singular trial publications on different interventions, Cosden 2003, Sacks 2011, and Stein 2011, and two trials represented by five publications. The first trial represented an evaluation of one intervention to two comparison groups, using different outcome measures (drug use at 12 months reported by Sacks 2004). The second trial represented three publications and four comparisons presenting follow‐up data successively between 12 and 60 months (Wexler 1999).
Treatment regimens and settings
Six studies were conducted in a secure setting. The evaluations considered a therapeutic community intervention and aftercare in comparison to some alternative‐sentencing option (Johnson 2012; Lanza 2013; Sacks 2004; Sacks 2008; Sacks 2011; Wexler 1999).
Two studies were conducted in a court setting. The evaluations compared assertive case management versus treatment as usual in a mental health drug court (Cosden 2003), and motivational interviewing with relaxation training in a group of adolescents with significant depression (Stein 2011).
No studies assessed the efficacy of pharmacological treatments.
No studies were identified in the community.
Countries in which the studies were conducted
All the studies were published in the US.
Duration of trials
The trial duration varied between 3 months' follow‐up, in Johnson 2012, Lanza 2013, and Stein 2011, to a 5‐year follow‐up (Wexler 1999). The remaining studies reported on outcomes at 12, 24, and 36 months (Cosden 2003; Sacks 2011; Sacks 2008; Sacks 2004).
Participants
Seven of the eight comparisons included adult drug‐using offenders. One study investigated the impact of motivational interviewing in adolescents aged 14 to 19 years (Stein 2011).
Three studies included female offenders (Cosden 2003; Johnson 2012; Stein 2011). Adult male offenders were the focus of the study populations in the majority of studies, with a mean age of 30 years.
In all study populations, the majority of participants were of white ethnic origin.
Mental health diagnoses varied across the studies (see Table 1 for more information).
| Study, year | Criteria used for diagnoses | Description of mental health problem |
| Determined by a psychiatrist/psychologist on the basis of a clinical interview and observations | Mood disorder Schizophrenia Bipolar disorder Other Dual diagnosis | |
| Hamilton Rating Scale for Depression Median duration of index episode in months Number of depressive episodes Number of previous suicide attempts DSM‐IV Axis I disorders using the SCID‐I/II. | Criteria for a major depressive disorder at least 4 weeks after substance abuse treatment Minimum score of 18 on the Hamilton Rating Scale for Depression. | |
| DSM‐IV Mini International Neuropsychiatric Interview Anxiety Sensitivity Index | Anxiety Mental health disorders Antisocial personality disorder Major depressive disorder Generalised anxiety disorder | |
| DIS | Diagnoses of lifetime Axis I or Axis II mental disorder Antisocial personality disorder | |
| Global Severity Index Beck Depression Inventory Lifetime of mental health PTSD Symptom Scale ‐ Interview Posttraumatic Stress Diagnostic Scale | Depression PTSD Lifetime of mental health | |
| DSM‐IV diagnostic criteria Beck Depression Inventory Post Traumatic Stress Disorder Symptom Scale Brief Symptom Inventory Global Severity Index | Depression PTSD Psychological distress | |
| CES‐D Scale | Scores > 16 indicate presence of significant depression. 69.8% had significant depressive symptoms | |
| Not specified | Antisocial personality disorder Phobias PTSD Depression Dysthymia Attention deficit hyperactivity disorder |
CES‐D: Center for Epidemiological Studies ‐ Depression; DIS: Diagnostic Interview Schedule; DSM‐IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; PTSD: post‐traumatic stress disorder; SCID: Structured Clinical Interview for DSM Disorders.
Excluded studies
We excluded 172 studies. (See Characteristics of excluded studies for further details.) Reasons for exclusion were: lack of criminal justice involvement in referral to the intervention; not reporting relevant drug or crime outcome measures or both at both the pre‐ and post‐intervention periods; and allocation of participants to study groups that were not strictly randomised or did not contain original trial data. We excluded the majority of studies because the study population were not offenders. We excluded one study because follow‐up periods were not equivalent across study groups (Di Nitto 2002), and another because the study intervention (acupuncture) did not measure our specified outcomes of drug use or criminal activity (Berman 2004). One study reported the protocol of a trial only (Baldus 2011), while another only contained conference proceedings (Kinlock 2009). For one trial, we were unable to obtain the data (Cogswell 2011), and for another we were unable to obtain the full‐text version (Rowan‐Szal 2005).
Risk of bias in included studies
Allocation
Randomisation
All of the nine included comparisons were described as randomised. Five of the included studies reported on how the randomisation sequence was generated and were judged as at low risk of bias (Cosden 2003; Johnson 2012; Lanza 2013; Sacks 2011; Stein 2011). The remaining three studies did not report how the randomisation sequence of participants was generated (Sacks 2004; Sacks 2008; Wexler 1999).
Characteristics at baseline
Five of the eight studies were similar on drug use at baseline (Johnson 2012; Sacks 2004; Sacks 2008; Sacks 2011; Stein 2011), two studies were rated unclear (Cosden 2003; Lanza 2013), and one study showed comparable baseline differences (Sacks 2004). For similarity on criminal justice measures, six studies were rated as similar (Cosden 2003; Johnson 2012; Sacks 2008; Sacks 2011; Sacks 2004; Stein 2011; Wexler 1999), and two were rated as unclear (Lanza 2013; Stein 2011).
Allocation concealment
Of the eight studies, only one adequately reported that the allocation process was concealed (Johnson 2012).
Blinding
We assessed blinding across four dimensions considering performance and detection bias across subjective and objective measures (see Appendix 14). For five of the eight studies, we considered blinding unclear on all four measures of blinding (Sacks 2004; Sacks 2008; Stein 2011; Wexler 1999). We rated one study as at high risk of bias on two of the four measures (Cosden 2003), and we rated another study as at low risk of bias across three of the four domains (Lanza 2013).
Incomplete outcome data
Loss to follow‐up was reported to differing extents in the included studies. We rated two studies as at low risk of bias (Cosden 2003; Sacks 2008), and we rated four as at low risk with limited attrition noted (Johnson 2012; Lanza 2013; Sacks 2004; Wexler 1999). We rated two studies as unclear (Sacks 2011; Stein 2011).
Selective reporting
We rated five of the eight trials as unclear (Cosden 2003; Sacks 2004; Sacks 2011; Stein 2011; Wexler 1999). We rated two studies as at low risk (Lanza 2013; Sacks 2008), and we rated one study as at high risk (Johnson 2012).
Other potential sources of bias
Of the eight studies, we rated four as at high risk of other bias (Cosden 2003; Johnson 2012; Stein 2011; Wexler 1999), three as at low risk with no further concerns (Lanza 2013; Sacks 2008; Sacks 2011), and the final study as unclear (Sacks 2004).
See Figure 4 and Figure 5 for more details.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Effects of interventions
See: Summary of findings for the main comparison Therapeutic community for drug‐using offenders with co‐occurring mental illness; Summary of findings 2 Mental health court for drug‐using offenders with co‐occurring mental illness; Summary of findings 3 Motivational interviewing and cognitive skills for drug‐using offenders with co‐occurring mental illness; Summary of findings 4 Interpersonal psychotherapy for drug‐using offenders with co‐occurring mental illness
We considered each of our studies in relation to the key objectives of the review and grouped them together by outcome measures and individual intervention type (see Table 2 for more details). We have summarised the main comparisons in summary of findings Table for the main comparison; summary of findings Table 2.
| Paper, year | Intervention | Comparison | Follow‐up | Outcome type | Measurement | Actual outcome |
| Sentencing and case management (mental health treatment court and assertive community treatment case management) | Treatment as usual | 6 and 12 months | Criminal activity dichotomous Self report drug use continuous | % and total mean and SD | % arrested and spent some time in jail % convicted of a new crime Mean Addiction Severity Index (drug) composite score | |
| Therapeutic community, counselling and aftercare | Treatment as usual and waiting‐list control | 12, 24, 36 months up to 5 years | Biological drug use dichotomous Criminal activity continuous Criminal activity dichotomous Self report drug use dichotomous | % and total mean and SD | % testing positive for illicit drugs at 12 months' follow‐up Mean months incarcerated in the year following release % any arrest % arrested for drug crime % arrested for property crime % arrested for violent crime % arrested for other crime % used drugs heavily in past year at 5 years Mean days until re‐incarceration % re‐incarcerated Mean days on parole to first return to custody % returned to prison within 3 years post‐ parole | |
| Modified therapeutic community (Personal Reflections therapeutic community and voluntary residential aftercare) | Intensive psychiatric services | 12 months | Criminal activity continuous Criminal activity dichotomous Self report drug use dichotomous | Mean and SD % and total | Mean number of days until incarceration Mean number of days until first crime % re‐incarceration % criminal activity % alcohol/drug offence % other (non‐alcohol/drug) offence % illegal drug use | |
| Therapeutic community (re‐entry modified) | Parole supervision case management | 12 months | Criminal activity dichotomous | % with total | % re‐incarcerated % self reported criminal activity | |
| Therapeutic community | Cognitive behavioural therapy | 6 and 12 months | Criminal activity dichotomous Criminal activity self report and official Self report drug use | % with total | Criminal activity, arrest, and drug‐ related activity (self‐reported) Criminal record data (% incarcerated, mean days to incarceration) % self‐reported illegal drug use | |
| Interpersonal psychotherapy | psycho‐educational | 3 months | biological drug use | % with total | Relapse within 3‐ month follow‐up period, defined as using drugs on at least 10% of non‐incarcerated days or any positive breath test/urine drug screen | |
| Cognitive behavioural therapy and acceptance and commitment therapy | control group | 3 months | Self report drug use dichotomous | % and total | Self report, corroborated by urinalysis | |
| Stein 2011 (high depression score) | Motivational interviewing | Relaxation training | 3 months | Self report drug use continuous | Mean and SD | Mean joints per day Mean % days used marijuana |
SD: standard deviation
Due to high heterogeneity of the interventions compared in the included studies, it was not possible to combine study results, and we performed no meta‐analyses for drug use measures and criminal activities. Furthermore as all the included studies were conducted in a secure or court setting, it was not possible to combine study results, and we performed no meta‐analyses.
1. Therapeutic community and aftercare versus treatment as usual
See summary of findings Table for the main comparison
Impact on self report drug use
Three studies reported results about self report drug use. One study found statistically significant reduction: Sacks 2004 (RR 0.58, 95% CI 0.36 to 0.93, 139 participants); the second study found nearly statistically significant reduction: Sacks 2008 (RR 0.73, 95% CI 0.53 to 1.01, 370 participants); while the third study found no statistically significant reduction: Wexler 1999 (RR 1.11, 95% CI 0.82 to 1.49, 576 participants).
Impact on criminal activity
Two studies reported no statistically significant reduction in re‐arrest following treatment: Sacks 2008 (RR 1.65, 95% CI 0.83 to 3.28, 370 participants); and Wexler 1999 comparing a secure establishment‐based therapeutic community program versus no treatment (RR 0.96, 95% CI 0.82 to 1.13, 428 participants), moderate quality of evidence; see Analysis 1.1
Three studies evaluated the impact of therapeutic community treatment using re‐incarceration measures. Two studies reported statistically significant reduction: Sacks 2004 comparing Personal Reflections therapeutic community and voluntary residential aftercare versus mental health programme (RR 0.28, 95% CI 0.13 to 0.63, 139 participants); and Sacks 2011 comparing re‐entry modified therapeutic community treatment versus parole supervision case management (RR 0.49, 95% CI 0.27 to 0.89, 127 participants). One study did not find statistically significant results: Sacks 2008 comparing a therapeutic community program versus cognitive behavioural intervention (RR 0.73, 95% CI 0.45 to 1.19, 370 participants), moderate quality of evidence, see Analysis 1.1
2. Mental health court and case management versus treatment as usual (standard court proceedings)
Seesummary of findings Table 2
Impact on self report drug use
The study did not assess this outcome.
Impact on self report criminal activity
One study reported no statistically significant reduction in criminal activity: RR 1.05, 95% CI 0.90 to 1.22, 235 participants (Cosden 2003), very low quality of evidence, see Analysis 2.1
3. Motivational interviewing and cognitive skills versus relaxation therapy
Seesummary of findings Table 3
Impact on self report drug use‐‐continuous
One study reported no statistically significant reduction in self report drug use: MD ‐7.42, 95% CI ‐20.12 to 5.28, 162 participants (Stein 2011), low quality of evidence, see Analysis 3.1
Impact on self report drug use‐‐dichotomous
One study reported no statistically significant reduction in self report drug use: RR 0.92, 95% CI 0.36 to 2.33, 41 participants (Lanza 2013), very low quality of evidence, see Analysis 3.2
Impact on self report criminal activity
The studies did not assess this outcome.
4. Interpersonal psychotherapy versus a psycho‐educational intervention
See summary of findings Table 4
Impact on self report drug use
One study reported no statistically significant reduction in self report drug use: RR 0.67, 95% CI 0.30 to 1.50, 38 participants (Johnson 2012), very low quality of evidence, see Analysis 4.1
Impact on self report criminal activity
The studies did not assess this outcome.
Cost and cost‐effectiveness
Four papers referred to the costs or cost‐effectiveness of the therapeutic community programmes. The Sacks 2011 paper suggested that cost‐beneficial analyses associated with each intervention in achieving the desired outcome would greatly assist how best to allocate scarce resources. The Prendergast five‐year evaluation presents economic differences when compared to the one‐year Amity outcome study. The Prendergast research suggests that optimal cost savings appear to require prison treatment plus aftercare rather than prison treatment alone (McCollister 2013). One study contained some information about cost, but not sufficient to conduct a cost‐effectiveness appraisal (Sacks 2004). The authors of this study noted that the additional marginal costs on top of the specific incarceration costs were USD7.37 per day, compared with the USD148.19 cost of a prison day. This suggests a substantial cost saving of using therapeutic community programmes as opposed to prison.
Discussion
Summary of main results
This systematic review provided evidence from eight trials. The trials were conducted in secure settings and the court judicial system. We did not identify any studies that evaluated interventions for drug‐using offenders with co‐occurring mental illness in the community who were on parole or under the care of the probation service. We therefore do not know whether such interventions work better in one setting as opposed to another. Four different types of treatment interventions were classified across the studies. These were divided into: case management via a mental health drug court, therapeutic community treatment, motivational interviewing with cognitive skills in comparison to relaxation training, and interpersonal psychotherapy in comparison to a psycho‐educational intervention. The therapeutic community studies reported statistically significant reductions in subsequent re‐incarceration, but not for re‐arrest. This finding supports previous research that demonstrates that the combination of therapeutic community treatment and aftercare release seem to produce the most consistent and successful results Mitchell 2012a. Though not addressed within this review, those clients also remained in treatment for the longest period appeared to benefit the most (Sacks 2004).
One of the included studies was specifically adapted therapeutic community treatment for women offenders. This study compared women assigned to therapeutic community treatment or standard treatment, a cognitive behavioural recovery and relapse prevention curriculum referred to in the system as the Intensive Outpatient Program (Sacks 2008). At six months the study found that both groups improved significantly on variables of mental health, substance use, criminal behaviour, and HIV risk. The authors note that further exploration of each model for different offender groups is required to permit a more precise utility of each model. The authors conclude that these preliminary findings suggest the importance of providing gender‐specific sensitive and comprehensive approaches within the correctional system to respond to the complex substance abuse needs of female offenders (Sacks 2008). The more recent follow‐up study investigated outcomes at 6 and 12 months. The outcomes followed a similar pattern, with both groups of women benefiting from treatment. Therapeutic community treatment was found to be more beneficial than cognitive behavioural therapy at improving re‐incarceration rates and lengthening the amount of time spent in the community before subsequent re‐incarceration (Sacks 2008).
We noted no statistically significant reductions for criminal activity or self report drug use with the use of case management via a mental health court; motivational interviewing with cognitive skills over relaxation training; and acceptance and commitment therapy (ACT)or interpersonal psychotherapy (Cosden 2003; Johnson 2012; Lanza 2013; Stein 2011). The interpersonal psychotherapy was evaluated using a pilot study of women suffering from major depression and substance use disorder (Johnson 2012). This study is primarily a feasibility study to assess the applicability of using interpersonal psychotherapy in a prison environment. While small, it is in fact one of the largest trials including women with co‐occurring substance misuse and mental health problems. The findings showed that participants undergoing interpersonal psychotherapy had significantly reduced levels of depression and substance misuse over the attention‐matched control. The study evaluating ACT in comparison to traditional cognitive behavioural therapy found higher levels of abstinence in the ACT (43.8%) when compared to the control (18.2%). These findings are similar to other studies that have used ACT albeit in non‐incarcerated populations (Hayes 2004). The authors attribute the success of ACT to the nature of the 'co‐joint' work between the therapist and client, the aim of which is to increase the flexibility and structure of the therapy allowing the client to have greater autonomy over decision‐making. They argue that cognitive behavioural therapy is in contrast more systematically directed by the therapist, leaving little scope for responsive change (Lanza 2013). In summary, the studies varied greatly in nature, and given that they represent a series of singular trials, caution is called for in interpreting their results.
The impact on criminal‐activity outcome measures varied, and the differences noted between the reductions in re‐incarceration but not re‐arrest could be a reflection of the measurement processes. For example, incarceration to prison is a longer process involving a court case, and as a numerical outcome measure is less likely to be recorded within the time frame of an experimental evaluation. In comparison, 'arrest' as a measurement outcome is more frequent and is recorded in the criminal justice system within a shorter time frame. Sacks 2011 also argues that participation in different treatment options does not necessarily lead to less involvement with the criminal justice system, but that the severity of the offences are reduced such that re‐incarceration is less likely. The follow‐up studies to the Wexler trial also commented on differential effectiveness of treatment outcomes (Prendergast 2003; Prendergast 2004). The authors argue that focusing on only one or two outcomes may mask the impact of treatment on other outcome domains that are of interest to various stakeholders. For example, measuring re‐arrest or re‐incarceration does not reveal the reason for why an individual has returned to correctional supervision. Questions that remain unanswered through such measurement include (i) the length of time an offender remains in the community until re‐arrest, (ii) knowledge about what crimes are committed, and (iii) the reasons for return.
In terms of addressing some of the complex issues of individuals with mental illness and co‐occurring substance abuse, the evidence from this systematic review provides little information. Only three studies discussed the differential treatment effects on the severity of depression (Cosden 2003; Johnson 2012; Stein 2011). The Cosden 2003 study noted that further understanding of how to help clients with serious mental illness with different levels of treatment is needed. The Johnson 2012 study noted that participants undergoing interpersonal psychotherapy had significantly reduced levels of depression and substance misuse over the attention‐matched control. The authors noted that the intensity of treatment delivered once the individual is released into the community is key to maintaining good outcomes. However, they go on to state that women often experience delays in treatment and service provision on release, and they suggest that alternative service provision such as phone treatment might be helpful in providing a more intensive post‐release treatment and useful in times of crisis.
Several successful treatment elements were reported throughout the five trials with a number of key themes identified. First, we noted the issue of treatment engagement as important. In the mental health court trial, the informal support from family and friends encouraged the engagement of clients within the community to longer term gain (Cosden 2003). Second, programmes that were specifically adapted to the needs of mental health clients tended to include a cognitive behavioural curriculum that emphasised criminal thinking and behaviour alongside psycho‐educational classes. The focus of combining these two types of mechanisms is to enhance an individuals ability to recognise and understand their substance misuse and mental health problems in more detail (Sacks 2004). Third, the longer an individual is engaged in treatment the better the outcome(s) (Wexler 1999).
Overall completeness and applicability of evidence
General applicability
The applicability of the evidence is hindered in general by the lack of trials covering a range of different treatment options for drug‐using offenders with co‐occurring mental illness. As the trials were conducted in the US judicial system, they are, therefore, limited in their generalisation to other criminal justice systems outside of the US. The current evidence suggests that therapeutic community treatment may have some effect in reducing re‐incarceration rates, but we do not know how such treatment facilitates the specific rehabilitation requirements of drug‐using offenders with co‐occurring mental illness, and the studies represent singular outcomes. For drug use measures, the review only reports on self report drug use, as not enough information using biological outcome measures of drug use (for example hair and urine analysis) was available. As a result, the self report information must be interpreted with caution. In addition, we can say nothing about whether the treatments are effective in reducing drug use and subsequent criminal behaviour while offenders are on parole or on probation in the community.
Mental health information
Although the review specifically sought to identify studies including participants with co‐occurring mental illness, the study descriptions of mental ill health varied (see Table 1). The Cosden 2003 study used a psychiatrist or psychologist to conduct a clinical interview to make a mental health diagnosis alongside substance misuse. This resulted in a mental health court sample of individuals diagnosed with a range of mental health problems including mood disorder, schizophrenia, bipolar disorder, and dual diagnosis. Other papers referred to use of the DSM‐IV diagnostic criteria (Sacks 2011), but subsequently provided little information with regards to individual mental illness needs. Demographic information in the Sacks study reported on other aspects of mental health prognosis, including lifetime mental health treatment, lifetime in patient care, and prescribed medication (Sacks 2004). The Wexler 1999 series of studies reported a range of diagnoses, including antisocial personality disorder, phobias, post‐traumatic stress disorder, depression, dysthymia, and attention deficit disorder, but did not describe how these diagnoses were confirmed or assessed within the population.
Six of the eight trials reported on change in mental health well‐being. Three trials reported on used of the Beck Depression Inventory, Global Severity Index, and the Posttraumatic Diagnostic Scale (Sacks 2004; Sacks 2008; Sacks 2011) Another study reported on depression but used the Hamilton Rating Scale for Depression (Johnson 2012). Two studies reported presence of mood disorder alongside schizophrenia, general anxiety disorder, and antisocial personality disorder (Cosden 2003; Lanza 2013). Future updates of this review will include mental health outcomes in order to assess the impact of treatment on mental health well‐being alongside criminality and drug use.
Cost information
Cost information within the studies was lacking, allowing for little comparison of cost‐effectiveness between different types of drug treatment programmes. Regular report of effect sizes would aid calculations for power analysis and provide estimates of the magnitude of treatment effect needed for cost‐benefit and cost‐effectiveness analysis.
Quality of the evidence
Overall, the 'Risk of bias' assessment was limited due to lack of information reported in the trials. We therefore rated most of the studies on the majority of 'Risk of bias' measures as unclear. The main limiting factor was the lack of reporting evidence, which prevented the reviewer authors from making a clear judgement of bias. Since the imprecision of reporting lowers the quality of evidence, this means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. In addition, a number of specific limitations were described relating to the study design (and leading to problems of selection bias), and sample sizes were small. The Stein 2011 study was noted as being relatively underpowered. Replication of the study is required to enhance the generalisation and external validity of the study findings. Similar modest sample sizes were reported by Sacks 2011 and Cosden 2003, who suggested that larger samples should be used to provide a more precise estimate of effect. The Cosden 2003 study also reported on the possibility of outcome bias, as the interviewer was not blind to the outcome condition of the participant, and loss to follow‐up (25% of the study sample were lost to follow‐up) at 12 months.
Another possible selection bias concern in the series of Wexler studies was that participants were randomly assigned to the prison therapeutic community treatment and regular prison conditions but not to aftercare (Wexler 1999; Prendergast 2003; Prendergast 2004). The authors noted that possible differences in personal motivation may account for some of the positive outcomes associated with participants' continued support for aftercare services. Subsequently these participants were noted as having the highest 'readiness scores', which suggests that motivation creates an important consideration on client selection (Wexler 1999).
Overall the quality of evidence was judged as moderate for therapeutic community and low to very low for mental health court, motivational interviewing, and interpersonal psychotherapy.
Potential biases in the review process
Besides the limitations associated with the literature, there are also two limitations of the review methodology. Specifically, the original review included an additional five fee‐paying databases and one search using DrugScope. In this current review, resources did not allow such extensive searching. While the electronic database searches were updated to April 2014, the website information has only been updated to November 2011. As a result, the literature will require further extensive searching when the review is next updated.
Study flow diagram of paper selection process: Original Review
Study flow diagram of paper selection process: First update
Study flow diagram of paper selection process: Second update
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1 Therapeutic community, Outcome 1 Criminal activity.
Comparison 2 Mental health court, Outcome 1 Self report dichotomous criminal activity.
Comparison 3 Motivational interviewing and cognitive skills, Outcome 1 Self report drug use continuous.
Comparison 3 Motivational interviewing and cognitive skills, Outcome 2 Self report drug use dichotomous.
Comparison 4 Interpersonal psychotherapy, Outcome 1 Self report drug use dichotomous.
| Therapeutic community for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Therapeutic community | |||||
| Criminal activity ‐ Re‐arrests | 117/340 (34.4%) | 167/458 (36.5%) | 1st study: 1.65 [0.83, 3.28] 2nd study:0.96 [0.82, 1.13] | 798 | ⊕⊕⊕⊝ | ‐‐ |
| Criminal activity ‐ Re‐incarceration | 71/283 (25.1%) | 47/353 (13.3%) | 1st study:0.28 [0.13, 0.63] 2nd study:0.73 [0.45, 1.19] 3rd study:0.49 [0.27, 0.89] | 636 | ⊕⊕⊕⊝ | ‐‐ |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 Across the 2 studies, 13 of the 18 'Risk of bias' items in total were rated as unclear risk; 2 of the 18 were rated as high risk. | ||||||
| Mental health court for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Mental health court | |||||
| Self report dichotomous criminal activity | Study population | RR 1.05 | 208 | ⊕⊝⊝⊝ | ‐‐ | |
| 724 per 1000 | 761 per 1000 | |||||
| Moderate | ||||||
| 725 per 1000 | 761 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 4 of the 9 items were rated as high risk; 4 of the 9 items were rated as unclear risk. | ||||||
| Motivational interviewing and cognitive skills for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Motivational interviewing and cognitive skills | |||||
| Self report drug use continuous | ‐‐ | The mean self report drug use continuous in the intervention groups was | ‐‐ | 162 | ⊕⊕⊝⊝ | ‐‐ |
| Self report drug use dichotomous | Study population | RR 0.92 | 41 | ⊕⊝⊝⊝ | ‐‐ | |
| 364 per 1000 | 335 per 1000 | |||||
| Moderate | ||||||
| 364 per 1000 | 335 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 1 of 9 items judged as high risk; 7 of 9 items judged as unclear risk. | ||||||
| Interpersonal psychotherapy for drug‐using offenders with co‐occurring mental illness | ||||||
| Patient or population: drug‐using offenders with co‐occurring mental illness | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of Participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Interpersonal psychotherapy | |||||
| Self report drug use dichotomous | Study population | RR 0.67 | 38 | ⊕⊝⊝⊝ | ||
| 474 per 1000 | 317 per 1000 | |||||
| Moderate | ||||||
| 474 per 1000 | 318 per 1000 | |||||
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence | ||||||
| 1 2 of 9 items rated as high risk; 2 of 9 items rated as unclear risk. | ||||||
| Study, year | Criteria used for diagnoses | Description of mental health problem |
| Determined by a psychiatrist/psychologist on the basis of a clinical interview and observations | Mood disorder Schizophrenia Bipolar disorder Other Dual diagnosis | |
| Hamilton Rating Scale for Depression Median duration of index episode in months Number of depressive episodes Number of previous suicide attempts DSM‐IV Axis I disorders using the SCID‐I/II. | Criteria for a major depressive disorder at least 4 weeks after substance abuse treatment Minimum score of 18 on the Hamilton Rating Scale for Depression. | |
| DSM‐IV Mini International Neuropsychiatric Interview Anxiety Sensitivity Index | Anxiety Mental health disorders Antisocial personality disorder Major depressive disorder Generalised anxiety disorder | |
| DIS | Diagnoses of lifetime Axis I or Axis II mental disorder Antisocial personality disorder | |
| Global Severity Index Beck Depression Inventory Lifetime of mental health PTSD Symptom Scale ‐ Interview Posttraumatic Stress Diagnostic Scale | Depression PTSD Lifetime of mental health | |
| DSM‐IV diagnostic criteria Beck Depression Inventory Post Traumatic Stress Disorder Symptom Scale Brief Symptom Inventory Global Severity Index | Depression PTSD Psychological distress | |
| CES‐D Scale | Scores > 16 indicate presence of significant depression. 69.8% had significant depressive symptoms | |
| Not specified | Antisocial personality disorder Phobias PTSD Depression Dysthymia Attention deficit hyperactivity disorder | |
| CES‐D: Center for Epidemiological Studies ‐ Depression; DIS: Diagnostic Interview Schedule; DSM‐IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; PTSD: post‐traumatic stress disorder; SCID: Structured Clinical Interview for DSM Disorders. | ||
| Paper, year | Intervention | Comparison | Follow‐up | Outcome type | Measurement | Actual outcome |
| Sentencing and case management (mental health treatment court and assertive community treatment case management) | Treatment as usual | 6 and 12 months | Criminal activity dichotomous Self report drug use continuous | % and total mean and SD | % arrested and spent some time in jail % convicted of a new crime Mean Addiction Severity Index (drug) composite score | |
| Therapeutic community, counselling and aftercare | Treatment as usual and waiting‐list control | 12, 24, 36 months up to 5 years | Biological drug use dichotomous Criminal activity continuous Criminal activity dichotomous Self report drug use dichotomous | % and total mean and SD | % testing positive for illicit drugs at 12 months' follow‐up Mean months incarcerated in the year following release % any arrest % arrested for drug crime % arrested for property crime % arrested for violent crime % arrested for other crime % used drugs heavily in past year at 5 years Mean days until re‐incarceration % re‐incarcerated Mean days on parole to first return to custody % returned to prison within 3 years post‐ parole | |
| Modified therapeutic community (Personal Reflections therapeutic community and voluntary residential aftercare) | Intensive psychiatric services | 12 months | Criminal activity continuous Criminal activity dichotomous Self report drug use dichotomous | Mean and SD % and total | Mean number of days until incarceration Mean number of days until first crime % re‐incarceration % criminal activity % alcohol/drug offence % other (non‐alcohol/drug) offence % illegal drug use | |
| Therapeutic community (re‐entry modified) | Parole supervision case management | 12 months | Criminal activity dichotomous | % with total | % re‐incarcerated % self reported criminal activity | |
| Therapeutic community | Cognitive behavioural therapy | 6 and 12 months | Criminal activity dichotomous Criminal activity self report and official Self report drug use | % with total | Criminal activity, arrest, and drug‐ related activity (self‐reported) Criminal record data (% incarcerated, mean days to incarceration) % self‐reported illegal drug use | |
| Interpersonal psychotherapy | psycho‐educational | 3 months | biological drug use | % with total | Relapse within 3‐ month follow‐up period, defined as using drugs on at least 10% of non‐incarcerated days or any positive breath test/urine drug screen | |
| Cognitive behavioural therapy and acceptance and commitment therapy | control group | 3 months | Self report drug use dichotomous | % and total | Self report, corroborated by urinalysis | |
| Stein 2011 (high depression score) | Motivational interviewing | Relaxation training | 3 months | Self report drug use continuous | Mean and SD | Mean joints per day Mean % days used marijuana |
| SD: standard deviation | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Criminal activity Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
| 1.1 Re‐arrests | 2 | Risk Ratio (M‐H, Random, 95% CI) | 0.0 [0.0, 0.0] | |
| 1.2 Re‐incarceration | 3 | Risk Ratio (M‐H, Random, 95% CI) | 0.0 [0.0, 0.0] | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Self report dichotomous criminal activity Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Self report drug use continuous Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 2 Self report drug use dichotomous Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Self report drug use dichotomous Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Totals not selected | |
