Featured Article
Article Title
Effectiveness of Psychological Interventions for Incarcerated Individuals with Depression or Posttraumatic Stress Disorder: A Systematic Review
Authors
Barry Rosenfeld- Department of Psychology, Fordham University, Bronx, New York, USA
Perry Callahan- Department of Psychology, Fordham University, Bronx, New York, USA
Andrea Carboni-Jiménez- Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada
Danielle B. Rice- Department of Psychology, St. Joseph’s Healthcare, Hamilton, Ontario, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
Elsa-Lynn Nassar- Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada
Jill T. Boruff- Schulich Library of Science and Engineering, McGill University, Montreal, Quebec, Canada
Kexin Li- Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada
Brett D. Thombs- Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada; Department of Psychiatry, McGill University, Montreal, Quebec, Canada
Abstract
The effectiveness of psychotherapy for depression and posttraumatic stress disorder (PTSD) has been well-established in community samples but its effectiveness in carceral settings is less clear. The present systematic review thus sought to evaluate the effects of psychological therapies for PTSD and depression in incarcerated samples. We searched five databases from inception through January 2023, for eligible randomized controlled trials (RCTs). Two reviewers independently reviewed the study eligibility, extracted the data, assessed the intervention reporting, and evaluated the risk of bias. Eleven RCTs met inclusion criteria, five addressing treatment of PTSD, and six addressing treatment of depression. Interventions produced mixed findings with respect to symptom reduction relative to active controls, with a significant risk of methodological bias in virtually all studies. Of the interventions studied, interpersonal psychotherapy produced the most encouraging, though clearly still tentative results for the treatment of depression. Results highlight the need for increased methodological rigor and additional research to examine the effectiveness of interventions that have yielded positive results in community samples.
Keywords
Incarceration, psychotherapy, posttraumatic stress disorder, PTSD, depression, systematic review
Summary of Research
“Over 10 million individuals are incarcerated globally. Within this population, the estimated prevalence of mental disorders is substantially higher than in community samples. Psychological therapies are first-line treatments for many of the disorders experienced by incarcerated adults, such as PTSD and depression… The current systematic review sought to evaluate the effects of psychological therapies for PTSD and depression in incarcerated samples… Given the high prevalence of mental disorders in carceral settings, treatment that reduces symptom severity can have a dramatic impact on a range of problem behaviors beyond simply reducing overall distress. Moreover, there is a growing body of evidence suggesting that the symptoms associated with depression and PTSD may be important factors in institutional adjustment and post-release outcomes…
While not all traumatic experiences result in the development of PTSD, [researchers] found that PTSD was associated with reoffending, even when controlling for comorbid mental health conditions and criminal history… Depression also appears to influence rates of reincarceration, albeit indirectly, through its association with family conflict and financial problems… In sum, statistically and clinically significant associations have been identified between depression, PTSD, and exposure to potentially traumatic events with both recidivism and suicide” (p. 468- 469).
“Given the high prevalence of mental disorders in incarcerated populations, prisons are de facto settings for the provision of mental health treatment. However, there are numerous barriers to effective care in the prison environment. First, many environmental factors have been shown to aggravate mental health problems, including solitary confinement, overcrowding, recent suicides, and living far from family members. In addition, individuals with preexisting mental health problems face higher rates of sexual victimization while incarcerated, further exacerbating issues such as depression and PTSD. Both individual and environmental factors can also influence participation in treatment… [research] found that staff and client ratings of the institutional climate were associated with treatment readiness and that both were higher in forensic psychiatric hospitals compared to prisons” (p. 469).
“Another challenge in correctional settings is the risk of premature cessation of treatment. In a meta-analysis of treatment studies in correctional settings, [researchers] estimated an overall attrition rate of 27.1% and found that risk factors for treatment drop-out overlapped considerably with risk factors for recidivism, indicating that those who might benefit the most from treatment may be the least likely to complete it… In short, the extent to which mood disorders and PTSD can be effectively addressed in carceral settings remains unclear” (p. 470).
“Psychological interventions were defined as strategies that target emotions, cognitions, stress, or behaviors, including but not limited to cognitive-behavioral therapy (CBT), exposure therapy, narrative therapies, and mindfulness… Eligible comparators included either an inactive control group (e.g., no treatment, waitlist) or an alternative treatment approach (i.e., an active comparison group such as supportive psychotherapy or substance abuse treatment without any intervention specific to PTSD or depression” (p. 471).
“The effectiveness of psychotherapy for the treatment of PTSD and depression in community-based settings is well established, but surprisingly little research has addressed these interventions in samples of incarcerated individuals… Both the treatment group and the control group, who engaged in mindfulness and general psychological services (but not gender-responsive or trauma-focused care), experienced reductions in PTSD and depression symptoms, with significantly greater improvement in most analyses for those participating in the Seeking Safety intervention” (p. 477).
“These studies typically demonstrated some improvement in symptoms but without evidence of stronger improvement in treatment versus control groups, however, two of these studies utilized ‘active’ comparison treatments. Hence, these results suggest that the type of intervention used to treat PTSD symptoms in a correctional setting may be less important than providing some form of mental health treatment” (p. 478).
“In short, while the evidence base for the treatment of depression is still limited, the available research provides tentative support for the use of psychotherapies, particularly IPT, for depression in incarcerated individuals” (p. 479).
“...Addressing the deleterious mental health consequences and obstacles to treatment posed by prison conditions is necessary in order to adequately treat this population” (p. 480).
Translating Research into Practice
“Given the abundance of effective therapies for depression, future research should address other potentially useful psychotherapy approaches in correctional settings, such as behavioral activation… Likewise, scheduling conflicts, privacy concerns and attrition might be reduced with greater reliance individual treatment. Greater availability of these interventions in carceral settings may also help de-stigmatize receipt of mental health services more generally” (p. 479).
“...Mental health providers should consider evidence from research conducted in non-prison settings in treatment planning. Similarly, future research should evaluate the treatment modalities that have proven effective outside of prison, in addition to addressing the methodological concerns outlined here” (p. 480).
Other Interesting Tidbits for Researchers and Clinicians
“In the study examining the effects of affect regulation on PTSD symptoms, the authors noted that participants reported difficulty applying skills due to the limited privacy and chaotic surroundings within the prison environment… only half of the participants originally assigned to the intervention condition were able to attend 15 or more of the 18 sessions due facility transfers, releases, and scheduling conflicts as well as drop-outs… ‘booster’ sessions after participants were released from prison [were] poorly attended despite consistently positive feedback, with participants citing chaotic home lives as a significant barrier. Although anecdotal, these challenges are reflected in previous research on the obstacles to successful therapy…
Equally striking is that virtually all of the studies relied on group-based interventions, with only two studies, both of which utilized IPT for treatment of depression, including a handful of individual ‘booster’ sessions. Given that IPT is typically delivered in an individual format in community settings—as are most psychotherapeutic interventions, treatment effects might be considerably stronger if delivered individually” (p. 479).
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