A test of core psychopathic traits as a moderator of the efficacy of a brief motivational intervention for substance-using offenders

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Depressive Symptoms Moderate the Association Between the Recent History of Alcohol Use Severity and Suicide Attempt History Among Adults in a Pretrial Jail Diversion Program

Background: Justice-involved individuals are at elevated risk for suicidal behavior; however, research examining risk for suicidal behavior in pretrial jail diversion programs (pretrial diversion) is limited. Aims: We aimed to test (1) associations between depressive symptoms and alcohol and drug use, and suicide attempt history (SAH), and (2) interactions between depressive symptoms and alcohol and drug use in relation to SAH among adults in an urban pretrial jail diversion program. Method: The design was cross-sectional, including self-report assessments and file reviews of historical information. Adults (N = 274; Mage = 33.72; 73.7% men; 52.6% non-Hispanic Black) completed assessments within two weeks of beginning the pretrial program. Results: Depressive symptoms were positively associated with SAH after adjusting for other covariates. The significant depressive symptoms by alcohol use interaction indicated that adults with low to average depressive symptoms evidenced a similar likelihood of SAH to those with high depressive symptoms when they also had elevated alcohol use scores. Limitations: We used cross-sectional self-report data. Conclusion: It may be important to conduct suicide risk assessments for justice-involved people who use alcohol even when depressive symptoms are low.

Substance use, current criminal justice involvement, and lifetime suicidal thoughts and behaviors history: The moderating role of thwarted belonging

OBJECTIVE

Criminal justice involvement, substance use, and suicide pose significant public health concerns; however, the unique and synergistic effects of these experiences among high-risk individuals remain understudied. We hypothesized positive main effects for alcohol-related severity, drug-related severity, current criminal justice involvement, and thwarted belonging (TB) on suicide ideation history (SIH) and suicide attempt history (SAH) and that TB would moderate these associations.

METHOD

We report on cross-sectional analyses of self-report assessments completed by 824 adult residential substance use patients.

RESULTS

Multinomial logistic regression analyses indicated that as alcohol- and drug-related severity increases, the probability of SIH and SAH increases; however, TB was only associated with a higher SIH probability. Significant two-way interactions (current criminal justice involvement*TB; alcohol-related severity*TB) indicated that (1) those high in TB with current criminal justice involvement were more likely to report a SIH than those without current criminal justice involvement; and (2) those low in TB and alcohol-related severity had the lowest SAH probability, whereas those low in TB and high in alcohol-related severity had the highest SAH probability.

CONCLUSION

The unique and combined effects of interpersonal and contextual risk factors may improve suicide risk conceptualization and assessment, and allow for tailored treatments for this high-risk population.

BRIEF MOTIVATIONAL INTERVENTION FOR SUBSTANCE USE MAY DECREASE VIOLENCE AMONG HEAVY ALCOHOL USERS IN A JAIL DIVERSION PROGRAM

Rates of harmful alcohol use are high among justice-involved individuals and may contribute to violent recidivism. Robust treatments for alcohol-related violence in criminal justice systems are thus a public health priority. In this analysis of existing randomized controlled trial data (N = 105), we examined the impact of a brief motivational intervention (BMI) for harmful substance use on violent recidivism among individuals in a pretrial jail diversion program. Results indicated that, after controlling for violence history, the intervention's impact on violent recidivism was moderated by baseline harmful alcohol use. Specifically, among people with severe alcohol problems at baseline, the BMI + standard care group had less violent recidivism at a 1-year follow-up than participants randomized to standard care alone. This finding was unchanged when we accounted for psychopathic traits. Our study provides preliminary evidence that a BMI may be useful for decreasing violent recidivism among heavy drinkers in criminal justice systems.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

How Effective are Psychosocial Group Workings in Improving Treatment Compliance and Self-Efficacy? An Experimental Study with Substance Users

INTRODUCTION

Group work is one of the most effective treatment methods in rehabilitation of substance use behavior. In addition, the individual's motivation to quit substance and self-efficacy perceptions of quitting are important factors for the course of the treatment. Therefore, the aim of this study was to investigate the effect of group work process on motivational processes (intrinsic and extrinsic motivation, interpersonal help seeking and confidence-in-treatment subscales) and self-efficacy perception of substance users.

METHOD

This is an experimental study with 43 substance users. The Treatment Motivation Questionnaire subscales were used to measure the effect of the group work on the dimensions of treatment motivation (intrinsic motivation, extrinsic motivation, confidence-in-treatment, interpersonal help seeking), and the General Self-Efficacy Scale was used to measure the effect of group work on the self-efficacy perceptions.

RESULTS

The group work resulted in a significant increase in participants' intrinsic motivation and confidence-in-treatment. However, group work did not result in any significant change in extrinsic motivation, interpersonal help seeking and the perception of self-efficacy. In the follow-up process, a significant decrease was observed in the participants' self-efficacy perceptions.

CONCLUSIONS

Group work with substance users increases the intrinsic motivation and confidence-in-treatment. Therefore, group work practices will increase the effectiveness of substance use treatment.

Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies

BACKGROUND

Many people who need specialty treatment for substance use disorders (SUDs) do not receive it. Clinical interventions could increase treatment utilization but are not routinely used. This systematic review aimed to describe clinical interventions that may increase SUD specialty treatment utilization (i.e., treatment initiation, attendance, meaningful engagement) and to determine which intervention(s) most consistently increase treatment utilization.

METHODS

We conducted a systematic review of clinical intervention studies (published in English between 2000 and 2017) reporting outcomes relevant to specialty SUD treatment utilization. Outcomes were treatment initiation, attendance, and meaningful engagement. Risk of bias was assessed using Cochrane guidelines and randomized controlled trials (RCTs) with bias scores < 3 were included in a synthesis of results. Proportions of positive to negative utilization outcomes were calculated for each low-bias RCT; studies with 50% positive outcomes or more were considered "majority-positive". Studies were categorized by theory-based approach.

RESULTS

Twenty-three RCTs had low risk of bias and were synthesized. Among intervention types with two or more studies, cognitive-behavioral (100% majority-positive) and coordinated care (67% majority-positive) interventions were most likely to increase treatment initiation, while 12-step promotion interventions were most likely to increase treatment attendance (50% majority-positive). One study (12-step promotion) measured meaningful engagement, with majority-positive outcomes.

CONCLUSIONS

A systematic review and narrative synthesis of clinical interventions promoting specialty SUD treatment utilization provided preliminary evidence that cognitive-behavioral and coordinated care interventions may increase treatment initiation, while 12-step promotion interventions may promote treatment attendance. More quality studies and greater consistency in treatment utilization measurement are needed.

Validation of the Levenson Self-Report Psychopathy Scale in Bulgarian Substance-Dependent Individuals

The co-occurrence of psychopathy and substance use disorders (SUDs) is associated with higher relapse rates and increased risk of violent offending. Studies on the validity of psychopathy measures in community samples and substance-dependent individuals (SDIs) are scarce. The aim of the current study was to examine the psychometric properties of the Levenson Self-Report Psychopathy Scale (LSRP) in a sample of Bulgarian SDIs and non-dependent controls. We tested 615 participants: 106 heroin users, 91 amphetamine users, 123 polysubstance users, and 295 controls. Confirmatory factor analyses replicated the tri-factor structure of the LSRP (egocentric, antisocial, callous). The scale demonstrated acceptable reliability and validity. SDIs scored significantly higher than controls on the total scale and subscales of the LSRP, indicating good discriminant validity. Overall, results indicate that the LSRP is a valid instrument for measuring psychopathy in Bulgarian community samples.

Lifetime History of Suicide Attempts among Not Guilty by Reason of Insanity State Hospital Inpatients: The Roles of past Harmful Substance Use and Current Social Support

This study tested current perceived social support (CPSS) as a moderator of the relation between previous substance use (PSU) and lifetime suicide attempt (SA) history among 200 NGRI inpatients. Results indicated no significant CPSS main effect. PSU was associated with greater odds of multiple prior lifetime SA. Moderation indicated those low in PSU but high in CPSS were least likely to report multiple prior lifetime SA. Conversely, NGRI inpatients with high CPSS and high PSU were most likely to report multiple lifetime SA. Our study suggests CPSS and PSU assessments may inform suicide risk assessments and interventions among NGRI inpatients.

A Procedure for Changing a Behavioral Health Treatment During a Trial, with Case Example in Suicide Prevention

During a trial, standardization can lock in a treatment that researchers learn is flawed and may be ineffective. In such cases, researchers typically decide between two options, continue the trial and monitor for iatrogenic effects or stop the trial. When faced with this dilemma while testing an adaptation of motivational interviewing to address suicidal ideation, our research team considered a third option, to correct the flaws in the intervention and study the effect on outcome. We explored the rationale for and against changing an intervention mid-trial and progressed through a series of steps to determine whether we should change the intervention, ultimately deciding to make changes and examine their impact. We developed a procedure that researchers can use to determine whether they should change an intervention during a trial, how to implement the changes, and how to redesign their study. When faced with evidence that a treatment is ineffective, researchers should consider changing the intervention and examining the effects of the changes on outcome. Such decisions may be particularly relevant in trials examining life-threatening outcomes. Making and studying these changes may increase the potential for the study to identify a treatment that produces a desired outcome.

Drug Abuse and Behavioral Transgressions during Methadone Maintenance Treatment (MMT) are Related to High Psychopathy Levels

Introduction: Studies which used the Psychopathy Checklist-Revised (PCL-R) among methadone maintenance treatment (MMT) patients focused mostly on methodological issues, without addressing its relationship to patients' misconduct during treatment. This paper tests the hypothesis that high PCL-R scores are related to high rates of drug abuse, and high numbers of behavioral transgressions in MMT during a 7-year period. Material and Methods: 107 MMT patients were recruited from a MMT clinic in Israel, and were administered the PCL-R. The questionnaires results as well as routine drug test findings were recorded between 7/2007 and 11/2007. Seven years later (7/2014), repeated drug test results were analyzed, and the number of behavioral transgressions during the entire period was computed. Results: High levels of psychopathy were related to drug test results indicating any illicit drug use, cocaine use and benzodiazepines misuse at the beginning of study, and limited to benzodiazepines misuse among patients who stayed in treatment at the 7-year follow-up. However, higher scores on different PCL-R facets were significantly associated with different types of drugs. The PCL-R's total score and all but the antisociality facet were positively correlated with a higher number of behavioral transgressions (such as, threats and/or verbal and physical aggression). Conclusions: Administration of the PCL-R during MMT may help identify patients with high illicit drug use levels and a higher chance of committing behavioral transgressions during treatment.

Interventions for female drug-using offenders

BACKGROUND

This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders.

OBJECTIVES

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both.

SEARCH METHODS

We searched 12 electronic bibliographic databases up to February 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'. In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence). One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported. One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence). One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence. One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence. One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence. One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence). One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence. One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence. One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence. One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported.

AUTHORS' CONCLUSIONS

The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.

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

BACKGROUND

This review represents one from a family of three reviews focusing on interventions for drug-using offenders. Many people under the care of the criminal justice system have co-occurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems in reducing criminal activity or drug use, or both.This review addresses the following questions.• Does any treatment for drug-using offenders with co-occurring mental health problems reduce drug use?• Does any treatment for drug-using offenders with co-occurring mental health problems reduce criminal activity?• Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)?• Does the type of treatment affect treatment outcome(s)?

SEARCH METHODS

We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drug-using offenders with co-occurring mental health problems.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane .

MAIN RESULTS

We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias.Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderate-certainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitive-behavioural therapy (one study; 314 participants), reporting no significant reduction in self-reported drug use (RR 0.78, 95% CI 0.46 to 1.32), re-arrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drug-related crime (RR 0.87, 95% CI 0.56 to 1.36), yielding low-certainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderate-certainty evidence.One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' follow-up on an Addictive Severity Index (ASI) self-report of drug use (mean difference (MD) 0.00, 95% CI -0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or re-incarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing low-certainty evidence.Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at three-month follow-up assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderate-certainty evidence. In comparison to a waiting list control, one study reported no significant reduction in self-reported drug use based on the ASI (MD -0.04, 95% CI -0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting low-certainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD -1.05, 95% CI -2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI -0.12 to 1.86), along with a small reduction in frequency of re-arrest (MD -0.66, 95% CI -1.31 to -0.01) up to 36 months, yielding low-certainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD -0.7, 95% CI -3.5 to 2.1), providing very low-certainty evidence.Two studies reported on the use of multi-systemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD -0.22, 95% CI -2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing low-certainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in re-arrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on low-certainty evidence.One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in self-reported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very low-certainty evidence. The final study (29 participants) compared legal defence service and wrap-around social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very low-certainty evidence.

AUTHORS' CONCLUSIONS

Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multi-systemic therapy, legal defence wrap-around services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes.

Determinants of Dropout From Correctional Offender Treatment

Research indicates that approximately one third of offenders admitted to social-therapeutic correctional facilities in Germany fail to complete treatment and that treatment dropout is linked to higher recidivism in both sexual and violent offenders. The purpose of this study was to examine determinants of treatment dropout in a social-therapeutic correctional facility in Germany. The sample consisted of 205 incarcerated adult male offenders (49.8% sexual, 38.1% non-sexual violent) admitted to correctional treatment. Completers and dropouts were compared on variables pertaining to demographics, offense type, substance abuse, psychopathy, risk, and protective factors. Univariate analyses showed that treatment dropouts demonstrated significantly higher scores on measures of risk and psychopathy and lower scores on protective factors. Logistic regression analyses identified unemployment, non-sexual violent index offense, higher risk scores (HCR-20), and Facet 1 (interpersonal deficits) of the Psychopathy Checklist-Revised (PCL-R) as significant predictors of treatment dropout. Surprisingly, substance abuse disorder was a negative predictor of dropout. With the exception of substance abuse, the results support the notion that treatment dropouts represent a group of high-risk offenders with particular treatment needs. Practical implications and suggestions for further research are discussed.

A Latent Profile Analysis of Violent Offenders Based on PCL-R Factor Scores: Criminogenic Needs and Recidivism Risk

Clinicians and theorists have often proposed the two psychopathic subtypes of "primary" and "secondary" psychopathy, with recent research indicating some empirical support for both psychopathy subtypes, though the findings across studies are far from uniform. For the current study, latent profile analysis was used to investigate if homogeneous latent classes exist within a sample of 215 adult male violent offenders from Berlin, Germany. The age of the offenders at the time of the index offense ranged from 19 to 59 years. The results indicated a solution with four latent classes, which we refer to as prototypical psychopaths (LC1), callous-conning offenders (LC2), sociopathic or dyssocial offenders (LC3), and general offenders (LC4). Validation of the four subtypes involved examination of differences on recidivism risk; criminogenic needs; and general, violent, and sexual reoffending. The results also are discussed in terms of the issue of treatment amenability.

Explicating the role of empathic processes in substance use disorders: A conceptual framework and research agenda

ISSUES

Elucidating the role of empathic processes in developmental pathways to substance use disorders could have important implications for prevention.

APPROACH

We searched the biomedical and social sciences literature to determine what is known about empathy and psychopathological manifestations of severe lack of empathy in the initiation, development and maintenance of psychoactive substance use. Thirty-seven empirical studies were identified and formally reviewed.

KEY FINDINGS

Adults with alcohol and stimulant use disorders exhibited detectable impairments in both cognitive and affective empathy, measured behaviourally, neuroanatomically and by self-report, relative to controls. There were no developmental studies specifically designed to test the role of empathy in substance use pathways, but several studies that included measures of empathy suggest that empathy may be protective. Studies on severe empathic deficits were mixed regarding a unique role of empathy in substance use trajectories, independent of interpersonal style, impulsivity and social deviance. Implications and Conclusions. In the context of findings and methodological limitations of this review, we recommend more rigorous examination of empathy across the spectrum of substance use behaviour. Future work should utilise the following: (i) prospective assessment of empathic capacity in substance abusers during and following treatment; (ii) large, developmentally based prospective designs beginning prior to substance initiation incorporating multiple measures of empathy; (iii) assessment of the moderating role of gender, race and ethnicity; and (iv) prospective study of empathy in children at elevated risk for substance use disorders. [Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders: A conceptual framework and research agenda.