Randomised Controlled Trial of a psycho-education programme for patients with psychosis in forensic settings

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Randomised Controlled Trial of a psycho-education
programme for patients with psychosis in forensic
settings

• Helen Walker
• Consultant Nurse Forensic Network
• Helen.walker6_at_nhs.net

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• Introduction to psycho-education
• Describe research project
• Present a summary of key findings for Part 1 and
  Part 2
• Draw conclusions and make recommendations

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Supported by

• Research Assistant
• The State Hospital-Lindsay Tulloch
• Principal Investigators
• The State Hospital Alan Steele
• Orchard Clinic Mark Ramm
• Rowanbank Clinic Leverndale Hospital
• Dr Emma Drysdale
• Clinical Advisor
• The State Hospital - Dr Gary MacPherson
• Funded by The State Hospital
• Supervised by Professor Colin Martin at The
  University of the West of Scotland

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Why psycho-education?

• Psycho-education for psychosis has been
  developed to explain illness and treatment to
  people with psychosis, in order to enable them to
  cope more effectively with their illness Favrod
  et al (2011).

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• Up to 1980s
• Relapse and re-hospitalisation (Neuman and
  Fuenning 1977)
• Compliance with medication (Roccella 1976)
• Knowledge gain (Gillum, 1974, Goldman and Quinn
  1988)

• Post 1990s
• Relapse and re-hospitalisation (Auguglia 2007,
  Lincoln 2007, Rummel-Kluge 2008, Xia et al 2011)
• Compliance with medication (Cunningham Owens
  2001)
• Symptomatology (Pekkala 2002)
• Insight (Merinder 1999)
• Knowledge gain (Jones 2001, Jennings 2002, Sibitz
  2007)
• Quality of life (Cross 2002, Bauml 2007)
• Social functioning (Atkinson Coia 1996)
• Patient satisfaction (Merinder 1999, Aho-Mustonen
  2011)

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Coping With Mental Illness

• 11 week group programme
• Foundation understanding mental illness and
  personality disorder, Stigma and myths, Looking
  at symptoms of psychosis, what caused my
  illness
• The Legal System risk assessment and risk
  planning, legal issues around admission and
  discharge
• Coping skills and recovery relapse and early
  warning signs, problem solving

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The study two parts

• Aim Evaluate the effectiveness of a
  psycho-education programme (Coping With Mental
  Illness) in a population of mentally disordered
  offenders with psychosis and capture therapeutic
  change
• Part 1 Multi-site Randomised Controlled Trial
  (cluster trial) The State Hospital (high),
  Orchard Clinic (med), Rowanbank (med) and
  Leverndale (low)
• Part 2 Structured interview using Repertory Grid
  technique across two sites (TSH and OC)
• The RCT will establish what might change for the
  individuals concerned and the interviews will
  explore why this has occurred.

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Process Part 1 - RCT

• Participants referred by multi-disciplinary team
• When adequate numbers were available, patients
  randomly allocated to either treatment or control
  (waiting list) group by Principle Investigator
  (PI) at each site
• Sealed envelope was issued to each (PI) at the
  outset with computer generated numbers for
  allocation-this was undertaken by UWS
• Chief Investigator and Research Assistant were
  blind to allocation
• Assessments undertaken at three stages, pre
  intervention, post intervention and six month
  follow up, over 3 ½ year period

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Assessment tools

• Clinician rated
• Schedule for the Assessment of Insight
  SAI(David 1990)
• Positive and Negative Syndrome Scale PANSS(Kay
  1987)
• Calgary Depression Scale for Schizophrenia CDSS
  (Addington 1993)
• Behavioural Status Index
• BEST-Index (Woods and Reed 2000)

• Self rated
• Forensic Assessment of Knowledge Tool (Walker
  2012)
• Assessment of Insight (Markova 2003)
• Rosenberg Self Esteem Inventory (Rosenberg1965)
• Locus of Control (Jomeen 2005)
• Liverpool University Neuroleptic Side Effect
  Rating Scale LUNSERS (Day 1995)
• Schizophrenia Quality of Life Scale-Revision 4
  SQLS-R4(Martin 2007)
• Hospital Anxiety and Depression Scale(Snaith
  1994)
• Patient satisfaction

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Data analysis

• Demographic details descriptive statistics
• Analysis of Variance (ANOVA) and Analysis of
  Covariance (ANCOVA) where appropriate
• IQ was the covariate -because there was a
  statistically significant difference in baseline
  scores between treatment and control groups
• Also significant difference between groups in age
  of illness onset and age of first conviction
• Non-parametric tests used where data was ordinal
  level or not normally distributed

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Registered as eligible participants (N 107 )
Received intervention (experimental group) as
allocated (n 46) Did not receive intervention
as allocated (n 0)
Received treatment as usual (TAU) as allocated (n
35) Did not receive treatment as usual as
allocated (n 0)
Completed trial (n 35)
Completed trial (n 30)

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Study sample
Hospital Site Male Female Total
The State Hospital 35 0 35
Rowanbank Clinic 8 1 9
The Orchard Clinic 24 1 25
Leverndale Hospital 12 0 12
79 2 81
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Study sample characteristics

• Age range 19-57, mean 37 years (sd 9.39).
• Ethnic origin (n75) were of White British or
  Irish origin, (n2) Black/Black African, (n1)
  Asian Bangladeshi,(n1)Chinese and (n2) of other
  mixed background.
• 44 of the sample originated from the West of
  Scotland.
• Marital status majority single (n60), only
  (n1) was married, (n20) were divorced,
  separated or widowed.
• Employment status prior to admission (n76) were
  unemployed. Only two participants were involved
  in professional trades, one was an apprentice and
  one was a student, (n15) had never been employed
  in their life.

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IQ scores using Wechsler Abbreviated Scale of
Intelligence
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Education

• Most educated in mainstream schools (n74), only
  one participant had no formal education, seven
  had behavioural problems and had special
  schooling

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Offending characteristics

• Index offence
• No offence (n30)
• Serious assault, murder, attempted murder,
  culpable homicide (n38)
• Sexual related offences
• (n3)
• Other (n10)

• History of drug (n64) and or alcohol misuse (n
  68)
• On most occasions it was not known whether this
  was linked to the index offence or not.
• Although over half of the participants had never
  entered high secure hospital prior to the current
  admission, (n32) had multiple re-admissions.

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Comparison of treatment versus control group
scores pre and post group (ANCOVA)
Assessment tools Treatment Mean Control Mean F Level of significance
FAKT pre 30 29    
FAKT post 36 29 9.45 p.003
SAI pre 10.9 10.6    
SAI post 12.2 10.7 2.34 p.13
PANSS ve pre 13.8 14.6    
PANSS ve post 12.4 14.3 1.92 p.17
PANSS ve pre 16.7 17.5    
PANSS ve post 15.2 17.9 1.22 P.17
BEST-Index empathy pre 100 100
BEST-Index empathy post 109 103 4.965 p .029
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Assessment tools Treatment Mean pre Treatment Mean post Treatment Mean 6 month Fup Level of significance
SQLS-R4 36 30 29 p.475
HADS Anxiety 7.5 6 5.9 p.989
HADS Depression 5.1 4.4 3.6 p.601
Rosenberg 18 19 20 p.835
BEST-Index (total score) 563 572 559 p.417
MHLC-C 63 64 62 p.526
LUNSERS 28 23 24 p.845
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Non parametric tests
Assessment tools Level of significance
CALGARY Kruskal-Wallis Test 1.121 p.290
Insight Scale Chi-square (? 2) 24.78 p.16

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    Paired Differences pre and post intervention Paired Differences pre and post intervention Paired Differences pre and post intervention Paired Differences pre and post intervention Paired Differences pre and post intervention t df Sig. (2-tailed)
    Mean Std. Deviation Std. Error Mean 95 Confidence Interval of the Difference 95 Confidence Interval of the Difference t df Sig. (2-tailed)
    Mean Std. Deviation Std. Error Mean Lower Upper t df Sig. (2-tailed)
SAI -1.254 3.555 .463 -2.181 -.328 -2.710 58 .009
FAKT -5.316 7.527 .997 -7.313 -3.319 -5.332 56 .000
Rosenberg -.579 4.656 .617 -1.814 .656 -.939 56 .352
PANSS positive .847 3.398 .442 -.038 1.733 1.916 58 .060
PANSS negative 1.288 4.764 .620 .047 2.530 2.077 58 .042
HADS anxiety .614 4.754 .630 -.647 1.875 .975 56 .334
HADS depression .404 3.122 .413 -.425 1.232 .976 56 .333
MHLC-C -.965 10.712 1.419 -3.807 1.877 -.680 56 .499
BEST-Index (total) -7.052 20.735 2.723 -12.504 -1.600 -2.590 57 .012
SQLS-R4 3.947 14.785 1.958 .024 7.870 2.016 56 .049
LUNSERS 2.772 16.893 2.237 -1.710 7.254 1.239 56 .221
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Part 2

• George Kelly (1905-1967)
• American Psychologist,
• developed a theory of
• personality
• Personal Construct
• Psychology (PCP)

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Why use Personal Construct Psychology (PCP) part
2

• Capture patient perspective.
• PSI is based within the person-centred tradition.
  
• Person-centred theory starts from a process
  theory of authenticity, not from a theory of
  disorders (Schmid, 2006).
• All participants bring with them their own ideas,
  experiences and opinions.
• Patients should be acknowledged as experts in
  their own experiences recent advances in
  understanding mental illness and psychotic
  experiences (The British Psychological Society,
  2000).
• Kingdon Turkington (2005) report,
  Individualising psycho-education helps people
  feel listened to and understood, and this
  approach adds to its effectiveness.

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Using personal construct theory/psychology

• In essence, PCT is a theory about how people
  make sense of the world around them.
• Personal construct psychology (PCP) describes the
  way in which this theory applies to an
  individual, based on the following underlying
  principles
• The explanation for any individuals behaviour
  lies within that individual.
• People are active in the world and not passive
  recipients of events going on around them.
• Change is always possible no one is the victim
  of their own history.
• The four key concepts which are important in
  understanding PCP are the process of construing,
  people as active scientists, constructive
  alternativism and PCP as a universal theory.

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The process of construing

• Construing refers to how people interpret events,
  and constructs are personal discriminations that
  individuals make between people, events or
  situations (Houston 1998).
• Construing is not the same as thinking because it
  involves the notion of contrast, and of making an
  active interpretation or discrimination.
• Example if a person described herself and her
  mother reliable, in direct contrast to her
  brother, then the discrimination reliable versus
  not reliable, is a construct which the person
  uses. This construct contributes to their view of
  the world, i.e. it is part of their construct
  system.

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Use of PCP with mentally disordered offenders

• A number of studies have been undertaken with
  a different focus
• mental illness and offending (Norris 1977, Goold
  1998)
• alcohol, drugs and offending (Blackburn 1993),
• sex offenders (Marshall and Barbaree 1990b),
• young offenders and delinquency (Stanley 1983,
  Viney 2002),
• violence and aggression (McCoy 1981, Blackburn
  1993)
• personality disordered offenders (Blackburn 1990,
  Dolan 1995).

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Sample repertory grid
1 How I was 10 years ago How I am now How my Dr sees me How I would like to be (ideal self) How I expect to be (expected self) 7
Have hope to move on           Have no sense of hope to move on
Have confidence to engage in groups           Negative feelings about groups
Understand my own illness and how it affects me           Have no understanding of what illness is all about
Dont realise others have the same problems           Realise that others have the same problems
Realise I am a valuable person in society           Think I am worthless
Have little or no control over how I think and feel Have control of my illness
Feel normal Dont feel normal
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Data analysis

• Grid Suite (Fromm 2011)
• Cluster Analysis using dendograms
• Principal Component Analysis

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Elements are indicated by red dots and positive /
negative constructs by green dots.
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Case study Dave

• Dave was born in the West of Scotland, dual
  diagnosis of paranoid psychosis and anti-social
  personality disorder and has been a patient in a
  high secure hospital for 2 years, following the
  attempted murder of his uncle. Aged 31, Dave is
  white, single and was unemployed prior to his
  admission, his IQ is in the low average category
  (80-89) and he has a history of both drug and
  alcohol misuse since his early teens. During the
  initial interview, undertaken prior to attendance
  at the group, Dave was particularly anxious about
  a pending court appearance and was very unsure as
  to whether his head was in the right place for
  doing the group. By his own admission he was
  feeling low and was worried about the potential
  success of his appeal to a lower level of
  security. He thought the group might be no more
  than a useful distraction at this point in time
  but did state he was keen to learn more about
  psychosis and how it affects you.

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Case study

• Before the programme, I felt that people I
  didnt like and those I admired saw me and my
  future negatively. I felt that I wanted to be and
  expected to be how I was ten years ago, even
  though at that time I had little control over my
  illness. I felt that a person I didnt like saw
  me before the programme as not being able to do
  stuff without being annoyed and having little
  control over my illness.

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Daves pre group psychometric scores

• SAI score (16) higher than the group as a whole
  (mean 10, standard deviation (sd) 5.2, n18).
• FAKT was poor (13) lower than the rest of the
  group (mean29, sd9.3, n18).
• Self esteem (14), lower than group average
  (mean19, sd5.8, n18) would fall into the
  category of low self esteem.
• Locus of Control (MHQL) low (40), by comparison
  to a group average of (mean61, sd12.6, n18).
• HADS (10) depression scale (mean5, sd4.2, n18)
  and 14 on HADS anxiety (mean7, sd5.2, n18)
• CDSS (8 )(mean2, sd4.S, n18) - higher than
  group average.
• PANSS ve symptom (13) (mean14, sd5.1, n18)
• PANSS -ve symptom score (25) (mean17.5, sd7.1,
  n18) and general 32 (mean29, sd8.6, n18).

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Case study post group

• Having confidence to engage with the group
  helped me to feel hopeful to move on. I felt more
  normal and that I could be a valuable person in
  society.
• There is evidence to suggest that Dave has
  accepted his past self maybe wasnt as idealistic
  as he initially thought and that there are areas
  of life that will need to change, if a
  successful future is what is wanted. A clear
  example of this is his drug use. Dave was
  getting by through regular use of hash,
  amongst other things and a few members of his
  family actively encouraged this, indeed it seemed
  to be the norm for both family and many of his
  closest friends. He was able to identify the
  links between the effect of drugs on his
  anti-social behaviour and the deterioration in
  his mental state, causing an increase in paranoid
  ideation.

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Daves post group psychometric scores

• Insight improved to (17) post intervention, again
  higher than the group (mean 11, (sd) 5.1,
  n18).
• Knowledge of illness much improved at (32) and on
  a par with others (mean32, sd9.5, n18).
• Self esteem improved slightly (15) - still lower
  than the group average (mean19, sd5.8, n18)-
  but on the threshold of low self esteem.
• Locus of Control increased to (48), group average
  of (mean62, sd11.3, n18).
• Dave improved on both HADS sub-scales, (9) on the
  HADS depression scale (mean4.8, sd4.7, n18)
  and (12) on the HADS anxiety (mean6.5, sd5.7,
  n18), both within normal range.
• CDSS score lowered to (5) (mean1.9, sd4, n18),
  still higher than the group average.
• PANSS ve symptom score improved lowering to (12)
  (mean13.4, sd5.3, n18), -ve symptom score was
  also slightly better (23) (mean16.4, sd6.7,
  n18) and general remained the same (32)
  (mean29, sd8.5, n18).

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Summary

• Advantages
• Improved knowledge
• Trend indicating improved insight, mental health,
  social behaviour and quality of life
• Patients like it
• Established programme protocol driven
• Meets low secure care standard
• Meets low intensity intervention criteria for
  Scottish Government HEAT target

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Limitations

• Difficulties associated with randomisation had
  impact on results
• Sample size too small to allow many of the
  psychometrics to reach significance, reducing
  generalisability beyond forensic context

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Recommendation for clinical practice

• Suggest this programme which has demonstrable
  benefits to the target population is utilised
  in clinical practice, across the forensic
  network, in its current or a (recognisable)
  modified form.