Department of Psychology, Swansea University, Swansea, UK.
Health Technol Assess. 2013 May;17(21):1-173, v-vi. doi: 10.3310/hta17210.
Anger is a frequent problem for many people with intellectual disabilities, and is often expressed as verbal and/or physical aggression. Cognitive-behaviour therapy (CBT) is the treatment of choice for common mental health problems, but CBT has only recently been adapted for people with intellectual disabilities. Anger is the main psychological presentation in which controlled trials have been used to evaluate CBT interventions for people with intellectual disabilities but these do not include rigorous randomised studies.
To evaluate (1) the impact of a staff-delivered manualised CBT anger management intervention on (a) reported anger among people with mild to moderate intellectual disabilities, and (b) anger coping skills, aggression, mental health, quality of life and costs of health and social care; (2) factors that influence outcome; and (3) the experience of service users, lay therapists and service managers.
A cluster randomised controlled trial based on 30 day centres (15 intervention and 15 control). Intention-to-treat comparisons of outcomes used a two-level linear regression model to allow for clustering within centres with baseline outcome levels as a covariate. Comparison of cost data used non-parametric bootstrapping. Qualitative analysis used interpretative phenomenological analysis and thematic analysis.
Recruited day centres had four-plus service users with problem anger who were prepared to participate, two-plus staff willing to be lay therapists, a supportive manager and facilities for group work, and no current anger interventions.
A total of 212 service users with problem anger were recruited. Thirty-three were deemed ineligible (30 could not complete assessments and three withdrew before randomisation). Retention at follow-up was 81%, with 17 withdrawals in each arm. Two to four staff per centre were recruited as lay therapists. Eleven service users, nine lay therapists and eight managers were interviewed.
The manualised intervention comprised 12 weekly 2-hour group sessions supplemented by 'homework'. Lay therapists received training and ongoing supervision from a clinical psychologist. Treatment fidelity, group attendance and resources used in intervention delivery were monitored.
The primary outcome was the service user-rated Provocation Index (PI), a measure of response to hypothetical situations that may provoke anger. Secondary trial outcomes were the key worker-rated PI; the service user- and key worker-rated Profile of Anger Coping Skills (PACS); the service user-rated PACS imaginal provocation test (PACS-IPT), a measure of response to actual situations known to provoke anger; aggression; mental health; self-esteem; quality of life; and health and social care resource use. Assessments were administered before randomisation and at 16 weeks and 10 months after randomisation.
Fourteen treatment groups were delivered, each with 12 sessions lasting an average of 114 minutes, with a mean of 4.9 service users and 2.0 lay therapists. The mean hourly cost per service user was £ 25.26. The mean hourly excess cost over treatment as usual was £ 12.34. There was no effect of intervention on the primary outcome - self-rated PI. There was a significant impact on the following secondary outcomes at the 10-month follow-up: key worker-rated PI, self-rated PACS-IPT and self- and key worker-rated PACS. Key workers and home carers reported significantly lower aggression at 16 weeks, but not at 10 months. There was no impact on mental health, self-esteem, quality of life or total cost of health and social care. Service users, key workers and service managers were uniformly positive.
The intervention was effective at changing anger coping skills and staff-rated anger. Impact on self-rated anger was equivocal. With hindsight there are reasons, from an analysis of factors influencing outcomes, to think that self-rated PI was not a well-chosen primary outcome. Widespread implementation of manualised lay therapist-led but psychologist-supervised anger management CBT for people with mild to moderate intellectual disabilities is recommended.
愤怒是许多智障人士经常遇到的问题，通常表现为言语和/或身体攻击。认知行为疗法（CBT）是常见心理健康问题的首选治疗方法，但 CBT 最近才被改编为智障人士使用。愤怒是进行对照试验评估针对智障人士的 CBT 干预措施的主要心理表现，但这些试验不包括严格的随机研究。
评估（1）由工作人员提供的基于手册的 CBT 愤怒管理干预对（a）轻度至中度智力障碍人士的报告愤怒，以及（b）愤怒应对技能、攻击性、心理健康、生活质量以及健康和社会护理成本的影响；（2）影响结果的因素；（3）服务使用者、非专业治疗师和服务经理的体验。
一项基于 30 个日间中心的群组随机对照试验（15 个干预组和 15 个对照组）。使用两级线性回归模型对结局进行意向治疗比较，允许在中心内进行聚类，将基线结局水平作为协变量。使用非参数引导法比较成本数据。定性分析使用解释现象学分析和主题分析。
招募的日间中心有四个以上有问题的愤怒服务使用者，他们愿意参加，两个以上愿意担任非专业治疗师的工作人员，有一个支持性的经理和团体工作的设施，且没有当前的愤怒干预措施。
共有 212 名有问题愤怒的服务使用者被招募。有 33 人被认为不符合条件（30 人无法完成评估，3 人在随机分组前退出）。在 10 个月的随访中，保留率为 81%，每组各有 17 人退出。每个中心招募 2 至 4 名工作人员作为非专业治疗师。对 11 名服务使用者、9 名非专业治疗师和 8 名经理进行了访谈。
基于手册的干预包括 12 次每周 2 小时的团体会议，辅以“家庭作业”。非专业治疗师接受临床心理学家的培训和持续监督。治疗的一致性、团体出勤率和干预交付中使用的资源都得到了监测。
主要结局是服务使用者自评的挑衅指数（PI），这是对可能引发愤怒的假设情况的反应的衡量标准。次要试验结局是关键人员评定的 PI；服务使用者和关键人员评定的愤怒应对技能概况（PACS）；服务使用者评定的 PACS 想象性挑衅测试（PACS-IPT），这是对已知会引发愤怒的实际情况的反应的衡量标准；攻击性；心理健康；自尊；生活质量；以及健康和社会护理资源的使用。评估在随机分组前和随机分组后 16 周和 10 个月进行。
共进行了 14 个治疗组，每组 12 次，每次持续 114 分钟，平均有 4.9 名服务使用者和 2.0 名非专业治疗师。每名服务使用者每小时的平均成本为 25.26 英镑。与常规治疗相比，每小时额外的平均成本为 12.34 英镑。干预对主要结局——自我评定的 PI 没有影响。在 10 个月的随访中，以下次要结局有显著影响：关键人员评定的 PI、自我评定的 PACS-IPT 和自我和关键人员评定的 PACS。关键工作人员和家庭护理人员在 16 周时报告的攻击性明显较低，但在 10 个月时没有。干预对心理健康、自尊、生活质量或健康和社会护理总成本没有影响。服务使用者、关键工作人员和服务经理的态度一致积极。
干预措施在改变愤怒应对技能和工作人员评定的愤怒方面是有效的。对自我评定的愤怒的影响是不确定的。事后分析表明，从影响结果的因素分析来看，选择自我评定的 PI 作为主要结局并不合适。建议在轻度至中度智力障碍人士中广泛实施基于手册的非专业治疗师主导但由心理学家监督的愤怒管理 CBT。
