Psychosocial interventions for prevention of psychological disorders in law enforcement officers

  • Review
  • Intervention

Authors


Abstract

Background

Psychosocial interventions are widely used for the prevention of psychological disorders in law enforcement officers.

Objectives

To assess the effectiveness and comparative effectiveness of psychosocial interventions for the prevention of psychological disorders in law enforcement officers.

Search methods

CCDANCTR-References was searched on 12/5/2008, electronic databases were searched, reference lists of review articles and included studies were checked, a specialist journal was handsearched, specialist books were checked and we contacted experts and trialists.

Selection criteria

Randomised and quasi randomised controlled trials were eligible. The types of participants were people employed directly in law enforcement, including police officers and military police, regardless of gender, age and country of origin, and whether or not they had experienced some psychological trauma. All types of psychosocial intervention were eligible. The relevant outcome measures were psychological symptoms, adverse events and acceptability of interventions.

Data collection and analysis

Data was entered into Review Manager 4.2 for analysis, but this review was converted to RevMan 5.0 for publication. Quality assessments were performed. Two authors independently selected studies, extracted data and assessed the quality of studies. Summary effects were to be calculated using RevMan but no meta-analyses were possible. For individual studies, dichotomous outcome data are presented using relative risk, and continuous outcome data are presented using the weighted mean difference. These results are given with their 95% confidence intervals (CI).

Main results

Ten studies were included in the review but only five reported data that could be used. Three of the ten studies were related to exercise-based psychological interventions. Seven were related to psychological interventions. No meta-analyses were possible due to diversity of participants, interventions and outcomes. Two studies compared a psychosocial intervention versus another intervention. Three studies compared a psychosocial intervention to a control group. Only one primary prevention trial reported data for the primary outcomes and, although this study found a significant difference in depression in favour of the intervention at endpoint, this difference was no longer evident at 18 months. No studies of primary prevention comparing different interventions and reporting primary outcomes of interest were identified.

The methodological quality of the included studies was summarised. No study met our full quality criteria and one was regarded as low-quality. The remainder could not be rated because of incomplete data in the published reports and inadequate responses from the trialists.

Authors' conclusions

There is evidence only from individual small and low quality trials with minimal data suggesting that police officers benefit from psychosocial interventions, in terms of physical symptoms and psychological symptoms such as anxiety, depression, sleep problems, cynicism, anger, PTSD, marital problems and distress. No data on adverse effects were available. Meta-analyses of the available data were not possible. Further well-designed trials of psychosocial interventions are required. Research is needed on organization-based interventions to enhance psychological health among police officers.

摘要

背景

對於執法人員預防心理疾病的心理社會處遇

心理社會處置通常廣泛的運用在預防執法人員產生心理疾病。

目標

評估預防執法人員產生心理疾病的心理社會處遇的效果及不同處遇間的比較效果。

搜尋策略

搜尋CCDANCTRReferences 到12/5/2008。搜尋電子資料庫,查詢回顧文獻及納入研究裡的參考文獻表。紙本搜尋專業期刊、專業書籍。和這領域的專家及研究者接觸。

選擇標準

挑選隨機和半隨機對照試驗。受試者的類型是直接在執法機構工作的人,包括警察、軍事警察,不管性別、年齡和國籍,不管是否有經歷一些心理創傷。納入所有型態的心理社會處遇。相關的結果測量是心理症狀,不良反應和對心理處遇的接受度。。

資料收集與分析

資料鍵入Review Manager 4.2 來分析,但是這個回顧文獻也會轉成RevMan 5.0 發表。也進行品質分析。兩位作者獨立選擇研究、摘錄資料、評估研究的品質。使用RevMan 計算摘要效果。在個別研究中,二分法變項以相對危險性來呈現。連續變項以加權平均數來呈現。以95%的信賴區間來呈現結果。

主要結論

在本文中採用10篇研究,只有5篇的資料可用。其中的3篇是以運動為基礎的心理處遇。7篇是有關心理處遇。由於受試者、處遇和結果的異質性,因此無法執行後設分析。2篇研究比較2種不同的心理社會處遇,3篇研究是比較控制組和一種心理社會處遇。只有一篇研究以初級預防為主要的結果,而這篇研究發現當研究結束時,接受處遇的憂鬱症患者有顯著的療效,但是這種差異在18個月後的追蹤已經不明顯。並沒有初級預防的研究是比較不同的處遇,也沒有研究是報告本文有興趣的主要結果。所採納的研究的方法學的品質整合裡,沒有一個研究完全符合我們的品質標準,甚至有一篇被認為是低品質的研究,其餘的研究無法被評價,因為在發表的報告中數據不完整,或研究者並沒有給予足夠的回答。

作者結論

只有來自個別、小的、低品質的研究中的少量資料的證據表明,警察人員能從心理社會處遇中獲得好處,特別在有身體症狀和心理症狀時,例如:焦慮,憂鬱,睡眠問題,好譏諷,憤怒,創傷後壓力症候群,婚姻問題和苦惱。目前沒有資料是有關不良反應的。所得的資料無法進行後設分析。有關於心理處遇的進一步精心設計的試驗是需要。所需要的研究是有關於加強警務人員的心理健康,以組織為基礎的心理處遇。

翻譯人

本摘要由彰化基督教醫院胡淑惠翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

預防警察人員得到心理疾病的心理社會處遇:當人們進行執法工作時會遇到許多事情,而這些都可能是工作上的壓力。其中包括工作方面的業務相聯繫的因素(工作內容)及組織因素(工作環境內容)。因此,使用多樣化的的處遇來努力防止執法人員產生心理疾病。有鑑於執法人員在執行業務功能的重要性,及目前並沒有明確的方式來處理他們可能發展出的心理問題,因此系統性的審查目前可得的證據來確定針對這些受試所進行的預防心理疾病的心理處遇的有效性。我們發現 10個隨機試驗,但在本文中不是所有這些有用的數據能採用,而且也無法進行定量分析。目前也沒有資料是有關不良反應的。而現有的證據僅限於單一,少數,低質量的研究分析。而這些證據表明了在心理方面的症狀和身體症狀上,警察能從社會心理處遇獲得好處。進一步精心設計、以提高警務人員的心理健康的心理處遇的研究是必需的。而同樣也需要以組織為基礎的相關處遇的研究。

Plain language summary

Psychosocial interventions to prevent psychological problems in police officers

People working in law enforcement are subject to many things that can act as work stressors. These include aspects of their job that are linked to operational factors (job content) and aspects that are linked to organizational factors (job context). A wide variety of interventions are used to try to prevent psychological disorders in law enforcement officers. In view of the importance of the functions performed by law enforcement officers, and the fact that there is no definitive approach to deal with psychological problems they may develop, a systematic review of the evidence is needed to determine the effectiveness of psychosocial interventions in preventing these problems in this select population. We found ten randomised trials, but not of all these contributed useful data for this review and quantitative meta-analyses were not possible. No data on adverse effects were available. The available evidence is, therefore, limited to the analysis of single, small and low quality trials. This suggests that police officers may benefit from psychosocial interventions in terms of psychological symptoms and physical symptoms. Further well-designed trials of psychosocial interventions to enhance the psychological health of police officers are required. Trials of organisation-based interventions are also needed.

Background

Law enforcement is an occupation with specific characteristics that can act as work stressors. There are higher sickness absence rates among police officers compared to other occupations and the two major causes of long term absence are musculoskeletal conditions, and depression and other stress-related disorders. Among police officers, 26% of the medical retirements are due to psychological or mental health disorders. Police medical retirements are a focus of particular concern due to substantially heightened costs for the State (HMIC 1997). In a study of burnout in police managers, 34% were labelled "distressed police managers" because they had the highest level of emotional exhaustion and depersonalization scores in the sample (Loo 2004). In a survey of the Royal Canadian Mounted Police only female officers indicated high levels of burnout on these subscales while, both men and women showed high burnout scores on the "personal accomplishment" subscale (Stearns 1990).

A variety of symptoms and reactions can occur, such as deteriorating work performance (absenteeism, low morale), negative psychological states (emotional burnout, frustration, depression, anxiety, anger), and psychosomatic and physical conditions such as headaches and ulcers (Burke 2000). These can also include a wide range of emotional and behavioral problems and psychosomatic symptoms such substance abuse, adjustment disorders, personality disorder (Saathoff 1990), depression, burnout, frustration, anger, acute stress, anxiety and stress (Burke 2000; Violanti 1985). Although one study has shown that female officers have statistically higher levels of somatization and depression, work-family conflicts (spillover) and destructive coping mechanisms are among the strongest and most consistent stressors in both men and women (He 2002). The estimated rate of probable major depression among 822 Taiwanese police was 21.6% (Chen 2006) and among 873 UK police officers, 41% were deemed to be 'cases' on the 12 item General Health Questionnaire (Collins 2003).

Past and recent studies have shown a high prevalence of excessive alcohol consumption among police officers. A study with a large-scale sample found that a significant number of police officers displayed at-risk alcohol consumption behaviour. By comparison to earlier studies, it has been shown that this proportion is not decreasing (Davey 2000). Another study found that almost half (48%) of male and 40% of females police officers consumed alcohol excessively, including continuous hazardous or harmful consumption and binge drinking (Richmond 1999). Stress has been shown to have a strong effect on alcohol use among the police and alcohol use is used, along with cynicism, as a coping mechanism during different phases of the police stress process (Violanti 1985).

Stressors among police offers can be readily organized into two categories. Those linked to operational factors (job content) and those linked to organizational factors (job context).

Operational stressors

The police service is one of the few occupations where people are expected to face physical dangers and, if necessary, to risk their lives (HMIC 1997). The FBI report published on law enforcement officers feloniously killed, shows that there was no statistical decrease in the five years through the turn of the century. In 1998, 61 officers were killed; in 1999, 42; in 2000, 51; in 2001, 70 and 56 in 2002 (FBI 2002).The Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) pilot study of 100 police officers identified sub-clinical levels of depression using the Centre for Epidemiologic Studies Depression scale but clinical levels of stress using the Impact of Events Scale (Violanti 1985). Among 157 members of an elite Brazilian police unit employed in critical incidents, the rate of full or partial post-traumatic stress disorder was 8.9% and 15.9%, respectively (Maia 2007).

Other job content stressors include exposure to physical risk such as being a victim of violence, witness to the murder of a companion or having to kill when necessary (Burke 2000). An examination of stressors in Norwegian police officers identified a difference between 'content' stressors such as 'fellow police hurt on duty' as being the more stressful but also being infrequent, while more frequent stressors were 'context' stressors such as 'working overtime' or 'lack of support' (Berg 2005). Similar responses were also given in a survey of 371 Australian police officers: 'witnessing the death of partner', 'participating in an act of corruption' and 'shooting somebody in the line of duty' were the most stressful job content events (Evans 1993).

Organizational stressors

In the Australian study, the most stressful job context events were 'failing police training course', 'failure on promotional examination' and 'unsatisfactory personnel evaluation' (Evans 1993). Other stressors found to be just as important include public contact that may sometimes result in a lack of respect, hostility, many hours of inactivity suddenly shifting to overwhelming responsibility (Burke 2000; Kroes 1974b), pressure for quick crucial decisions, lack of perceived value of their role in society, low income (in most countries), equipment in disrepair, internal organisation structure (Burke 2000) and dealing with the criminal justice system (Burke 2000; Kroes 1974; Kroes 1974b).

Helplessness and feelings of a lack of control in the work environment might also be a major source of stress for police officers. The organisational culture and workload are the key issues in officer stress where the degree of symptomatology worsens each year (Collins 2003). In a study examining the sources of stress-related symptoms among 1206 police officers, the highest ranking occupational stressors were not specific to policing, but to organisational issues such as demands of work impinging upon human life, lack of consultation and communication, lack of control over workload, inadequate support and excess workload in general (Kirkaldy 1995).

Shift work is also a factor, police officers reported significantly worse sleep quality and less average sleep time compared with a control group not involved in the police. Although the life-threatening aspects of police work were related to nightmares, the routine stressors of police service seemed to the most common cause affecting global sleep quality (Neylan 2002).

Another very important aspect of being a police officer is the perhaps unique subculture where, on the one hand, there exists a fraternity-subculture with high social support from peers but, on the other hand, there are also the expectations about behaviours and attitudes of a 'macho culture' (e.g., control, dominance and authority) which include a lack of willingness to seek help in dealing with stress, difficulty in admitting psychological weakness and a constant pressure for police officers to control their emotions and to appear efficient (Burke 2000). However despite this, when support is offered, it is generally accepted (Karlsson 2003).

Because police officers have unique organizational and cultural issues, specific interventions may be necessary for them. Two types of initiative are often cited as the most effective in interventions to alleviate the stressors of police officers. According to Brown and Campbell (Brown 1994), these are the organizational initiatives such as recruitment and selection interventions, counselling interventions, training interventions and work/family initiatives or physical fitness initiatives, and individual initiatives such as the use of self-help, peer-support and active coping responses because of their association with greater job satisfaction (Burke 2000).

Psychosocial interventions include all psychological interventions, social interventions (such as social skills training and befriending) and packages of interventions that have a psychosocial focus even if they also include some more biological interventions (DH 2001). Psychotherapies involving cognitive-behavioural approaches, exposure, exposure plus ritual prevention (ERP), cognitive therapy and stress inoculation have a promising record of experimental evidence of effectiveness in dealing with anxiety and stress disorders (Hunot 2007). Empirically supported psychological interventions for depression are behaviour therapy, brief psychodynamic therapy and cognitive behaviour therapy (CBT) (Chambless 2001). Cognitive behaviour therapy or cognitive therapy focuses on recognizing distorted thinking and learning to replace it with more realistic substitute ideas. Exposure therapy is a form of behaviour therapy in which the person confronts feelings, phobias or anxieties about a traumatic event and relives it in the therapy situation. Stress inoculation is a type of behaviour therapy that tries to cope with stressful situations and consists of three phases: the educational, rehearsal and application phases. Psychodynamic therapy is a term given to approaches used in surfacing true feelings, enabling understanding. The therapy assumes the existence of an unconscious mind which stores over-painful feelings. It works to unravel the natural defences to these feelings, helping to diminish them. Supportive therapy focuses on supporting reality testing, providing ego support, and maintains or re-establishes a usual level of functioning.

Physical activity and fitness have been identified as possible moderators of the stress-illness relationship. Physical activity may play an important role in the management of mild-to-moderate mental health diseases, especially depression and anxiety. In a systematic review on physical activity and mental health, increased aerobic exercise or strength training was found to reduce depressive symptoms significantly. Anxiety symptoms and panic disorder also improve with regular exercise, and beneficial effects appear to be similar to those from meditation or relaxation (Paluska 2000). Sufficient evidence now exists for the effectiveness of exercise in the treatment of clinical depression. Furthermore, exercise has a moderate reducing effect on state and trait anxiety and can improve physical self-perceptions and in some cases global self-esteem. There is also now good evidence that aerobic and resistance exercise enhance mood states, and weaker evidence that exercise can improve cognitive function (primarily assessed by reaction time) in older adults. Together, this body of research suggests that moderate regular exercise should be considered as a viable means of treating depression and anxiety and improving mental well-being in the general public (Fox 1999; Larun 2006). In a meta-analysis with 34 studies, aerobically fit subjects had a reduced psychosocial stress response compared to either their baseline values or the control group (Crews 1987).

In view of the importance of the functions performed by law enforcement officers, and the fact that there is no definitive approach to deal with this problem, a systematic review of the documented evidence regarding the effectiveness of psychosocial interventions for the prevention of psychological problems in this select population is vital.

Objectives

We performed a systematic review assessing the effectiveness of psychosocial interventions for the prevention of psychological disorders in law enforcement officers. This included primary prevention (before disorders occurred) to reduce its incidence, secondary prevention (in a population with known risk factors) and tertiary prevention (after the disorder had occurred).

Methods

Criteria for considering studies for this review

Types of studies

Randomised or quasi randomised controlled trials. Randomised crossover trials were also eligible, but only the first phase of treatment would be included.

Types of participants

Individuals employed directly in law enforcement, including all levels of police officers and military police, regardless of gender, age, and country of origin, and whether or not they have experienced some psychological trauma. Civilians working in police organisations were excluded. Army personnel in combat situations were excluded.

Types of interventions

Psychosocial interventions, as long as they were manualised or described by study's authors, allowing replication. These could include:

  • CBT, cognitive and behavioural interventions (e.g. mental imaging training, stress reduction programs, behaviour reduction programs, psycho-education interventions, relaxation).

  • Supportive therapies (e.g. counselling sessions, social support).

  • Psychodynamic therapies.

  • Exercise therapies (e.g. anaerobic and aerobic training, short exercise program, circuit weight training, physical activity, fitness and training).

  • Non-pharmacological alternative strategies (e.g. acupuncture, Reiki, diet, meditation).

Psychosocial intervention could be compared to another psychosocial intervention, no treatment (including treatment as usual, attention placebo, psychological placebo or waiting list), pharmacotherapy, or combined pharmacotherapy and psychosocial interventions.

Types of outcome measures

A wide range of instruments were available to measure possible behavioural and psychosocial problems associated with police officers. These instruments varied in quality and validity. For our analyses, the minimum standards for the inclusion of data were that the psychometric properties of the instrument had been described in a peer-reviewed journal.

Outcome measures of interest were:

Primary outcomes
  1. Ocurrence of psychological disorders

  2. Psychological symptoms (change in symptoms between baseline and endpoint)

Secondary outcomes
  1. Reduction in other psychological or behavioural symptoms, such as hostility, flashbacks, intrusive thoughts, mood swings, rage attacks, social isolation, suicide, accidents, alcohol abuse, sleep problems, drug abuse, smoking habits

  2. Specific outcomes related to the job: absenteeism, job satisfaction and mood, job stress, and burnout

  3. Quality of life

  4. Adverse events experienced by the police officer

  5. Acceptability of intervention as assessed directly by questioning trial participants and indirectly by the drop-out rates

  6. Physiological or biochemical analysis related to psychological health

Whenever possible, studies were grouped into time periods according to the evaluation of outcomes: short term (less than 6 weeks), medium term (between 6 weeks and 6 months), and long term (over 6 months); and analysed separately.

Search methods for identification of studies

We attempted to identify all relevant published and unpublished trials, irrespective of language or country.

Electronic searches

The following databases were searched to identify randomised or quasi-randomised controlled trials Cochrane Depression, Anxiety and Neurosis Controlled Trials References Register (CCDANCTR-References), Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Lilacs and PsycINFO.

CCDANCTR-References was searched on 12/5/2008 using the following terms

Free-text = Police* or "Law Enforce*"

The MEDLINE search strategy was as follows:

1 law enforcement.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1889)
2 police$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (5073)
3 law officer$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (12)
4 1 or 2 or 3 (6661)
5 exp Mental Processes/ (380854)
6 exp Mental Disorders/ (554765)
7 exp PSYCHOLOGICAL TECHNIQUES/ (67607)
8 5 or 6 or 7 (909754)
9 randomized-controlled-trial.pt. (198152)
10 controlled clinical trial.pt. (67773)
11 randomized controlled trials.sh. (36154)
12 random allocation.sh. (52597)
13 double blind method.sh. (80589)
14 single blind method.sh. (8737)
15 clinical trial.pt. (400002)
16 exp Clinical trials/ (162754)
17 (clin$ adj25 trial$).ti,ab. (107224)
18 ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$ or dummy$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (109275)
19 placebos.sh. (23474)
20 placebo$.ti,ab. (87368)
21 random$.ti,ab. (302881)
22 research design.sh. (39968)
23 comparative study.sh. (1174165)
24 exp evaluation studies/ (512022)
25 follow up studies.sh. (296255)
26 prospective studies.sh. (184088)
27 (control$ or prospectiv$ or volunteer$).ti,ab. (1506746)
28 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (3249416)
29 (animals not humans).sh. (2847046)
30 28 not 29 (2516742)
31 4 and 8 and 30 (572)

Descriptors and synonyms for police, as well as descriptors and synonyms for psychosocial interventions were used and modified according to specific requirements of each electronic database.

The EMBASE, LILACS, PsycINFO and CENTRAL searches are shown in Table 1.

Table 1. Search strategies for electronic databases
CENTRALEmbaseMedlineLilacsPsycinfo
police*1 law enforcement.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (2855)
2 police$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (5114)
3 law officer$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (7)
4 1 or 2 or 3 (7479)
5 exp Mental Function/ (612989)
6 exp Mental Stress/ (8292)
7 exp "PSYCHOLOGICAL AND PSYCHOSOCIAL PHENOMENA"/ (591886)
8 exp Mental Disease/ (505071)
9 exp "PSYCHOLOGICAL AND PSYCHIATRIC PROCEDURES, TECHNIQUES AND CONCEPTS"/ (314390)
10 5 or 6 or 7 or 8 or 9 (1196912)
11 controlled study.de. (1929109)
12 clinical trial.de. (330242)
13 major clinical study.de. (959116)
14 randomized controlled trial.de. (93598)
15 double blind procedure.de. (55153)
16 clinical article.de. (940030)
17 random$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (298276)
18 compar$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (1527056)
19 control$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (2530718)
20 follow up.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (328615)
21 ((singl$ or doubl$ or tripl$ or trebl$) adj (blind$ or mask$ or dummy)).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (74724)
22 placebo$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (120622)
23 (clinic$ adj (trial$ or study or studies$)).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name] (123974)
24 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 (4402152)
25 human.de. (4854146)
26 nonhuman.de. (2535992)
27 25 and 26 (332713)
28 26 not 27 (2203279)
29 24 not 28 (3241082)
30 4 and 10 and 29 (1929)
1 law enforcement.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (1889)
2 police$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (5073)
3 law officer$.mp. [mp=title, original title, abstract, name of substance word, subject heading word] (12)
4 1 or 2 or 3 (6661)
5 exp Mental Processes/ (380854)
6 exp Mental Disorders/ (554765)
7 exp PSYCHOLOGICAL TECHNIQUES/ (67607)
8 5 or 6 or 7 (909754)
9 randomized-controlled-trial.pt. (198152)
10 controlled clinical trial.pt. (67773)
11 randomized controlled trials.sh. (36154)
12 random allocation.sh. (52597)
13 double blind method.sh. (80589)
14 single blind method.sh. (8737)
15 clinical trial.pt. (400002)
16 exp Clinical trials/ (162754)
17 (clin$ adj25 trial$).ti,ab. (107224)
18 ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$ or dummy$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (109275)
19 placebos.sh. (23474)
20 placebo$.ti,ab. (87368)
21 random$.ti,ab. (302881)
22 research design.sh. (39968)
23 comparative study.sh. (1174165)
24 exp evaluation studies/ (512022)
25 follow up studies.sh. (296255)
26 prospective studies.sh. (184088)
27 (control$ or prospectiv$ or volunteer$).ti,ab. (1506746)
28 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 (3249416)
29 (animals not humans).sh. (2847046)
30 28 not 29 (2516742)
31 4 and 8 and 30 (572)
(POLICE$) or (LAW ENFORCEMENT OFFICERS) or (LAW ENFORCEMENT OFFICERS/) or (LAW ENFORCEMENT OFFICERS/HI) or (LAW ENFORCEMENT OFFICERS/LJ) or (LAW ENFORCEMENT OFFICERS/SN) or (LAW ENFORCEMENT OFFICERS/ST) or (LAW ENFORCEMENT OFFICERS/TD) or (LAW ENFORCEMENT OFFICERS/UT) [Palavras] and (Exerci$) or (psyc$) or (awar$) or (intervent$) or (train$) or (fitn$) or (condit$) or (phys$) or (debr$) [Palavras] and ((Pt ENSAIO CONTROLADO ALEATORIO OR Pt ENSAIO CLINICO CONTROLADO OR Mh ENSAIOS CONTROLADOS ALEATORIOS OR Mh DISTRIBUICAO ALEATORIA OR Mh MÉTODO DUPLO-CEGO OR Mh MÉTODO SIMPLES-CEGO) AND NOT (Ct ANIMAIS AND NOT (Ct HUMANO AND Ct ANIMAIS)) OR (Pt ENSAIO CLÍNICO OR Ex E05.318.760.535$) OR (Tw clin$ AND (Tw trial$ OR Tw ensa$ OR Tw estud$ OR Tw experim$ OR Tw investiga$)) OR ((Tw singl$ OR Tw simple$ OR Tw doubl$ OR Tw doble$ OR Tw duplo$ OR Tw trebl$ OR Tw trip$) AND (Tw blind$ OR Tw cego$ OR Tw ciego$ OR Tw mask$ OR Tw ma! scar$)) OR Mh PLACEBOS OR Tw placebo$ OR (Tw random$ OR Tw randon$ OR Tw casual$ OR Tw acaso$ OR Tw azar OR Tw aleator$) OR (Mh PROJETOS DE PESQUISA) AND NOT (Ct ANIMAIS AND NOT (Ct HUMANO AND Ct ANIMAIS)) OR (Ct ESTUDO COMPARATIVO OR Ex E05.337$ OR Mh SEGUIMENTOS OR Mh ESTUDOS PROSPECTIVOS OR Tw control$ OR Tw prospectiv$ OR Tw volunt$ OR Tw volunteer$) AND NOT (Ct ANIMAIS AND NOT (Ct HUMANO AND Ct ANIMAIS))) AND NOT Mh ANIMAIS [Palavras]1 law enforcement.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (2389)
2 police$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (7311)
3 law officer$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (10)
4 1 or 2 or 3 (8700)
5 exp Mental Disorders/ (235177)
6 exp Mental Health/ (14471)
7 5 or 6 (247415)
8 random$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (52019)
9 ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or dummy or mask$)).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (10763)
10 placebo$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (17094)
11 crossover.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (2536)
12 assign$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (35953)
13 allocat$.mp. [mp=title, abstract, subject headings, table of contents, key concepts] (7927)
14 ((clin$ or control$ or compar$ or evaluat$ or prospectiv$) adj25 (trial$ or studi$ or study)).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (187127)
15 exp placebo/ (1419)
16 exp treatment effectiveness evaluation/ (6693)
17 exp mental health program evaluation/ (1546)
18 exp experimental design/ (38566)
19 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 (290627)
20 animal.po. (169731)
21 (human or inpatient or outpatient).po. (1605807)
22 20 and 21 (5084)
23 20 not 22 (164647)
24 19 not 23 (271546)
25 4 and 7 and 24 (115)
     

Searching other resources

1. Handsearching: We handsearched the Journal of Police Science and Administration (volumes 1 to 17: 1973 to 1990).

2. Reference lists of review articles and included studies, and books related to police officers were checked.

3. Personal Communication: The first author of reports of controlled studies and reviews on the subject was approached, as were experts in the field, for information on trials in progress or currently unpublished studies.

Data collection and analysis

Selection of studies

Two authors (VP and JRL) checked the titles and abstracts of the articles identified by the search. The full text for each potentially relevant study was obtained and independently selected for critical appraisal.

Data extraction and management

Data on patients, methods, interventions used, randomisation process, outcomes, and results were extracted by the first author (VP) using a specially designed form, and checked by a co-author (HMG). Possible disagreements were resolved through discussion. Missing data were obtained from trialists, whenever possible.

Assessment of risk of bias in included studies

In order to ensure that variation is not due to systematic errors in the design of a study, two authors (VP and JRL) assessed the methodological quality of the selected trials independent of each other. Quality was assessed using the criteria described in the Cochrane Reviewers Handbook at the time that much of this work was done (Alderson 2004). These are based on evidence for a strong relationship between the potential for bias in the results and allocation concealment in the trial, as defined below:

Selection bias

A. Adequate allocation concealment
B. Mentioned as randomised, but details of randomisation unreported and impossible to be acquired from the author of primary study
C. Randomised by a process where the allocation could be predictable in some way (birth date, arriving order, etc)

Attrition bias/Detection bias

Three other methodological criteria were considered according to three conditions, MET, UNCLEAR and NOT MET:

  • Were the data assessors blinded?

  • Was there no systematic difference between the comparison groups regarding the withdrawals and was it less than 15%?

The following answers were used for the above methodological questions:

Met: criteria appropriately applied and either described or obtained from the author of the study
Unclear: criteria not described and impossible to be obtained from the author of the study
Not met: criteria inappropriately applied

Included studies were classified as
(a) low risk of bias: all criteria met
(b) moderate risk of bias: one or more unclear issues
(c) high risk of bias: one or more unmet issues

Performance bias was considered according to the criterion mentioned above, for those study designs in which the blinding of care providers could be applied.

Assessment of heterogeneity

Heterogeneity in the results of the trials was assessed both by inspection of graphical presentations and by observing the I-square test of heterogeneity (Higgins 2003). For quantifying inconsistency, the statistic I²=[(Q - df)/Q] x 100%, where Q is the chi-squared statistic and df is its degrees of freedom would be considered. A value greater than 50% in this test may be considered indicative of substantial heterogeneity. Possible reasons for heterogeneity were expected and pre-specified as follows:

  1. That treatment effects differ according to the different kinds of intervention strategies

  2. That response differs when psychosocial therapies are provided in conjunction with prescribed drugs

  3. According to the characteristics of participants in the trials (administrative police, mounted police, vice squad, drug squad, riot police, beat policeman, military police, female police, etc

  4. According to length of follow-up.

These sources of heterogeneity would be assessed by looking at separate subgroups of trials.

Since considerable clinical and methodological diversity was anticipated across studies, we planned to use the random effect model for any meta-analyses.

Assessment of reporting biases

The possibility of publication bias could not be examined using a funnel plot because there were only five included studies with data.

Data synthesis

For dichotomous outcomes, the measure of treatment effect was the relative risk (RR) with a 95% confidence interval. The relative risk from individual trials was to be combined when possible through meta-analysis. If the overall estimate was significant, the number needed to treat (NNT) to produce one outcome would be calculated.

For continuous data, we applied the following standards: (a) standard deviations and means had to be reported or obtained from authors; and (b) for data with finite limits, such as endpoint scale data, the standard deviation, when multiplied by two, had to be less than the mean; otherwise the mean is unlikely to be an appropriate measure of the centre of the distribution (Altman 1996). Only non-skewed data was analysed. For any meta-analyses, weighted mean difference would be calculated if the same instrument had been used for the outcome measure. Standardised mean difference would be used if different instruments were used for the same outcome.

It was not possible to obtain all missing data, so we did not carry out an ITT analysis and the data was based on completers only (Unnebrink 2001).

Subgroup analysis and investigation of heterogeneity

Sub-group analysis were planned on different kinds of interventional strategies:
1. different categories of psychosocial intervention(psychotherapy, counselling, brief interventions, coping strategies,psycho-education interventions,fitness, training, physical activity, etc)
2. individual versus group therapies (familial or with workmates)
3. psychosocial versus non-pharmacological intervention (acupuncture, Reiki, religion, diet,meditation,etc)

Sensitivity analysis

Sensitivity analyses were planned to estimate the robustness of our results according to the judgements about the methodological quality of the included studies.

Results

Description of studies

The electronic searches identified a total of 25 studies and handsearches identified three more. Of these, 10 were included, 16 excluded and two are awaiting classification as the hard copies have not yet been obtained.

Studies were excluded for the following reasons: 14 were not randomised controlled trials or quasi randomised controlled trials (Arokoski 2002; Bar 2004; Carlier 1998; Carlier 2000; Danish 1970; Godschalx 1984; Harrel 1993; Meadows 1985; Norris 1990; Pinfold 2003; Richmond 1999b; Schmit 1996; Tolin1999; Wallace 1977) and the aims of the intervention in the final study were outside the scope of current review (Gersons 2000; McMurray 1998).

Of the included studies, most were described as 'randomised', although there is uncertainty about the randomisation method used in one (Norvell 1993) so it was classified as 'quasi-randomised' (CCT). McNulty 1984 was described its randomisation method as 'equally spread' so it was classified as a quasi-randomised controlled trial (CCT). O'Neill 1982 was described as a controlled clinical trial (CCT).

Patient selection

The majority of these trials involved populations that were comparable. All patients were serving law enforcement officers, although there were three trials with police trainees (Backman 1997; Sarason 1979; Shipley 2002). Five trials included both men and women (Backman 1997; Doctor 1994; Sarason 1979; Shipley 2002; Wilson 2001). In the majority of the trials, clinical diagnosis was not used to include to exclude participants (Aremu 2006; Backman 1997; Doctor 1994; McNulty 1984; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; Wilson 2001). In one study, the diagnosis for inclusion was to be overweight by 20% (Short 1984). No characteristics of patient selection were mentioned in one trial (O'Neill 1982).

Cultural Setting

Five studies were undertaken in United States (O'Neill 1982; Norvell 1993; Sarason 1979; Short 1984; Wilson 2001). The others were carried out in Sweden (Backman 1997), Australia (McNulty 1984), Canada (Shipley 2002), Nigeria (Aremu 2006) and the United Kingdom (Doctor 1994).

Sample size

The number of patients randomised in the trials ranged from 18 (Sarason 1979) to 90 (Aremu 2006) with a total of 583 individuals in all ten trials combined.

Outcomes measures

In nine trials, psychological measures were assessed in the form of stress, anxiety, anger, physical symptoms, self concept, job stress, hostility, burnout, cynicism and marital relationship (Aremu 2006; Backman 1997; Doctor 1994; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984; Wilson 2001). In two trials, physiological measures were assessed (Backman 1997; McNulty 1984).

Interventions

The psychosocial interventions that were evaluated are outlined here and discussed in more detail below.

Stress management program versus psycho-educational interventions (McNulty 1984; O'Neill 1982; Sarason 1979; Wilson 2001).
Mental imaging training (at home) (Backman 1997).
Counseling group sessions (Doctor 1994).
Circuit weight training (Norvell 1993).
Visuo-Motor Behavior Rehearsal (Shipley 2002).
Social Skills Training versus Problem-solving skills training versus control (Aremu 2006).
Aerobic program (including theory) versus theory on exercise program (Short 1984).

Risk of bias in included studies

The full text of all potentially relevant studies was obtained and critically appraised by two authors (VP and HMG).

Allocation

Two authors (VP and HMG) assessed the methodological quality of the included studies using the criteria described in the Cochrane Reviewers' Handbook (Alderson 2004). We wrote to the authors of the ten studies requesting more details on the randomisation process that they used. We received responses from three (Backman 1997; Doctor 1994; Wilson 2001). Only one study had adequate allocation concealment and this was scored A (Doctor 1994). The method of randomisation was unclear or not reported in eight trials which were scored B (Aremu 2006; McNulty 1984; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984; Wilson 2001).The method of randomisation was inadequate, scoring C, in one study (Backman 1997).

Blinding

In three trials (Backman 1997; Doctor 1994; Wilson 2001) blinding was appropriately applied and the criteria of 'assessors concealed' was met. In six trials (McNulty 1984; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984) the necessary information was not described and so these were considered to be 'unclear'.

Incomplete outcome data

In three studies (Backman 1997; Doctor 1994; Wilson 2001) the criteria were met. It was considered 'not met' only for the body symptom scale assessment in Backman 1997. In six studies (Aremu 2006; McNulty 1984; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984) the criteria was not described so was considered 'unclear'. One study (Norvell 1993) was classified as not met.

Overall methodological quality

In eight trials, data were not available for all methodological variables, none of the authors could provide the data and the necessary information was not included in the trial report (Aremu 2006; McNulty 1984; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984; Wilson 2001). The necessary information regarding assessor concealment and attrition bias was provided for one study (Wilson 2001). Information on all the methodological data was provided for Backman 1997. The necessary information was obtained in part from the trial report and also from communication from the author for the Doctor 1994 trial.

Overall, the criteria for good methodological quality of the included studies were partly met. The Doctor 1994 trial was the only one to meet the criteria of low risk of bias. Wilson 2001 came closest of the other trials to fulfilling the criteria of partly met. Aremu 2006; Backman 1997; McNulty 1984; Norvell 1993; O'Neill 1982; Sarason 1979; Shipley 2002; and Short 1984 had unclear issues, which was partly due to incomplete reporting. We are unsure of the randomisation procedure in Norvell 1993 and O'Neill 1982. Follow-up was of 3 months (Wilson 2001) and 18 months (Backman 1997).

Included studies were classified as
(a) low risk of bias: all criteria met: Doctor 1994.
(b) moderate risk of bias: one or more criteria partly met and unclear issues: Aremu 2006; McNulty 1984; O'Neill 1982; Sarason 1979; Shipley 2002; Short 1984; and Wilson 2001.
(c) high risk of bias: one or more unmet issues; Backman 1997 and Norvell 1993.

Effects of interventions

Quantitative meta-analyses were not possible.

Primary Prevention - Intervention versus Control

Only one trial reported data for primary intervention (intervention versus control) (Backman 1997). Ten outcomes were measured. There was significant difference in favour of the intervention group on the depression, sleep, cynicism and symptoms scale measures. There were significant differences in favour of the control group in general health and coping; and no differences between intervention and control groups in bodily symptoms scale, Jenskins activity, burnout and vital exhaustion.

Primary outcomes

Depression: One study (Backman 1997) comparing Mental Imaging Training versus control, with a sample size of 60 participants at endpoint (N = 60) and at follow-up (N = 60) contributed to this outcome. There was a significant difference in favour of the intervention at the endpoint (MD (fixed) -2.14, 95%CI -4.00 to -0.28) but at 18 month follow-up there was no statistical difference between the two groups (MD (fixed) -0.97, 95%CI -2.43 to 0.49).

Secondary Oucomes

General Health Questionnaire: One study (Backman 1997) comparing Mental Imaging Training versus control, with a sample size of 63 participants at endpoint (N = 63) and at follow-up (N = 63) contributed to this outcome. There was a significant difference in favour of the control group at the endpoint (MD (fixed) 2.74, 95% CI 0.78 to 4.70) but at the 18 month follow-up the difference was not statistically significant (MD (fixed) 1.30, 95% CI -0.61 to 3.21).

IBM Coping: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 65 participants at endpoint (N = 65) and at follow-up (N = 65). There was a statistical difference in favour of the control group at the endpoint (MD (fixed) 2.83, 95% CI 1.51 to 4.15) and again at the 18 month follow-up (MD (fixed) 2.24, 95%CI 1.06 to 3.42).

Jenkin's Activity Survey: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 63 participants at the endpoint (N = 63) and at follow-up (N = 63). There was no statistical difference between the groups at the endpoint (MD (fixed) 1.1, 95%CI -2.83 to 0.61) but by the 18 month follow-up there was a statistical difference in favour of the intervention group (MD (fixed) 2.77, 95% CI -4.66 to -0.88).

Karolinska Sleep Questionnaire (Impaired Awakening:subscale): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 66 participants at endpoint (N = 66) and at follow-up (N = 66).There was a statistical difference in favour of the intervention group at the endpoint (MD (fixed) -1.58, 95%CI -2.46 to -0.70) and at the 18 month follow-up (MD (fixed) -1.06, 95%CI -1.84 to -0.28).

Karolinska Sleep Questionnaire (Sleep Quality subscale): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 64 participants at endpoint (N = 64) and at follow-up (N = 64). There was a statistical difference in favour of the intervention group at the endpoint (MD (fixed) -1.97, 95% CI -3.55 to -0.39) and at the 18 month follow-up (MD (fixed) -1.68, 95% CI -3.28 to -0.08).

Karolinska Sleep Questionnaire (Sleepiness): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 63 participants at endpoint (N = 63) and at follow-up (N = 63). There was a statistical difference in favour of the intervention group at the endpoint (MD (fixed) -1.82, 95% CI -3.05 to -0.59) and at the 18 month follow-up (MD (fixed) -1.19, 95% CI -2.34 to -0.04).

Bodily Symptom Scale - Worry Depression: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 60 participants at endpoint (N = 60) and at follow-up (N = 60). There was no statistical difference between the groups at the endpoint (MD (fixed) -2.14, 95% CI -4.00 to 0.28) or at the 18 month follow-up (MD (fixed) -0.97, 95% CI -2.43 to 0.49).

Burnout (Emotional subscale): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 67 participants at follow-up. There was no statistical difference between the groups (MD (fixed) 0.02, 95% CI -1.78 to 1.82).

Burnout (Despersonalization subscale): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 67 participants at follow-up. There was no statistical difference between the groups (MD (fixed) 0.16, 95% CI -1.00 to 0.68).

Burnout (Personal Accomplishment subscale): One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 67 participants at follow-up. There was no statistical difference between the groups (MD (fixed) 0.58, 95% CI -0.85 to 2.01).

Vital Exhaustion: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 67 participants at endpoint (N = 67) and at follow-up (N = 67). There was no statistical difference between the groups at the endpoint (MD (fixed) -2..49, 95% CI -5.57 to 0.59) but there was a statistical difference in favour of the intervention group at the 18 month follow-up (MD (fixed) -3.94, 95% CI --6.95 to 0.93).

Cynicism: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 64 participants at endpoint (N = 64) and at follow-up (N = 64). There was a statistical difference in favour of the intervention group at the endpoint (MD (fixed) -6.99, 95% CI -12.13 to -1.85) and at the 18 month follow-up (MD (fixed) -8.22, 95% CI -14.11 to -2.33).

Symptom Scale: One study (Backman 1997) comparing Mental Imaging Training versus control contributed to this outcome, with a sample size of 60 participants at endpoint (N = 60) and at follow-up(N = 60). There was a statistical difference in favour of the intervention group at the endpoint (MD (fixed) -2.14, 95% CI -4.00 to -0.28) but not at 18 month follow-up (MD (fixed) -0.97, 95% CI -2.43 to 0.49).

Dropouts: One study (Backman 1997) contributed to this outcome. Drop-out was more common in the intervention group (2/37) than in control group (1/38). This difference is not statistically significant (RR 2.05, 95%Cl 0.19 to 21.70).

Adverse effects: No data were reported for this outcomes.

Primary Prevention - Intervention versus Intervention

No studies were identified for this comparison.

Secondary Prevention - Intervention versus Control

There was only one study of secondary prevention (intervention versus control) (Norvell 1993) that reported data and two studies that contributed to the dropouts analysis (Doctor 1994; Norvell 1993). Eight outcomes were measured. There were significant differences in favour of the intervention group in depression, anxiety, general subscale, physical scale symptoms scale. There were no statistically significant differences between the intervention and control groups in hostility, somatization, job descriptive scale and perceived stress scale.

Primary outcomes
SCL-90

Hostility subscale: One study (Norvell 1993) contributed to this outcome (N = 29). There was no statistical difference between the groups at the endpoint (MD (fixed) -3.84, 95% CI -8.48 to 0.80) .

Depression subscale: One study (Norvell 1993) contributed to this outcome (N = 29). There was a significant difference in favour of the intervention group at the endpoint (MD (fixed) -7.32, 95% CI -11.79 to -2.85).

Anxiety subscale: One study (Norvell 1993) contributed to this outcome (N = 29). There was a significant difference in favour of the intervention group at the endpoint (MD (fixed) -6.80, 95% CI -9.22 to -4.38).

Perceived Stress Scale: One study (Norvell 1993) contributed to this outcome (N = 29). There was no statistical difference between the groups at the endpoint (MD (fixed) -3.1, 95%CI -6.94 to 0.60)

Secondary Outcomes

General subscale: One study (Norvell 1993) contributed to this outcome (N = 29). There was a statistical difference in favour of the intervention at the endpoint (MD (fixed) -6.22, 95% CI -10.78 to -1.66).

Somatization subscale: One study (Norvell 1993) contributed to this outcome (N = 29) There was no significant difference between the groups at the endpoint (MD (fixed) -1.84, 95%CI -5.68 to 2.00).

Physical Symptom Scale: One study (Norvell 1993) contributed to this outcome (N = 29). There was a significant difference in favour of the intervention group at the endpoint (MD (fixed) -5.23, 95% CI -8.02 to -2.44).

Job Descriptive Scale: One study (Norvell 1993) contributed to this outcome (N = 29). There was no significant difference between the groups at the endpoint (MD (fixed) -8.82, 95% CI -21.73 to 4.09).

Perceived Stress Scale: One study (Norvell 1993) contributed to this outcome (N = 29). There was no significant difference between the groups at the endpoint (MD (fixed) -3.17, 95%CI -6.94 to 0.60).

Dropouts: Two studies contributed to this outcome (Doctor 1994; Norvell 1993). Drop-out was more common in the intervention groups (23/64) than in the control groups (7/44), with a significant difference in favour of the control group (RR 2.27, 95% CI 1.01 to 5.10).

Adverse effects: No data were reported for this outcome.

Secondary Prevention - Intervention versus Intervention

In secondary prevention (intervention versus intervention) only one study (Wilson 2001) reported data on the primary outcomes and two studies contributed to the analysis of dropouts (Short 1984; Wilson 2001). Seven outcomes were measured. There was a significant difference in favour of the intervention (eye movement desensitization and reprocessing (EMDR)) at endpoint in Anger(Trait), PTSD, marital relationship and Distress Scale. There was no significant difference between the groups in Anger (State), Tennesse Self Concepto Scale and Job Stress Scale.

Primary Outcomes

Anger - Trait: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62) and at follow-up (N = 62). There was a significant difference in favour of EMDR over Brief Eclectic Psychotherapy (BEP) at the endpoint (MD (fixed) -1.50, 95% CI -2.71 to -0.29) and at the six month follow-up (MD (fixed) -3.46, 95% CI -4.90 to -2.02)

Anger - State: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62) and at follow-up (N = 62). There was no significant difference at the endpoint (MD (fixed) 0.25, 95% CI -0.78 to 1.28) but there was a significant difference in favour of EMDR over BEP at six month follow-up (MD (fixed) -1.28, 95% CI -2.40 to -0.16)

Diagnosis of PTSD: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62) and at follow-up (N = 61). There was a significant difference in favour of EMDR over BEP at endpoint (OR (fixed) 0.42, 95% CI 0.04 to 4.91) and again at six month follow up (OR (fixed) 0.28, 95%CI 0.03 to 2.985).

Subjective Units of Distress Scale: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62). There was a significant difference in favour of EMDR over BEP at the endpoint (MD (fixed) -2.28, 95% CI -2.57 to -1.99)

Secondary Outcomes

Tennessee Self Concept Scale: One study (Short 1984) contributed to this outcome at the endpoint (N = 45). There was no significant difference at the endpoint (MD (fixed) 3.70, 95% CI -14.86 to 22.26)

Job Stress Scale: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62). There was no significant difference between the groups at endpoint (MD (fixed) -0.66, 95% CI -3.43 to 2.11)

Marital Relationship: One study (Wilson 2001) contributed to this outcome at the endpoint (N = 62). There was a significant difference in favour of EMDR over BEP at the endpoint (MD (fixed) 22.70, 95% CI 9.67 to 35.73) .

Dropouts: There were no reported dropouts in either study (Short 1984; Wilson 2001).

Adverse effects: No data were reported for this outcome.

Tertiary Prevention- Intervention versus Control

No studies were identified for this comparison.

Tertiary Prevention- Intervention versus Intervention

No studies were identified for this comparison.

All prevention versus control - post hoc selected outcomes

Primary Outcomes

Depression: Two studies (Backman 1997; Norvell 1993) contributed to this outcome at endpoint (N = 89). There was a significant difference in favour of psychosocial intervention (MD (standard) -0.80, 95%CI -1.36 to -0.24) at endpoint. The heterogeneity was within accepted limits (I2 32.8%).

Missing data

Doctor 1994 used the General Health Questionnaire but did not report the data.
Doctor 1994 measured job stress but did not report the data.
Sarason 1979 measured anxiety but did not report the data.
Sarason 1979 measured hostility but did not report data.
McNulty 1984 measured hormone levels but did not report the data.
Wilson 2001 used the Police Stress Inventory and did not report data.
Wilson 2001 measured Coping Responses but did not report the data.
Wilson 2001 used the Symptom Checklist (SCL-90) but did not report the data.

O'Neill 1982 measured SCL 90, State-Trait Anxiety Index, Michigan Alcoholism Screening Test, Myers-Briggs Type Indicator and Police Job Stress Inventory but did not report these data.

Shipley 2002 measured CSAI-2 State Anxiety Inventory-2, Subjective evaluations and Performance evaluations but did not report these data.

Aremu 2006 measured Police Interpersonal self image but did not report data.

Sub-group analyses

Insufficient data were available for the a priori sub-group analyses.

Sensitivity analysis

Insufficient data were available for the a priori sensitivity analyses.

Publication bias

Insufficient data were available for the a priori analysis of publication bias.

Discussion

Psychosocial interventions are a common treatment for stress related symptoms and psychological disorders in police officers. The strength of this review lies in its rigorous methods, which include thorough searching for evidence, systematic appraisal of study quality, and systematic and well defined data synthesis. Its main limitation is the lack of evidence with which to inform its results and conclusions. This is similar to another Cochrane review of preventing occupational stress in healthcare workers which found 14 randomised trials, three cluster-randomised trials and two crossover trials, including a total of approximately 2,800 participants and concluded 'limited evidence is available for the effectiveness of interventions to reduce stress levels in healthcare workers. Larger and better quality trials are needed' (Marine 2006). In our review, it is disappointing that despite thorough searching, only 10 randomised studies - with a total of 583 individuals - of psychosocial interventions for the prevention of psychological disorders in police officers were identified. Only four studies contributed outcome data (Backman 1997; Norvell 1993; Short 1984; Wilson 2001) and one further study reported on dropouts only (Doctor 1994).

None of the psychosocial interventions targeted the "job context" stressors, which are far greater the "job content" stressors.

The ten included studies investigated different interventions, participants, and outcomes. For this reason, the studies were analysed in three separate groupings (primary, secondary and tertiary intervention), and the data could not be integrated in a meta-analysis. For an overview of the results of included studies, see the Figures and the Table 'Characteristics of included studies'.

If the results of more trials of high quality become available, our estimates of the effectiveness of psychosocial interventions for the prevention of psychological disorders in law enforcement officers may be made more precise by the quantitative synthesis of trial data, if there is not excessive heterogeneity.

The limited evidence base limits the precision of our results. It also means that a single unidentified trial, or new trials, could have a substantial effect on the findings and conclusions of this review. As so few studies are available, indirect methods of identifying publication bias such as funnel plots are of very limited value, and were therefore not conducted.

The main findings of this review are as follows:

Primary outcomes at endpoint

Psychological symptoms were significantly improved by psychological interventions when compared with a control intervention for depression (Backman 1997). Anger trait, diagnosis of PTSD, marital relationship and distress, depression, anxiety and physical symptoms were all statistically significantly improved (Wilson 2001). Our analyses of drop-outs revealed no statistically differences between any interventions.

Primary outcomes at follow-up of 6 or 18 months

There were statistically significant differences in psychological symptoms (including anger and PTSD) for eye movement desensitization and reprocessing (EMDR) when compared with brief eclectic psychotherapy (BEP) (Wilson 2001). There were no statistically significant differences between the intervention and control group as regards depression (Backman 1997).

Most of the psychological symptoms measured were statistically significantly improved by an intervention when compared with the control group at the endpoint and at the follow up. There were no significant differences for some psychological symptoms including stress (job, stress, burnout, perceived stress) (Backman 1997).

Our findings are based on psychosocial interventions tested in individual trials with small number of participants, which tried to help police officers to cope with stressful events in the workplace rather than interventions aimed at the provision of social and organizational support in their operational experiences which might have changed the conditions or circumstances that may actually causes their occupational stress. There is a huge need for organization-based psychosocial interventions to be examined in police forces.

Authors' conclusions

Implications for practice

There is insufficient evidence to show whether police officers benefit from psychosocial interventions including exercise-based interventions. There is lack of evidence that psychosocial interventions can reduce stress-related psychological symptoms.

Implications for research

Further high quality and appropriately large and statistically powered studies of psychosocial interventions in law enforcement officers are required. Specifically, randomised controlled trials with adequate methodological quality (minimising performance, attrition and detection biases). This review would be greatly improved if missing data from the included studies and additional data from new high quality studies were added. Future research is needed to assess organization-based psychosocial interventions.

Acknowledgements

The authors would like to thank the staff of the Brazilian Cochrane Centre for their help with daily difficulties. We would also like to show our gratitude to Regis Andriolo, Bernardo Soares and Humberto Saconato for their useful comments on the protocol of this review, the CCDAN editorial team for their advice on the protocol and Professor Simon Wessely for guidance and comments on drafts of the protocol and full review.

This review is sponsored by the Associação Fundo de Incentivo à Psicofarmacologia (AFIP) .

Data and analyses

Download statistical data

Comparison 1. Primary Prevention - Intervention versus Control
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Depression1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
1.1 Post-treatment160Mean Difference (IV, Fixed, 95% CI)-2.14 [-4.00, -0.28]
1.2 Follow-up - 18 months160Mean Difference (IV, Fixed, 95% CI)-0.97 [-2.43, 0.49]
2 General Health Questionnaire1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
2.1 Post treatment163Mean Difference (IV, Fixed, 95% CI)2.74 [0.78, 4.70]
2.2 Follow-up - 18 months163Mean Difference (IV, Fixed, 95% CI)1.30 [-0.61, 3.21]
3 IBM-Coping1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Post-treatment165Mean Difference (IV, Fixed, 95% CI)2.83 [1.51, 4.15]
3.2 Follow-up- 18 months165Mean Difference (IV, Fixed, 95% CI)2.24 [1.06, 3.42]
4 Jenkin's Acivity Survey1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
4.1 Post- treatment163Mean Difference (IV, Fixed, 95% CI)-1.11 [-2.83, 0.61]
4.2 Follow-up- 18 months163Mean Difference (IV, Fixed, 95% CI)-2.77 [-4.66, -0.88]
5 Karolinska Sleep Questionnaire - Impaired Awakening1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
5.1 Post-treatment166Mean Difference (IV, Fixed, 95% CI)-1.58 [-2.46, -0.70]
5.2 Follow-up- 18 months166Mean Difference (IV, Fixed, 95% CI)-1.06 [-1.84, -0.28]
6 Karolinska Sleep Questionnaire - Sleep Quality1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
6.1 Post-treatment164Mean Difference (IV, Fixed, 95% CI)-1.97 [-3.55, -0.39]
6.2 Follow-up- 18 months164Mean Difference (IV, Fixed, 95% CI)-1.68 [-3.28, -0.08]
7 Karolinska Sleep Questionnaire - Sleepiness1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
7.1 Post-treatment163Mean Difference (IV, Fixed, 95% CI)-1.82 [-3.05, -0.59]
7.2 Follow-up- 18 months163Mean Difference (IV, Fixed, 95% CI)-1.19 [-2.34, -0.04]
8 Bodily Sympton Scale/Worry Depression1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
8.1 Post-treatment160Mean Difference (IV, Fixed, 95% CI)-2.14 [-4.00, -0.28]
8.2 Follow-up 18 months160Mean Difference (IV, Fixed, 95% CI)-0.97 [-2.43, 0.49]
9 Burnout - Emotional1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
9.1 Follow-up 18 months167Mean Difference (IV, Fixed, 95% CI)0.02 [-1.78, 1.82]
10 Burnout - Despersonalization1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
10.1 Follow-up 18 months167Mean Difference (IV, Fixed, 95% CI)-0.16 [1.00, 0.68]
11 Burnout - Personal Accomplishment1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
11.1 Follow-up 18 months166Mean Difference (IV, Fixed, 95% CI)0.58 [-0.85, 2.01]
12 Vital Exhaustion1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
12.1 Post-Treatment163Mean Difference (IV, Fixed, 95% CI)-2.49 [-5.57, 0.59]
12.2 Follow-up 18 months163Mean Difference (IV, Fixed, 95% CI)-3.94 [-6.95, -0.93]
13 Cynicism1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
13.1 Post-Treatment164Mean Difference (IV, Fixed, 95% CI)-6.99 [-12.13, -1.85]
13.2 Follow-up 18 months164Mean Difference (IV, Fixed, 95% CI)-8.22 [-14.11, -2.33]
14 Symptom Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
14.1 Post treatment160Mean Difference (IV, Fixed, 95% CI)-2.14 [-4.00, -0.28]
14.2 Follow-up 18 months160Mean Difference (IV, Fixed, 95% CI)-0.97 [-2.43, 0.49]
15 Dropouts175Risk Ratio (M-H, Fixed, 95% CI)2.05 [0.19, 21.70]
Analysis 1.1.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 1 Depression.

Analysis 1.2.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 2 General Health Questionnaire.

Analysis 1.3.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 3 IBM-Coping.

Analysis 1.4.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 4 Jenkin's Acivity Survey.

Analysis 1.5.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 5 Karolinska Sleep Questionnaire - Impaired Awakening.

Analysis 1.6.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 6 Karolinska Sleep Questionnaire - Sleep Quality.

Analysis 1.7.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 7 Karolinska Sleep Questionnaire - Sleepiness.

Analysis 1.8.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 8 Bodily Sympton Scale/Worry Depression.

Analysis 1.9.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 9 Burnout - Emotional.

Analysis 1.10.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 10 Burnout - Despersonalization.

Analysis 1.11.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 11 Burnout - Personal Accomplishment.

Analysis 1.12.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 12 Vital Exhaustion.

Analysis 1.13.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 13 Cynicism.

Analysis 1.14.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 14 Symptom Scale.

Analysis 1.15.

Comparison 1 Primary Prevention - Intervention versus Control, Outcome 15 Dropouts.

Comparison 2. Secondary Prevention - Intervention versus Control
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 SCL-90 Hostility1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
1.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-3.84 [-8.48, 0.80]
2 SCL-90 Depression1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
2.1 Post-treatment129Mean Difference (IV, Fixed, 95% CI)-7.32 [-11.79, -2.85]
3 SCL-90 Somatization1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-1.84 [-5.68, 2.00]
4 SCL-90 Anxiety1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
4.1 Post-treatment129Mean Difference (IV, Fixed, 95% CI)-6.80 [-9.22, -4.38]
5 SCL-90 General1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
5.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-6.22 [-10.78, -1.66]
6 Physical Symptoms Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
6.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-5.23 [-8.02, -2.44]
7 Job Descriptive Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
7.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-8.82 [-21.73, 4.09]
8 Perceived Stress Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
8.1 Post-Treatment129Mean Difference (IV, Fixed, 95% CI)-3.17 [-6.94, 0.60]
9 Dropouts2108Risk Ratio (M-H, Fixed, 95% CI)2.27 [1.01, 5.10]
Analysis 2.1.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 1 SCL-90 Hostility.

Analysis 2.2.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 2 SCL-90 Depression.

Analysis 2.3.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 3 SCL-90 Somatization.

Analysis 2.4.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 4 SCL-90 Anxiety.

Analysis 2.5.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 5 SCL-90 General.

Analysis 2.6.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 6 Physical Symptoms Scale.

Analysis 2.7.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 7 Job Descriptive Scale.

Analysis 2.8.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 8 Perceived Stress Scale.

Analysis 2.9.

Comparison 2 Secondary Prevention - Intervention versus Control, Outcome 9 Dropouts.

Comparison 3. Secondary Prevention - Intervention versus Intervention
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Anger Trait1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
1.1 Post-Treatment162Mean Difference (IV, Fixed, 95% CI)-1.5 [-2.71, -0.29]
1.2 Follow-up 6 months162Mean Difference (IV, Fixed, 95% CI)-3.46 [-4.90, -2.02]
2 Anger Stait1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
2.1 Post-treatment162Mean Difference (IV, Fixed, 95% CI)0.25 [-0.78, 1.28]
2.2 Follow-up 6 months162Mean Difference (IV, Fixed, 95% CI)-1.28 [-2.40, -0.16]
3 Tenessee Self Concept Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
3.1 Post-Treatment145Mean Difference (IV, Fixed, 95% CI)3.70 [-14.86, 22.26]
4 Diagnosis of PTSD1 Odds Ratio (M-H, Fixed, 95% CI)Subtotals only
4.1 Post test162Odds Ratio (M-H, Fixed, 95% CI)0.42 [0.04, 4.91]
4.2 Follow-up 6 months161Odds Ratio (M-H, Fixed, 95% CI)0.28 [0.03, 2.85]
5 Job Stress Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
5.1 Post-Treatment162Mean Difference (IV, Fixed, 95% CI)-0.66 [-3.43, 2.11]
6 Marital Relationship1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
6.1 Post-Treatment162Mean Difference (IV, Fixed, 95% CI)-22.70 [-35.73, -9.67]
7 Subjective Units of Disturbance Scale1 Mean Difference (IV, Fixed, 95% CI)Subtotals only
7.1 Post-Treatment162Mean Difference (IV, Fixed, 95% CI)-2.28 [-2.57, -1.99]
Analysis 3.1.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 1 Anger Trait.

Analysis 3.2.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 2 Anger Stait.

Analysis 3.3.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 3 Tenessee Self Concept Scale.

Analysis 3.4.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 4 Diagnosis of PTSD.

Analysis 3.5.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 5 Job Stress Scale.

Analysis 3.6.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 6 Marital Relationship.

Analysis 3.7.

Comparison 3 Secondary Prevention - Intervention versus Intervention, Outcome 7 Subjective Units of Disturbance Scale.

Comparison 4. All Prevention versus Control - post-hoc selected outcomes
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Depression2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Post-treatment289Std. Mean Difference (IV, Random, 95% CI)-0.80 [-1.36, -0.24]
Analysis 4.1.

Comparison 4 All Prevention versus Control - post-hoc selected outcomes, Outcome 1 Depression.

What's new

DateEventDescription
5 November 2008AmendedAuthor details updated

History

Protocol first published: Issue 1, 2006
Review first published: Issue 3, 2008

DateEventDescription
9 May 2008New citation required and conclusions have changedFull review published for the first time.
28 April 2008AmendedConverted to new review format.
6 June 2007New citation required and conclusions have changedSubstantive amendment

Contributions of authors

Valentina Penalba: planned, designed and coordinated the review, extracted data, analysed and interpreted the data, and wrote the results and discussion
Jose Roberto Leite: helped develop the protocol, checked studies, and the Abstract and discussion.
Hugh McGuire: checked studies, extracted data, and wrote the results section

Declarations of interest

None known.

Sources of support

Internal sources

  • AFIP - Associaçao Fundo de Incentivo a Psicofarmacologia, Brazil.

External sources

  • Brazilian Cochrane Centre, Brazil.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Aremu 2006

MethodsRandomisation: method not specified
Allocation concealment: not stated
Assessors concealed: not stated
Attrition bias :not stated
ITT: not stated
Follow-up: not stated
Participants90 Police Officers (Assistant Superintendent of Police: 27; Superintendent of Police: 20; Deputy Superintendet of Police: 16; Chief Superintendent of Police:14; Assistant Commissioner of Police: 13)
Age: 27 to 47 (mean 37.8)
Diagnosis: none
Gender (M/F): not stated
Role of law enforcement: police officers
Years of employment in law enforcement officers: between 2 and 23 years of service
InterventionsInterventions - Primary prevention
Experimental Intervention: Social Skills Training (SST)
Session duration: 1 1/2 hours
Period of training: 8 weeks
Frequency of sessions: weekly
Number of sessions: 8
Experimental Intervention: Problem-Solving Skills Training: PST
Session duration: 1 1/2 hours
Period of training: 8 weeks
Frequency of sessions: weekly
Number of sessions: 8
Control Group: Assesment only
General counselling on community policing was given to the control group after the administration of the post -test
OutcomesPolice Interpersonal Self-Image Scale (PISS)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Backman 1997

MethodsRandomisation: Randomisation stratified by gender
Allocation concealment: no. The person in charge of the treatment patients was the one in charge of allocation after the randomisation was done by the computer.
Assessors concealed: yes. People who assessed the blood sample and the questionnaire were not aware of the group states
Attrition bias: no. Equal numbers of dropouts in each group
ITT: no
Follow-up: 18 months
Participants75 male and female Swedish police trainees. Experimental group: 25 men and 12 women; Control group: 26 men and 12 women
Age: not specified
Diagnosis: none
Gender (M/F): 25/12 and 26/12
Role of law enforcement: police trainees
Interventions

Intervention - Primary prevention
Mental imaging training:
1) Theory: Trainees received instruction in stress theory
2) Physical and mental relaxation: Trainees practiced first physical relaxation and then mental relaxation at home using a cassette type
3) Learning activities: included problems management, triggers and self image, goal, environment, technique, concentration and practical training.
4) Trained at home: trainees were encouraged to train at home five times a week( 44% did so, 10% twice a week).
Session duration: 2 hours
Period of training: 10 weeks
Frequency: 1 day/week
Supervised training: monitored by facility staff.
Specially trained police officers from the Swedish National Counter Terrorist Squad carried out the mental training program.

Control Group:
Assesment only

OutcomesJenkins' Activity Survey (Typ-A)
Appels - Vital exhaustion
Cynicism - Cook, Medley
General Health Questionnaire - Goldberg, Banks
IPM - Coping
Bodily symptom scale
Karolinska Sleep Questionnaire
Burnout scale-Maslach
Prolactin (ug/L)
Cortisol (nmol/L)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?High riskC - Inadequate

Doctor 1994

MethodsRandomization: Quasi randomised. Sequentially numbered
Allocation concealment: yes
Assessors concealed: yes
Attrition bias: no. Equal numbers of drop-outs: 9 for 31 participants in the experimental group and 7 for 29 in the control group
ITT: no
Follow-up: no
Participants61 males and females. Experimental group: 31. Control group: 29
Age: 22 to 55
Diagnosis: none
Gender (M/F): 59/2
Role of law enforcement: Uniformed officers of constable and sergeant rank of two stations
InterventionsIntervention: Secondary prevention
Psychotherapy: counselling group sessions
Session duration: 1 hour
Period of training: 12 weeks
Frequency: 1 days/week
Adaptation strategy for psychotherapy: attendance was not obligatory but was encouraged by giving an equivalent amount of time off work in lieu
Counseling sessions: led by a registrar in psychiatry
Control group: No treatment. Assessment only
OutcomesGeneral Health Questionnaire
Sick leave records
Stress situation questionnaire (outcome measured before, but not after, the intervention)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Low riskA - Adequate

McNulty 1984

MethodsRandomisation: Controlled Clinical Trial. Method of allocation not specified. Quasi randomised Controlled trial
Allocation concealment: not stated
Assessors concealed: not stated
Attrition bias: not stated
ITT: not stated
Follow-up: no
Participants44 police recruits
Age: mean 22.2
Gender: not stated
Diagnosis: none
Role of law enforcement: police recruits
Interventions

Intervention: Secondary Prevention
Strees Management training. Physical and cognitive modes of handling stress with the specific request made that the recruits practice the technique between sessions
Period of Training: 10 weeks
Session duration: 90 minutes
Regime: Group
Frequency: weekly

Control Group:
Ocassional lectures on stress in formal setting at irregular periods
Session duration: not stated
Period of training: 5 months
Frequency: irregular

OutcomesHormone analysis: adrenaline and noradrenaline
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Norvell 1993

MethodsRandomisation: method not specified.
Allocation concealment: not specified
Assessors concealed: not specified
Attrition bias : yes, not met .19 people dropped out from the treatment and there was no report of dropouts in the control group
ITT: not stated
Follow-up: not stated
Participants48 participants. Experimental Group: 33 and Control Group: 15.
Age: mean 32.84 (SD 7.88) (experimental and control group combined). This is based on 43 participants only.
Gender (M/F): 45/0
Diagnosis: none
Role of law enforcement officers: state law enforcement officers
Years of employment in law enforcement: 8.56 6.63
InterventionsIntervention: Secondary Prevention
Intervention group
Exercise form: individualized instruction in proper exercise technique and training guide written for this experiment. Circuit weight training. Intensity: Training involved 12 circuit machines. The amount of resistance for all exercise was set such that the weight could be lifted a minimum of 8 but not more than 12 repetitions. Weight was adjusted throughout the program such that when 12 or more repetitions were performed, participants were instructed to increase the resistance by 5% at the next session.
Session duration: 20 minutes
Period of training: 16 weeks
Number of sessions: 48
Frequency: 3 days/week.
Supervised training: monitored by facility staff
Control group:
Waiting list
Exercise form: instructed to refrain from additional exercise programs in the interim
OutcomesHopkins Symptom Checklist (SCL-90) Global Severity Index.
Job Descriptive Index (JDI)
Cohen-Hoberman Inventory of Physical Symptoms (CHIPS)
Perceived Stress Scale
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

O'Neill 1982

MethodsRandomisation: Randomisation stratified by gender
Allocation concealment: no. The person in charge of the treatment was the one in charge of allocation after the randomisation was done by the computer.
Assessors concealed: yes. People who assessed the blood sample and the questionnaire were not aware of the group states.
Attrition bias: no. Equal numbers of dropouts in each group.
ITT: no
Follow-up: 18 months
Participants86 Sheriff police officers. 86 in the Intervention group (because 39 declined the invitation and an additional of 28?).
Age: not stated
Gender (M/F): not stated
Diagnosis: none
Role of law enforcement officers: sheriff officers
Years of employment in law enforcement: not stated
Interventions

Intervention: Secondary Prevention
Experimental group:
1) Physical fitness modality:approach intervention: exercise and sport fitness
Regime: individual training
Period of intervention: not stated
Session duration:not stated
Frequency: 2 individual training
2) Psychological stress education approach in groups
Regime: group
Period of intervention: not stated
Session duration:1 1/2 hours
Frequency: weekly
3) Psychophysical modality :combination of Physical + Psychological approach (Two individual training + 1 1/2 weekly.)
Period of intervention: not stated
Session duration: not stated (physical approach) + 1 1/2 hour (psychological approach)
Frequency: weekly (psychological approach); not stated (physical approach)
Regime: Group and individually

4) Education: group only
Period of Intervention: not stated
Session duration: none
Regime: group
Frequency: not stated

OutcomesSCL 90
State-Trait Anxiety Index
Michigan Alcoholism Screning Test
Myers-Briggs Type Indicator
Police Job Strees Inventory
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Sarason 1979

MethodsRandomization: method not stated
Allocation concealment: not stated
Assessors concealed: not stated
Attrition bias: not stated
ITT: not stated
Follow up: not stated
Participants18 participants. Numbers in the experimental and control groups not specified.
Age: 22 to 34 years.
Gender (M/F): 10/8
Diagnosis: none
Role of law enforcement: Police Academy trainees
InterventionsIntervention: Primary prevention
Intervention group
Stress management program:
Regime: group
Development of awareness of their cognitive and physiological responses to anger-provoking and threatening situations and the way in which these responses can interfere with performance was accomplished through role playing, modelling and self-monitoring of responses during stressful situations.The idea was to develop a repertory of adaptive cognitive responses for use in preparing for an coping with stressors.Subjects also trained in progressive relaxation. Trainees observed models who displayed adaptive coping responses in the face of stress and practiced using coping skills themselves under conditions of stress.
Session duration: 2 hours
Period of training: 6 sessions
Control group:
Short course in abnormal psychology
Period of training: 6 sessions
Session duration: 2 hours
OutcomesState-Trait Anxiety Inventory
Test Anxiety Scale
Endler Hunt SR Inventory of Hostility
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Shipley 2002

MethodsRandomization: method not stated
Allocation concealment: not stated
Assessors concealed: not stated
Attrition bias: not stated
ITT: not stated
Follow up: none
Participants54 men and women. Experimental Group: 26 and Control Group: 28. Ontario Provincial.
Years of employment in law enforcement: 0
Age: not stated
Duration of illness: none
Gender (M/F): 20/6 and 20/8
Diagnosis: none
Role of law enforcement: police officers
InterventionsIntervention: Secondary Prevention
Visuo-Motor Behavoir Rehearsal
Session duration: 10 minutes of progressive relaxation portion + 20 minutes of an imagery/mental rehearsal portion administered by the senior author.
Period of training: once
Frequency: none.
The progressive relaxation portion of the exercise comprised a breathing exercise followed by systematic relaxation of major muscle groups, beginning with the head and face and concluding with the calves. The imagery/rehearsal portion was comprised of energizing cue words, positive self-statements, and imagery. They were instructed to have an open mind about the experience and to adopt a relaxed seating position.
Control group:
No treatment. Assessment only
OutcomesCSAI-2 State Anxiety Inventory-2
Subjetive evaluations
Performance evaluations
NotesNeed to contact the author for data for CSAI-2 before and after the intervention
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Short 1984

MethodsRandomisation: method not specified
Allocation concealment: not specified
Assessors concealed: not specified
Atrition bias: not specified
ITT: not specified
Follow-up: not specified
Participants45 participants from the large Metropolitan Police Department. Experimental Group: 22 and control group: 23
Age: 29 to 52 years (combining experimental and control group).
Gender (M/F): 22/0 23/0
Diagnosis: considered to be at least 20% over their optimum body weights.
Role of law enforcement officers: police officers
Interventions

Intervention: Secondary Prevention
Experimental Group: Conditioning Group
Theory exercise topics: instruction on topic regarding the principles of exercise; basic and advanced nutrition education; behavior modification techniques for altering dietary habits and the principles of cardiac conditioning, muscle development and endurance.
Session duration: 90 + 45 minutes
Period of training: 8 weeks
Frequency: 1 day/week
Number of sessions: 8

Exercise form: aerobic conditioning program. A supervised interval program of walk-jog activities of increasing duration and distance.
Session duration: 90 minutes
Period of training: 8 weeks
Frequency: 3 day/week
Regime: not stated

Control Group:Instruction group (instruction alone)
Exercise form: maintain activity habits similar to those before the study and refrain from any extra physical conditioning during the study.
Theory exercise topics: instruction on topic regarding the principles of exercise; basic and advanced nutrition education; behavior modification techniques for altering dietary habits and the principles of cardiac conditioning, muscle development and endurance.
Session duration: 90 minutes
Period of training: 8 weeks
Frequency: 1 day/week

OutcomesTennesse Self Concept Scale (TSCS)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Wilson 2001

MethodsRandomisation: method not specified
Allocation concealment: not specified
Assessors concealed: met. An independent assessor who was blind to the treatment allocation administered all outcomes measures.
Attrition bias : no
ITT: no
Follow-up: 6 months after the last assessment.
Participants62 men and women from the Colorado Spring Police Department. Experimental group: 33 and control roup 29.
Age: 23 to 53 years (mean: 36.8 SD: 7.02)
Diagnosis: none
Gender (M/F): 50/12
Role of law enforcement officers: police officers
Exclusion criteria: not having a significant other who would participate, being in current therapy for the specific stressor, being unwilling to meet the time commitments for the study.
Interventions

Intervention: Secondary Prevention
Experimental intervention
Stress Management Program:EMDR
Session duration: 120 minutes
Period of training: 3 times
Frequency of sessions: not sated

Control Group
Job stress Program
Video course as a tool for reducing stress. Each topic is accompanied by workbook, which provides an overview for the 15 minutes video tape for that topic. The workbook includes stop and reflect questions that focus attention on the issues covered in the videotape, a summary of the skills and strategies discussed in the tape and a stop and reflect section to design a plan of action for dealing with stressors.
Session duration: 1 hour
Period of training: 6 sessions

OutcomesSubjective Units of Disturbance Scale (SUDS)
State-trait Anger Expression Inventory (STAXI)
Police Stress Inventory (PSI)
Job Stress Survey (JSS)
Coping Response Inventory (CRI)
Marital relationship Test (MAT)
Post-traumatic Stress Diagnostic Scale (PTSD)
Symptom Check List-90-Revsed (SCL-90-R)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment?Unclear riskB - Unclear

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Arokoski 2002Non-randomised controlled trial.
Bar 2004Non-randomised controlled trial.
Carlier 1998Non-randomised controlled trial.
Carlier 2000Non-randomised controlled trial.
Danish 1970Non-randomised controlled trial.
Gersons 2000Outcomes not relevant to the current review. Not a prevention intervention.
Godschalx 1984Non-randomised controlled trial.
Harrel 1993Non-randomised controlled trial.
McMurray 1998Outcomes not relevant to the current review. Cluster randomised controlled trial.
Meadows 1985Outcomes not relevant to the current review. Non-randomised controlled trial.
Norris 1990Non-randomised controlled trial.
Pinfold 2003Non-randomised controlled trial.
Richmond 1999bNon-randomised controlled trial.
Schmit 1996Non-randomised controlled trial.
Tolin1999Non-randomised controlled trial.
Wallace 1977Non-randomised controlled trial.

Ancillary