International Adaptation of a brief Problem-Solving Skills (the IAPPS trial) training for people in custody with severe mental illness in Poland: an open multicentred, parallel group, feasibility randomised controlled trial.

This open multicentred feasibility randomised controlled trial conducted in two Polish prisons demonstrates that an adapted brief problem-solving skills intervention for men with severe mental illness is feasible to deliver and retain, despite logistical challenges and differential follow-up rates.

The Gist

Imagine a prison not just as a place of confinement, but as a crowded, noisy room where everyone is stressed, bored, and struggling to solve the massive problems in their lives. For many inmates, especially those with severe mental health issues, these problems feel like a tangled knot they can't untie, leading to depression, violence, or self-harm.

This paper is about a team of researchers trying to teach these men a new way to untie that knot using a tool called Problem-Solving Skills (PSS). They tested this in two Polish prisons to see if it was even possible to run such a study in such a difficult environment.

Here is the story of their experiment, broken down into simple parts:

1. The Goal: A "Feasibility" Test

Think of this study not as the final exam, but as a dress rehearsal. The researchers didn't try to prove the training definitely cures depression yet. Instead, they wanted to answer three practical questions:

• Could they get enough people to say "yes" to joining?
• Could they keep the people in the study until the end?
• Could they actually deliver the training without the prison rules stopping them?

2. The Players and the Setting

• The Setting: Two high-security prisons in Poland. Imagine these as very strict, busy hotels where the guests (inmates) have nowhere to go and very little to do.
• The Guests: 64 men, mostly Polish, with an average age of 53. Many had been in prison before, and most were serving life sentences. They all had mental health diagnoses (like depression, schizophrenia, or personality disorders).
• The Team: Researchers from the UK and Poland who acted like "coaches" trying to teach a new game.

3. The Intervention: The "Problem-Solving Toolkit"

The researchers took a proven method used in the UK and adapted it for Polish culture. Think of it as a 7-step recipe for solving life's headaches:

1. Is there a problem?
2. Describe it clearly.
3. Gather information.
4. Think of different options.
5. Pick the best option.
6. Make a plan.
7. (Implied) Try it out.

How it worked:
Instead of long, boring lectures, the men met in tiny groups (max 5 people) for just 1.5 hours over two weeks. They watched a short cartoon animation about someone solving a relationship problem, filled out a workbook, and practiced the steps. It was like a "mini-boot camp" for the brain.

4. The Experiment: The "Tug-of-War"

The men were randomly split into two teams:

• Team A (The Intervention): Got the Problem-Solving training plus the usual prison care (doctors, nurses, etc.).
• Team B (The Control): Got only the usual prison care.

5. The Results: Did the Rehearsal Work?

The results were a mix of "Great news!" and "We hit a few walls."

• Recruitment (Getting people to join): They managed to sign up 48% of the people they approached. In the chaotic world of prisons, getting nearly half the people to say "yes" is like getting half the crowd at a concert to stay for the encore. It was a success.
• Retention (Keeping people): Almost everyone (95%) finished the study. This is likely because most of these men were serving life sentences; they weren't going anywhere, so they stayed in the study.
• The Hiccups (The "Prison Regime"): Prisons are unpredictable.
  • The researchers planned to test the men after 6 weeks, but prison schedules forced them to wait until 10 weeks.
  • They planned for multiple training sessions, but prison rules only allowed one session.
  • Some men in the training group were less likely to finish the final paperwork than the control group, perhaps because they were busy or distracted.

6. The Takeaway: Why This Matters

Even though the study wasn't big enough to prove the training cures depression, it proved something vital: You can do high-quality science inside a prison.

• The Analogy: Imagine trying to build a house in a storm. This study proved that you can lay the foundation and frame the walls even when the wind is howling. It didn't prove the house is perfect yet, but it proved the blueprint works.
• The Future: The data shows that with careful planning, researchers can teach mental health skills to prisoners in Poland. This paves the way for a much bigger, more detailed study in the future to see if this "toolkit" actually stops depression and violence.

In short: The researchers successfully tested the waters. They showed that teaching problem-solving skills to prisoners with mental health issues is possible, acceptable, and worth doing, even in the complex, rigid environment of a Polish prison.

Technical Summary

1. Problem Statement

• Context: The mental health of incarcerated individuals is a global public health crisis, characterized by disproportionately high rates of depression, self-harm, and violent behavior compared to the general population.
• Specific Challenge: In Poland, as in many jurisdictions, resources for individualized therapy in prisons are scarce. Furthermore, cultural stigma surrounding mental health disclosure in Poland creates barriers to intervention.
• Gap: While Problem-Solving Skills (PSS) training has shown efficacy in UK prisons and community settings, there is a lack of evidence regarding its feasibility, acceptability, and delivery within the Polish prison system for men with severe mental illness.
• Objective: To assess the feasibility of delivering an adapted, brief PSS intervention in two Polish prisons to inform the design of a future definitive large-scale Randomized Controlled Trial (RCT).

2. Methodology

• Study Design: An open-label, multi-centred, parallel-group feasibility Randomized Controlled Trial (RCT).
• Setting: Two closed prison facilities in Poland with therapeutic wings: ZK Racibórz and ZK Kłodzko.
• Participants:
  • Target: Male adults (18+) residing in therapeutic units with a mental health diagnosis.
  • Inclusion: Sentence length >3 months; ability to provide informed consent.
  • Exclusion: Learning disabilities, risk to research staff, or inability to consent.
  • Sample: 129 screened, 64 randomized (31 to Intervention, 33 to Control).
• Intervention:
  • Group: Adapted Problem-Solving Skills (PSS) + Care As Usual (CAU).
  • Content: A 7-step cognitive-behavioral model (Is there a problem? Describe it; Get info; Think options; Choose option; Make plan).
  • Delivery: Delivered by a qualified CBT Psychotherapist in groups of up to 5.
  • Format: Two weeks of sessions (originally planned as multiple sessions, condensed due to prison regime constraints). Included a digital animation, workbook completion, and skill practice.
  • Control: Care As Usual (CAU) only (standard prison medical/psychological services).
• Outcome Measures:
  • Primary: Recruitment rate, follow-up rates, and feasibility of delivery (attrition).
  • Secondary: Depression (PHQ-9), General Mental Health (GHQ-28), and Coping Strategies (COPE-36).
• Statistical Analysis: Descriptive statistics (means, SDs, medians) and 95% confidence intervals. No power calculation for statistical significance was performed as this was a feasibility study. Analysis was Intention-to-Treat (ITT).

3. Key Contributions

• Cultural Adaptation: Successfully adapted a UK-based PSS model for the Polish cultural context, addressing specific barriers such as the stigma of admitting to mental health issues.
• Feasibility in Complex Settings: Demonstrated that RCTs can be implemented within the restrictive and unpredictable environment of Polish prisons.
• Protocol Deviation Handling: Documented necessary adaptations (e.g., changing follow-up from 6 to 10 weeks, condensing intervention sessions) due to prison regime constraints, providing a roadmap for future researchers in similar environments.
• Population Specificity: Focused on a high-need, often overlooked demographic: men with severe mental illness (including personality disorders, schizophrenia, and hyperactivity) serving long-term or life sentences.

4. Results

• Recruitment:
  • Rate: 48% (64 participants randomized out of 129 screened).
  • Exclusions: 67 excluded (58 declined, 5 refused post-consent, 2 deemed a risk).
• Retention & Follow-up:
  • Completion: 96% retention at 10 weeks post-randomization (30 in PSS group, 32 in CAU group).
  • Demographics: Mean age 53.5 years; 95% Polish origin; 85% were repeat offenders; 96% were serving life sentences.
• Intervention Delivery:
  • The intervention was successfully delivered, though logistical constraints forced a condensation of the schedule.
  • Differential follow-up was noted: Intervention group participants were slightly less likely to complete the post-test battery compared to the CAU group, though overall retention remained high.
• Secondary Outcomes (Descriptive):
  • Depression (PHQ-9) & Social Dysfunction: Post-test scores were slightly lower (indicating improvement) in the PSS group compared to the CAU group, though the study was not powered to determine statistical significance.
  • Coping Strategies (COPE-36): Scores were similar between groups.
  • Safety: No adverse events were reported.

5. Significance and Limitations

• Significance:
  • Proof of Concept: The study confirms that brief, evidence-based psychological interventions are feasible and acceptable for men with severe mental illness in Polish prisons.
  • Future Research: Provides critical data on recruitment timelines and resource requirements to power a definitive Phase III RCT.
  • Policy Implication: Supports the integration of low-cost, high-impact psychological skills training into prison therapeutic units to address the crisis of mental health and violence in custody.
• Limitations:
  • Sample Size: Fell short of the target (64 vs. 80), limiting the precision of feasibility estimates.
  • Generalizability: Findings are specific to male prisoners with severe mental illness in therapeutic wings; results may not apply to female prisoners or those without complex mental health needs.
  • Protocol Deviations: The intervention was delivered in a single condensed session rather than the planned multi-session format, and follow-up was extended to 10 weeks, potentially affecting engagement metrics.
  • Short Follow-up: A 10-week period may be insufficient to assess long-term behavioral changes or relapse prevention.

Conclusion: The IAPPS trial successfully demonstrated that adapting and delivering a brief Problem-Solving Skills intervention in Polish prisons is feasible. While the study was not designed to prove clinical efficacy, the high retention rates and successful delivery provide a strong foundation for a larger, definitive trial to evaluate the intervention's impact on depression, self-harm, and violence in this population.