You are on page 1of 24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

U.S. National Library of Medicine - The World's Largest Medical Library Home > Clinical Guides > Antisocial Personality Disorder:... > INTERV ENTIONS FOR PEOPLE WITH ANTISOCIAL... Print
Pu bMed Hea lt h . A ser v ice of t h e Na t ion a l Libr a r y of Medicin e, Na t ion a l In st it u t es of Hea lt h .

National Collaborating Centre for Mental Health (UK). Antisocial Personality Disorder: Treatment, Management and Prev ention. Leicester (UK): British Psy chological Society ; 201 0. (NICE Clinical Guidelines, No. 7 7 .)

7 INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS
7.1 INTRODUCTION
Both psy chological and pharmacological interv entions for people with antisocial personality disorder are poorly researched and direct ev idence on the treatment of this population is scarce. Three relativ ely recent rev iews failed to identify any high-quality ev idence for people receiv ing treatment for antisocial personality disorder (Salekin, 2002; Warren et al. , 2003; Duggan et al. , 2007 a). A number of approaches hav e been adopted to address this problem: the use of lower quality ev idence, including ev idence such as case studies and case series (for ex ample, Salekin, 2002); the use of research on other personality disorders or mix ed populations of people with personality disorder including a proportion with antisocial personality disorder, usually a relativ ely small proportion (for ex ample, Warren et al. , 2003); and consideration of the impact of treatments for comorbid problems (such as drug misuse) in antisocial personality disorder populations (Duggan et al. , 2007 a). All three approaches are problematic in guiding treatment choice for antisocial personality disorder because of difficulties understanding causality (Salekin, 2002), lack of generalisability (Warren et al. , 2003), and the lack of direct ev idence for the treatment of the disorder itself (Duggan et al. , 2007 a). In order to address these limitations, the GDG opted to identify the best av ailable ev idence on: i. the treatment of people with antisocial personality disorder this was to ensure that new studies or studies ex cluded by other rev iews could be considered ii. the treatment of specific components of the diagnostic construct of antisocial personality disorder (for ex ample, impulsiv ity and aggression) this was to include important ev idence on the treatment of a particular aspect of antisocial personality disorder iii. interv entions for offenders that aim to reduce re-offending this was considered important because offending and related behav iours are both key to the difficulties associated with antisocial personality disorder. The GDG recognised that the inclusion of ev idence for offending behav iour was potentially controv ersial and that offending behav iour might be seen as a poor prox y outcome in the treatment of antisocial personality disorder. The rationale for using offending behav iour as a prox y for a diagnosis of antisocial personality disorder (where the latter has not been recorded) is threefold. First, a history of antisocial behav iour is a particular feature of antisocial personality disorder in the DSM-IV diagnostic sy stem (APA, 2000), specifically the failure to conform to social norms with respect to lawful behav iours as indicated by repeatedly performing acts that are grounds for arrest. Second, interv entions aimed at reducing offending behav iour often focus on other diagnostic criteria of antisocial personality disorder as mediating v ariables in the treatment process. To date, such work has included studies of impulsiv ity , aggressiv eness, and lack of remorse as treatment targets. Therefore, ev idence that has a bearing on the amelioration of these factors is also potentially relev ant to the treatment of antisocial personality disorder. Third, surv ey s of offenders v ery often find high rates of personality disorder that are significantly abov e the lev els found in community -based studies of prev alence, in particular among those who are imprisoned and those with entrenched patterns of more serious offences. As noted earlier, a surv ey for the UK Office for National Statistics interv iewed 3,1 42 prisoners and found that 49% of male sentenced prisoners, 63% of males on remand, and 31 % of female prisoners met criteria for diagnosis of antisocial personality disorder (Singleton et al. , 1 998).

7.1.1 T reatment of comorbid disorders


Giv en the limited ev idence for the treatment of antisocial personality disorder and that guidance on disorders commonly comorbid with antisocial personality disorder generally does not consider the impact of antisocial personality disorder on treatment recommendations, the GDG decided to rev iew the ev idence for the treatment of comorbid disorders. The ev idence on the treatment of comorbid disorders was restricted to populations with antisocial personality disorder, and ev idence was not ex trapolated from studies of offenders or other populations. In the rev iew of interv entions for offending behav iour, the GDG also decided to include studies of interv entions for drug and alcohol

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

1/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

misuse and dependence in offender populations where such studies met quality criteria.

7.2 PSYCHOLOGICAL INTERVENTIONS FOR ANTISOCIAL PERSONALITY DISORDER


7.2.1 Introduction
There has been little formal dev elopment of psy chological interv entions specifically for the treatment of antisocial personality disorder with considerably more emphasis placed on the psy chological treatment of other personality disorders, primarily borderline personality disorder (for ex ample, Kernberg, 1 984; Linehan, 1 997 ). As with personality disorder more generally , psy choanaly tic approaches to treatment held sway initially (Cordess & Cox , 1 998); more recently dev elopments in cognitiv e behav ioural treatments hav e emerged but such approaches in antisocial personality disorder are not supported by a strong ev idence base (Duggan et al. , 2007 a). Psy chological interv entions for comorbid disorders are, by contrast, well dev eloped and are as effectiv e or more effectiv e than pharmacological treatments for common mental disorders (for ex ample, NCCMH, 2005a, 2005b, 2006). This suggests that such interv entions may hav e a significant role to play in the treatment of comorbid disorders in antisocial personality disorder. Similarly effectiv e psy chological treatments for drug and alcohol disorders hav e also been dev eloped (NCCMH, 2007 a) and may again be of benefit to people with antisocial personality disorder with comorbid drug and alcohol problems. Although psy chological interv entions specifically for antisocial personality disorder are limited, interv entions for some of the components of the antisocial personality disorder diagnostic construct hav e been better dev eloped, principally for the treatment or management of aggression. Howev er, the relev ance of anger management as an interv ention for an aspect of the antisocial personality disorder diagnostic construct may be limited. Anger is not ex plicitly included in the diagnostic criteria for antisocial personality disorder and while anger may be related to impulsiv ity and aggression, reducing anger may not reduce impulsiv ity and aggression. Equally , when deliv ered to offenders, anger management interv entions may reduce lev els of anger without hav ing an impact on offending, aggressiv e or v iolent behav iours if the causes of those behav iours in an indiv idual are unrelated to anger. The majority of literature on anger management has focused on populations of college students (Edmonson & Conger, 1 996; Del V ecchio & OLeary , 2004; Beck & Fernandez, 1 998). The GDG felt that it would not be appropriate to ex trapolate from college students with elev ated lev els of anger to people with antisocial personality disorder. As a consequence, this rev iew is not concerned with the efficacy of anger management in these populations. In contrast to the limited dev elopment of specific treatment for antisocial personality disorder, there has been considerable dev elopment of interv entions aimed at reducing offending behav iour. These include a wide range of cognitiv e and behav ioural interv entions (for ex ample, Landenberger & Lipsey , 2005; Lipsey et al. , 2001 , 2007 ; Lipton et al. , 2002; Tong & Farrington, 2006; Wilson et al. , 2005), and to a lesser ex tent therapeutic communities (Lees et al. , 2003). Within the UK criminal justice sy stem the use of cognitiv e and behav ioural interv entions such as Reasoning and Rehabilitation (for ex ample, Cann et al. , 2003) and Enhanced Thinking Skills (for ex ample, Friendship et al. , 2002) is widespread. Current practice Healthcare services Most people with antisocial personality disorder in the community remain undiagnosed and untreated (Department of Health, 2003). They do not come into contact with mental health serv ices and often do not perceiv e any need for treatment of their personality problems. Some people with the disorder may seek treatment for comorbid mental health disorders, including anx iety and depression, but whether they hav e a formal diagnosis of antisocial personality disorder or not, they may nev ertheless be ex cluded from serv ices because of their personality disorder or the mistaken belief that they will not be able to benefit from treatment. People with antisocial personality disorder may also make limited use of inpatient serv ices in a crisis but are unlikely to be offered or engage in long-term treatment. In contrast to mental health serv ices, a significant number of people with antisocial personality disorder are treated by drug and alcohol serv ices in both the statutory and non-statutory sector. Here the focus on treatment will be on the drug or alcohol misuse not the personality problem. Health serv ices treating people specifically for their antisocial personality disorder are largely limited to specialist healthcare serv ices such as forensic serv ices. Howev er, ev en within forensic serv ices specific prov ision for antisocial personality disorder is underdev eloped. At the v ery sev ere end of the spectrum the recent dev elopment of the Dangerous and Sev ere Personality Disorder Serv ice (Home Office, 1 997 ) has seen the establishment of new units in two special hospitals (Rampton and Broadmoor) and two high secure prisons (HMP Frankland and HMP Whitemoor). The criminal justice system

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

2/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

The large majority of people receiv ing interv entions for antisocial personality disorder and related problems will be in the criminal justice sy stem, with the interv entions prov ided either by the probation or prison serv ices. The ex plicit aim of these interv entions is to reduce offending behav iour. These interv entions are highly manualised and subject to stringent quality assurance and auditing (T3 Associates, 2003). Whether indiv iduals in the criminal justice sy stem receiv e interv entions will depend on a range of factors including the av ailability of places on offending behav iour programmes in the institution or probation serv ice, the ty pe and length of their sentence (as this may or may not facilitate their enrolment in a programme), and, if they are in prison, whether they v oluntarily choose to enrol on a programme. The majority of psy chological interv entions deliv ered in the criminal justice sy stem are cognitiv e behav ioural and largely based on social learning theory , a dev elopment of behav ioural learning models that has been adapted to take account of findings from cognitiv e and dev elopmental psy chology (Bandura, 2001 ). These interv entions include: behav iour modification; relax ation training; sy stematic desensitisation; social skills training; problem-solv ing therapy ; cognitiv e therapy ; and moral reasoning or moral reconation therapy . V irtually all of these methods hav e been employ ed in efforts to reduce offending behav iour and this represents the largest research base of ev idence for interv entions with offenders. The literature has been rev iewed in a number of meta-analy ses (for ex ample, Lipton et al. , 2002; Landenberger & Lipsey , 2005; Tong & Farrington, 2006; Lipsey et al. , 2007 ). Bey ond the health and criminal justice sy stem interv entions, the prov ision of care and support for people with antisocial personality disorder is also v ery limited. As they may cause disruption and a threat to staff or other serv ices users, people with antisocial personality disorder may find themselv es ex cluded from a range of serv ices that might otherwise support them in the community (including during transition from the care of the criminal justice sy stem to the community ), such as housing, welfare and employ ment serv ices.

7.2.2 Definition and aim of review


The rev iew considered psy chological interv entions for antisocial personality disorder and its constructs. This included interv entions for people specifically diagnosed with antisocial personality disorder, but also interv entions for the sy mptoms or behav iours associated with this diagnostic construct including anger, impulsiv ity and aggression. Howev er, studies of populations with diagnoses of serious mental illness (including schizophrenia) were ex cluded. In addition, interv entions for offending behav iour in people without a diagnosis of antisocial personality disorder were considered, including for offenders with substance misuse problems. Outcom es For the rev iew of the effectiv eness of interv entions for adults with antisocial personality disorder, the GDG chose re-offending as the primary outcome. There are a number of measures of re-offending including conv iction, arrest, breaches of conditions attached to parole or probation, re-incarceration and recidiv ism. Conv iction was considered the most robust measure but where this was not reported other re-offending outcomes were ex tracted in the order of priority listed abov e.

7.2.3 Databases searched and inclusion/exclusion criteria


Information about the databases searched and the inclusion/ex clusion criteria used for this section of the guideline can be found in Table 28 (further information about the search for health economic ev idence can be found in Appendix 1 1 .) T able 28 Databases searched and inclusion/ex clusion criteria for clinical ev idence. The rev iew team conducted a series of sy stematic searches for RCTs that assessed the efficacy and cost effectiv eness of psy chological interv entions specifically for the treatment of antisocial personality disorder, behav iours or sy mptoms associated with the antisocial personality disorder construct, and offending behav iour (see Table 31 ). T able 31 Study information table for group-based cognitiv e and behav ioural interv ention compared with non-treatment control for substance misuse offenders. One trial (DAV IDSON2008) met the eligibility criteria of the GDG in the first sy stematic search to assess the treatment of antisocial personality disorder. Two further searches were conducted separately on behav iours and sy mptoms associated with the antisocial personality disorder construct, and on offending behav iour.
11

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

3/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

7.2.4 Studies considered11


A total of 22 trials relating to clinical ev idence met the eligibility criteria set by the GDG, prov iding data on 3,237 participants. Of these, two trials were reported in books (JOHNSON1 995, PORPORINO1 995), two were reports from the US Department of Justice (AUSTIN1 997 , PULLEN1 996), and 1 8 were published in peer-rev iewed journals between 1 97 3 and 2008 (ARMSTRONG2003, DAV IDSON2008, DEMBO2000, DUGAN1 998, ELROD1 992, GREENWOOD1 993, GUERRA1 990, KINLOCK2003, LEEMAN1 993, LIAU2004, OSTROM1 97 1 , ROHDE2004, ROSS1 988, SCHLICHTER1 981 , SHIV RATTAN1 988, SPENCE1 981 , V AN V OORHIS2004, V ANNOY 2004). In addition, 97 studies were ex cluded from the analy sis. The most common reason for ex clusion was lack of a comparison group (further information about both included and ex cluded studies can be found in Appendix 1 5). For the treatment of people with antisocial personality disorder, there was one trial (DAV IDSON2008) that met the eligibility criteria of the rev iew prov iding information on 39 participants. For the treatment of people with sy mptoms or behav iour associated with the antisocial personality disorder construct, there was one trial that inv estigated the treatment of anger by comparing anger management with control (V ANNOY 2004). For the treatment of offending behav iour in adults with substance misuse problems, there were four trials inv estigating cognitiv e and behav ioural interv entions, three of which were group-based interv entions (AUSTIN1 997 ; JOHNSON1 995; KINLOCK2003) and one which was indiv idually based (DUGAN1 998). For the treatment of offending behav iour in adults, there were fiv e trials comparing group-based cognitiv e and behav ioural interv entions with control (ARMSTRONG2003; LIAU2004; PORPORINO1 995; ROSS1 988; V ANV OORHIS2004). For the treatment of offending behav iour in y oung people, sev en trials compared group-based cognitiv e and behav ioural skills interv entions with control (GUERRA1 990; LEEMAN1 993; OSTROM1 97 1 ; PULLEN1 996; ROHDE2004; SCHLICHTER1 981 ; SPENCE1 981 ); one trial was on indiv idual cognitiv e and behav ioural interv entions (SHIV RATTAN1 988) and three trials compared multi-component interv entions with control (ELROD1 992; GREENWOOD1 993; DEMBO2000).

7.2.5 Clinical evidence for the treatment of antisocial personality disorder


The search identified one study relating to the treatment of antisocial personality disorder (DAV IDSON2008). The study compared CBT with treatment as usual for people with antisocial personality disorder liv ing in the community (see Table 29 and Table 30). Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . T able 29 Study information table on CBT for treatment of antisocial personality disorder. T able 30 GRADE ev idence summary for interv entions for antisocial personality disorder. DAV IDSON2008 did not find an effect for CBT on anger or v erbal aggression compared with treatment as usual for people with antisocial personality disorder in the community . The trial did find a small, non-significant effect for social functioning and phy sical aggression compared with treatment as usual.

7.2.6 Clinical evidence summary for the treatment of antisocial personality disorder
The ev idence for the treatment of antisocial personality disorder in the community is limited to one trial. The quality of the ev idence is low to moderate where further research is likely to hav e an impact on the effect estimate of CBT in the community for people with antisocial personality disorder. The limited economic ev idence from this trial suggests that CBT may not be cost sav ing in the short term (see below).

7.2.7 Economic evidence for the treatment of antisocial personality disorder


One economic study on psy chological treatment of antisocial personality disorder was included in the sy stematic economic literature rev iew (Dav idson et al. , 2008). The study , which was conducted in the UK, was a simple cost analy sis of CBT plus treatment as usual v ersus treatment as usual alone conducted alongside an RCT included in the guideline sy stematic rev iew of clinical ev idence (DAV IDSON2008). The study ex amined healthcare costs (including psy chiatric care, accident and emergency v isits and primary care), social work costs and costs borne by the criminal justice sy stem. The time horizon of the analy sis was 1 2 months. Ov erall, the total cost per person in the CBT group was higher than the respectiv e cost in the treatment as usual group

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

4/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

(38,004 v ersus 31 ,097 , respectiv ely ). The healthcare cost was similar in both groups (1 ,295 in the CBT group and 1 ,1 33 in the TAU group). The cost of prov iding CBT was 1 ,300 per participant. Details on the methods used in the sy stematic rev iew of the economic literature are described in Chapter 3. Ev idence tables for all economic studies included in the guideline economic literature rev iew are in Appendix 1 4.

7.2.8 Clinical evidence for the treatment of the constructs of antisocial personality disorder
One trial relating to clinical ev idence for the treatment of the constructs of antisocial personality disorder met the eligibility criteria set by the GDG, prov iding data on 31 participants (V ANNOY 2004). The included study was a trial of group-based anger management v ersus waitlist in an offender population. This small study reported data only on a continuous measure and was considered to be of low quality . The outcomes of the trial were trait anger (STAXI; SMD 0.64, 1 .36 to 0.09) and state anger (STAXI; SMD 0.96, 1 .7 0 to 0.21 ).

7.2.9 Clinical evidence summary for the treatment of the constructs of antisocial personality disorder
The ev idence for the treatment of the constructs of antisocial personality disorder is ex tremely limited and does not support the dev elopment of any recommendations.

7.2.10 Economic evidence for the treatment of the constructs of antisocial personality disorder
No ev idence on the cost effectiv eness of treatment of the constructs of antisocial personality disorder was identified by the sy stematic search of the literature. Details on the sy stematic search of the literature are prov ided in Chapter 3.

7.2.11 Clinical evidence for the treatment of offending in substance misuse offenders
The rev iew found four trials that inv estigated cognitiv e and behav ioural interv entions for the treatment of offending in substance misuse offenders, three of which were group based interv entions (AUSTIN1 997 ; JOHNSON1 995; KINLOCK2003) and one was indiv idually based (DUGAN1 998). This rev iew prov ided data on 582 participants (see Table 31 and Table 32). Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . T able 32 GRADE ev idence summary for the treatment of offending in substance misuse offenders. For the treatment of offending in substance misuse offenders, the fiv e included studies were identified as cognitiv e and behav ioural interv entions. The rev iew found this interv ention to hav e a medium effect on offending and major infractions combined (RR = 0.7 6; 0.60, 0.97 ) and a small non-significant effect on mean number of offences (SMD 0.1 9; 0.1 8 to 0.55).

7.2.12 Clinical evidence summary for the treatment of offending in substance misuse offenders
There appears to be modest ev idence for the effectiv eness of cognitiv e and behav ioural interv entions, primarily deliv ered in groups, in reducing offending for adults with substance misuse problems. This effect has been found in a v ariety of settings including institutional prison-based settings and outpatient and probation settings in the community .

7.2.13 Economic evidence for the treatment of offending in substance misuse offenders
One study met the inclusion criteria for the sy stematic economic literature rev iew (Alemi et al. , 2006). The study , which was conducted in the US, compared the costs ov er 2.7 5 y ears of a combination of probation and substance misuse treatment v ersus probation alone. Ov erall, a combination of probation and treatment was $6,300 more ex pensiv e than traditional probation per participant annually , mainly because of greater mental hospitalisation and additional treatment costs. The study characteristics and results are presented in the form of ev idence tables in Appendix 1 4. Details on the sy stematic search of the economic literature are prov ided in Chapter 3.

7.2.14 Clinical evidence for the treatment of offending behaviour in adults


There were fiv e trials comparing the effects of group-based cognitiv e and behav ioural interv entions with control on re-offending for adult offenders treated within the criminal justice sy stem (institutional settings or in the community on probation or parole) (see Table 33 and Table 34). Conv iction was

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

5/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

considered the most robust measure of re-offending but where this was not reported, other re-offending outcomes were ex tracted (for further details see Section 7 .2.2). Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . T able 33 Study information table for group-based cognitiv e and behav ioural interv entions for offenders. T able 34 GRADE ev idence summary for group-based cognitiv e and behav ioural interv ention for offenders. Group-based cognitiv e and behav ioural interv entions were found to prov ide a modest effect on reoffending (RR 0.7 8; 0.55 to 1 .08). The population included in this analy sis was predominantly adult male offenders. LIAU2004, which included a small proportion of female offenders, was not included in the meta-analy sis because it was not possible to ex tract intention-to-treat (ITT) data.

7.2.15 Clinical evidence summary for the treatment of offending behaviour in adults
There appears to be modest ev idence for the effectiv eness of group-based cognitiv e behav ioural skills interv entions, deliv ered in community and institutional settings, in reducing offending for adults in the criminal justice sy stem. Group-based cognitiv e behav ioural skills interv entions for offending behav iour deliv ered to offenders in criminal justice settings (prison/institutional settings and probation/parole) hav e a small but positiv e effect on the rate of re-offending for adult male offenders aged 21 and ov er. Howev er, the more limited ev idence base on y oung adult offenders aged 1 8 to 20 indicates that y oung offenders do not respond to these interv entions.

7.2.16 Health economic evidence for the treatment of offending behaviour


Sy stem atic literature rev iew One US study focusing on interv entions targeted at adult offenders was identified by the sy stematic search of economic literature (Zhang et al. , 2006). The study ev aluated a state-wide multiple community -based serv ices parole programme in California by comparing programme costs with incarceration costs av oided because of decreases in recidiv ism. Ov er 2 y ears, programme participants had lower recidiv ism and reincarceration rates than the untreated population, resulting in significant net sav ings of $21 million. Econom ic m odelling Objective The guideline sy stematic rev iew and meta-analy sis of clinical ev idence demonstrated that prov ision of Reasoning and Rehabilitation, a group-based cognitiv e behav ioural skills interv ention (Cann et al. , 2003), to adult offenders can potentially reduce the rates of future offending behav iour. Offending behav iour leads to substantial costs to the society , including the criminal justice sy stem and v ictims of crime. A cost analy sis was undertaken to assess whether the costs to the NHS of prov iding Reasoning and Rehabilitation to adults with offending behav iour are offset by future cost sav ings resulting from reduction in re-offending behav iour in this population. Methods Intervention examined Reasoning and Rehabilitation programmes are offered to people with offending behav iour in institutional and community correctional settings. They ty pically consist of 38 curriculum-based sessions of 2 hours duration each ov er approx imately 8 to 1 2 weeks. Programmes are deliv ered to small groups of eight to ten participants (T3 Associates, 2003). Costs considered in the analysis A simple economic model was dev eloped to estimate the net total costs (or cost sav ings) associated with prov ision of Reasoning and Rehabilitation to adult offenders. Published ev idence on the costs incurred by adults with offending behav iour is limited. One study conducted in the UK that assessed the effectiv eness of CBT in adults with antisocial personality disorder reported 1 2-month serv ice costs incurred by this population, including healthcare, social work and criminal justice sy stem costs (Dav idson et al. , 2008). The total costs per adult with antisocial personality disorder receiv ing CBT ov er 1 2 months were 38,000. Of these, only 7 % were healthcare costs (including prov ision of CBT); the v ast majority of costs were associated with social work and use of criminal justice sy stem serv ices. NICE recommends that economic analy ses of healthcare interv entions adopt a NHS and PSS

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

6/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

perspectiv e (NICE, 2006a). Howev er, the criminal justice sy stem and social and other public serv ices are likely to bear the majority of costs incurred by adults with offending behav iour and only a small proportion of costs fall on the NHS and PSS. For this reason, the economic analy sis adopted a broader perspectiv e than that of the NHS and PPS, including any costs to public serv ices for which appropriate information was av ailable. Ex isting clinical ev idence suggests that prov ision of Reasoning and Rehabilitation to adults with offending behav iour may reduce rates of re-offending, and therefore costs relating to crime. It is unknown whether participation of adult offenders in such programmes has an effect on other costs, such as costs to health and social care serv ices, although it is likely that reducing offending behav iour may result in a decrease in other costs too. Because of lack of appropriate relev ant data that could inform the economic model, the analy sis has considered only interv ention costs (that is, costs of prov iding Reasoning and Rehabilitation) and costs related to crime/adult offending behav iour. All other categories of public sector costs, such as health and social care costs, were conserv ativ ely assumed to be the same for adult offenders participating in Reasoning and Rehabilitation programmes and for those not receiv ing the interv ention, and were subsequently omitted from the analy sis. This is acknowledged as a limitation of the economic analy sis. Howev er, costs relating to crime are likely to constitute the most substantial part of the costs incurred by adult offenders; therefore, the economic analy sis is likely to hav e considered the majority of costs associated with prov iding Reasoning and Rehabilitation to adults with offending behav iour. Model input param eters Clinical efficacy of Reasoning and Rehabilitation and baseline re-offending rate in adult offenders Clinical data on re-offending rates associated with Reasoning and Rehabilitation were taken from three studies (PORPORINO1 995; ROSS1 988; V AN V OORHIS2004). Meta-analy sis of these data undertaken for the guideline showed that the interv ention reduced the rate of re-offending in adult offenders compared with no treatment, but results were non-statistically significant at the 0.05 lev el (mean RR of reoffending for Reasoning and Rehabilitation v ersus control: 0.7 8; 95% CI: 0.55 to 1 .08). These results were characterised by considerably high heterogeneity caused by inclusion of ROSS1 988 in the metaanaly sis. When this study was remov ed, there was no heterogeneity in the results but the effect of the interv ention was reduced (mean RR of re-offending for Reasoning and Rehabilitation v ersus control: 0.88; 95% CI: 0.7 5 to 1 .03). Details of the clinical studies considered in the economic analy sis are av ailable in Appendix 1 5. The forest plots of the respectiv e meta-analy ses are prov ided in Appendix 1 6. The baseline re-offending rate for adults with prev ious offending behav iour was taken from a national report containing 1 2-month data on re-offending for adults released from custody or commencing a court order (sentences under probation superv ision ex cluding fines) in England and Wales in 2006 (Ministry of Justice, 2008a). According to this document, the re-offending rate in this population was 39% ov er 1 2 months. This rate was determined by the number of offenders in the cohort offending at least once during the 1 2-month follow-up period, where the offence resulted in a court conv iction or an out-of-court disposal. The 1 2-month rate of adult re-offending following prov ision of Reasoning and Rehabilitation in the economic analy sis was calculated by multiply ing the estimated RR of re-offending of the interv ention v ersus control by the baseline re-offending rate. Intervention costs (costs of providing the Reasoning and Rehabilitation programme) In order to estimate total interv ention costs, relev ant resource use was estimated and combined with respectiv e unit costs. Resource use estimates associated with prov ision of a Reasoning and Rehabilitation programme were adopted from T3 Associates (2003) and were consistent with resource use described in studies prov iding the efficacy data for this analy sis. According to these estimates, the ev aluated interv ention consisted of 38 sessions lasting 2 hours each, deliv ered to groups of eight adults with offending behav iour. The unit cost of therapists prov iding Reasoning and Rehabilitation was assumed to equal that of clinical psy chologists (Band 7 ) due to lack of more relev ant unit cost estimates. Howev er, it is recognised that therapists prov iding Reasoning and Rehabilitation may be on a lower salary scale, and therefore the total interv ention cost may hav e been ov erestimated. The national unit cost of clinical psy chologists has been estimated at 67 per hour of client contact in 2006/07 prices (Curtis, 2007 ). This estimate was based on the mid-point of Agenda for Change salaries Band 7 of the April 2006 pay scale according to the National Profile for Clinical Psy chologists, Counsellors and Psy chotherapists (NHS, 2006). It includes salary , salary on costs, ov erheads and capital ov erheads but does not take into account qualification costs as the latter are not av ailable for clinical psy chologists. Based on the abov e resource use estimates and the unit cost of clinical psy chologists, the cost of prov iding the Reasoning and Rehabilitation programme was estimated at 637 per adult with offending behav iour at 2006/7 prices. Costs of adult offending behaviour/cost savings from reducing adult re-offending rates In order to estimate the annual cost resulting from re-offending behav iour by adult offenders, three ty pes of data are needed:

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

7/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

proportion of different ty pes of offences committed by adult re-offenders costs associated with each ty pe of offence number of offences per adult re-offender per y ear. Data on the proportion of different ty pes of offences committed by adult re-offenders in England and Wales were deriv ed from a national report published by the Ministry of Justice (2008a). The same document reported that the number of offences per adult re-offender were 3.7 42 ov er 1 2 months. Costs associated with each ty pe of offence committed by adult offenders were taken from a v ariety of sources, as reported in Chapter 5, Section 5.4.1 4. Costs were uplifted to 2007 prices using the Retail Prices Index (Office for National Statistics, 2008). The cost per offence committed by adult re-offenders was estimated as the mean cost of all offences weighted by the proportion of offences committed on av erage by an adult re-offender. Table 35 shows the percentage of offences committed by adult reoffenders, the cost of each ty pe of offence as estimated in the literature, and the weighted av erage cost per offence committed by adult re-offenders. T able 35 Percentage and costs of offences committed by adult re-offenders.

The av erage cost per offence committed by adult re-offenders was estimated at 2,7 06. Since this population commits 3.7 42 offences ov er 1 2 months (Ministry of Justice, 2008a), the 1 2-month cost associated with offending behav iour is 1 0,1 27 per adult re-offender. T im e horizon of the analy sis The three studies included in the guideline meta-analy sis of clinical data on Reasoning and Rehabilitation had time horizons ranging between 4 and 9 months. It is not known whether the beneficial effect of Reasoning and Rehabilitation lasts bey ond 9 months. Therefore, for the base-case analy sis, a 1 -y ear time horizon was chosen; alternativ e time horizons up to 5 y ears were tested in sensitiv ity analy sis, to ex plore the magnitude of potential sav ings that could be gained if the interv ention has a longer lasting effect. Discounting Costs incurred bey ond 1 2 months were discounted at an annual rate of 3.5%, as recommended by NICE (NICE, 2006a). Table 36 prov ides all input parameters utilised in the base-case analy sis of the economic model of Reasoning and Rehabilitation for adults with offending behav iour. T able 36 Input parameters utilised in the economic model assessing the net costs (or sav ings) resulting from prov ision of Reasoning and Rehabilitation to adults with offending behav iour. Sensitiv ity analy sis One- and two-way sensitiv ity analy ses were undertaken to ex plore the robustness of the results under the uncertainty characterising some model input parameters. The following scenarios were tested in sensitiv ity analy sis: Use of the 95% CIs of the RR of re-offending of Reasoning and Rehabilitation v ersus control. Ex clusion of data from ROSS1 988, which introduced heterogeneity in the meta-analy sis (resulting in a mean RR of re-offending of Reasoning and Rehabilitation v ersus control: 0.88 with 95% CIs 0.7 5 to 1 .03). Reduction in the baseline re-offending rate for adult offenders; an annual rate of 30% was tested. Ex tension of the time horizon of the analy sis bey ond 1 y ear; although currently there is no ev idence to suggest that Reasoning and Rehabilitation programmes hav e a clinical effect lasting longer than 1 y ear, consecutiv e time horizons of 2 to 5 y ears were tested in sensitiv ity analy sis to ex plore the magnitude of potential cost sav ings achiev ed by prov ision of the interv ention to adult offenders, if the interv ention has a longer lasting effect. Potential net sav ings accrued ov er 2 to 5 y ears were also estimated assuming that the effect of the interv ention was reduced ov er time; in this scenario the RR of Reasoning and Rehabilitation v ersus control was multiplied by a factor of 1 .1 5 for ev ery y ear after the first y ear following initiation of the interv ention, to capture this assumed decline in the clinical effect ov er time, until Reasoning and Rehabilitation had no beneficial effect ov er control. Combination of alternativ e time horizons between 1 and 5 y ears with the rest of the hy potheses described abov e.

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

8/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

In addition, threshold analy ses identified the v alues of specific input parameters where the results of the analy sis were rev ersed. The parameters tested were the relativ e effect of Reasoning and Rehabilitation v ersus control (ex pressed in RR), the av erage cost of offence committed by adult reoffenders, and the baseline re-offending rate of adults with offending behav iour ov er 1 2 months. Results Base-case analysis The reduction in the re-offending rates achiev ed by prov ision of Reasoning and Rehabilitation to adult offenders y ielded cost sav ings equalling 869 per adult with offending behav iour ov er 1 y ear. Because the prov ision of Reasoning and Rehabilitation programmes costs 637 per adult offender, the interv ention results in an ov erall net sav ing of 232 per adult with offending behav iour ov er 1 y ear. Full results of the base-case analy sis are reported in Table 37 . T able 37 Results of economic analy sis assessing the net costs (or sav ings) resulting from prov ision of Reasoning and Rehabilitation to adults with offending behav iour. Sensitivity analysis Results of the cost analy sis were sensitiv e to the different scenarios tested in sensitiv ity analy sis. The results of meta-analy sis (both including and ex cluding ROSS1 988) were not statistically significant at the 0.05 lev el and therefore using the upper 95% CI of the RR of the interv ention v ersus control did not lead to any sav ings because offending behav iour was in these cases increased following prov ision of Reasoning and Rehabilitation to adult offenders. In all other scenarios Reasoning and Rehabilitation resulted in net sav ings within the first y ear. Although no long-term studies could demonstrate whether the beneficial effect of the programme in reducing offending behav iour lasts bey ond 1 y ear, sensitiv ity analy sis showed that, if such a longer effect ex ists, then the interv ention could sav e on av erage 3,424 per adult offender ov er 5 y ears (or 1 ,57 8, when ROSS1 988 was ex cluded from analy sis). Threshold analy sis showed that the interv ention became cost neutral ov er 1 y ear when the cost per offence committed by adult offenders fell at 1 ,980, when the baseline rate of re-offending was reduced at 29% ov er 1 2 months, and when the RR of the interv ention v ersus control was a max imum of 0.84. Full results of one- and two-way sensitiv ity analy ses are presented in Table 38. T able 38 Results of sensitiv ity cost analy sis of prov iding Reasoning and Rehabilitation to adults with offending behav iour. In addition, threshold analy ses identified the v alues of specific input parameters where the results of the analy sis were rev ersed. The parameters tested were the relativ e effect of Reasoning and Rehabilitation v ersus control (ex pressed in RR), the av erage cost of offence committed by adult reoffenders, and the baseline re-offending rate of adults with offending behav iour ov er 1 2 months. Discussion limitations of the analysis The results of the economic analy sis indicate that Reasoning and Rehabilitation programmes for adults with offending behav iour might be cost sav ing from a wide economic perspectiv e in the UK. The substantial interv ention costs, resulting from the high intensity of such programmes, could be offset by sav ings from a reduction in the rates of re-offending in adults. Howev er, economic results were characterised by uncertainty , as rev ealed in sensitiv ity analy sis. This uncertainty was caused by the statistical insignificance characterising the clinical data utilised in the economic model. Although adult offenders incur a wide v ariety of costs, such as health and social serv ice costs and costs to the criminal justice sy stem (Dav idson et al. , 2008), the economic analy sis considered only interv ention costs and costs relating to offending behav iour, owing to lack of ev idence for a difference in other costs between Reasoning and Rehabilitation and no treatment. Cost data on offending behav iour were deriv ed from sev eral published sources reporting UK data and included, in most cases, a wide range of costs, such as costs incurred in anticipation of offending behav iour, for ex ample security ex penditure, costs directly resulting from offending, such as costs of stolen or damaged property , emotional and phy sical impact on v ictims, costs of offering health and other serv ices to v ictims, as well as costs to the criminal justice sy stem. Although it is acknowledged that omission of other health and social care costs constitutes a limitation of the analy sis, ex isting ev idence indicates that costs of offending behav iour are probably the most significant costs incurred by adult offenders. Moreov er, the interv ention reduces offending behav iour and this can potentially lead to a reduction in other costs such as healthcare costs and social benefit pay ments. If this is the case, then the economic analy sis has only underestimated the net sav ings gained from Reasoning and Rehabilitation programmes. Moreov er, some cost data utilised in the economic analy sis consisted ex clusiv ely of costs to the criminal justice sy stem. Other costs, such as healthcare costs and emotional distress of v ictims, the financial and economic burden to the families of both v ictims and offenders, and the feelings of fear and insecurity at anticipation of crime were not considered in most documents reporting cost data on

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

9/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

offending behav iour. Consideration of these factors might increase the reported figures on cost-sav ings resulting from reduction in offending behav iour achiev ed by offering Reasoning and Rehabilitation programmes to adult offenders. Rates of re-offending are higher in adults with more sev ere offending behav iour, as ex pressed by the number of prev ious offences they committed in the past. Moreov er, this population commits a higher numbers of offences per y ear (Ministry of Justice, 2008a). Therefore, prov iding Reasoning and Rehabilitation to adults with more serious history of offending behav iour is likely to lead to higher cost sav ings from reduction in offending behav iour. Reasoning and Rehabilitation programmes are intensiv e interv entions and are therefore characterised by high costs. It is possible that sav ings resulting from reduction in re-offending do not outweigh interv ention costs. Howev er, ev en if the interv ention resulted in a modest net cost per person, considering the further potential benefits to participants and their families from implementation of the programme (such as increase in employ ment rates, reduction in drug and alcohol misuse and other healthcare costs), this cost may be justified. The time horizon of the economic analy sis was 1 y ear, as av ailable ev idence came from relativ ely shortterm studies, with a max imum time horizon of 9 months. There is currently no ev idence that Reasoning and Rehabilitation has a beneficial effect in reducing offending behav iour ex tending bey ond this time. Nev ertheless, in order to ex plore the potential magnitude of cost sav ings resulting from implementing the interv ention, the economic analy sis considered multiple consecutiv e time periods of 1 and up to 5 y ears to ascertain if the beneficial effect is retained in adult offenders. Further research is needed to ex plore whether the effect of the interv ention lasts in the long term, as this would hav e substantial financial and emotional (positiv e) implications for society . Conclusion Group-based cognitiv e behav ioural interv entions deliv ered as Reasoning and Rehabilitation programmes are potentially cost effectiv e in the UK setting. Besides the clinical benefits to adults with offending behav iour, they may produce net cost sav ings to society , resulting from reduction in offending behav iour.

7.2.17 Evidence to recommendations


There is relativ ely robust clinical ev idence indicating that cognitiv e and behav ioural interv entions are moderately effectiv e for offenders. The economic analy sis showed that such interv entions are potentially cost sav ing, as the interv ention costs may be offset by sav ings associated with a reduction in re-offending; howev er, the results of economic analy sis were characterised by great uncertainty . The finding of a reduction in re-offending is supported by ev idence from cognitiv e and behav ioural interv entions for offenders with substance misuse problems, which also hav e a significant impact on reducing offending in a population with a high incidence of antisocial personality disorder. The GDG judged that it would be reasonable to conclude that such interv entions were likely to be effectiv e for people with antisocial personality disorder. As was noted in the Section 7 .2.1 , these interv entions were dev eloped and prov ided almost ex clusiv ely within the criminal justice sy stem. Howev er, in addressing offending behav iour the interv entions also attempt to focus on problems with impulsiv ity , aggression and rule-breaking. Such problems are also ex perienced by people with antisocial personality disorder without criminal records. In light of this the GDG felt it reasonable to ex trapolate from this dataset of offenders and support the use of group-based cognitiv e and behav ioural interv entions for non-offending populations with antisocial personality disorder in the community . In addition, the GDG considered that it would be possible to ex trapolate these findings to people who meet criteria for DSPD and therefore concluded that cognitiv e and behav ioural interv entions would likely be moderately effectiv e in this population. Howev er, it was also felt that the interv ention would need to be adapted in order to be beneficial for people with DSPD. The GDG also noted the recommendation in the borderline personality disorder guideline (NICE, 2009) supporting use of multi-modal treatments, for ex ample the combination of indiv idual and group treatments. Giv en that a proportion of people who meet criteria for DSPD may hav e comorbid personality disorders, including borderline personality disorder, the GDG considered this recommendation when formulating recommendations for antisocial personality disorder. Such modifications would include ex tending the nature and duration of the interv ention and prov iding close monitoring and superv ision of staff.

7.2.18 Recommendations for offending behaviour in adults


7 .2.1 8.1 . For people with antisocial personality disorder, including those with substance misuse problems, in community and mental health serv ices, consider offering group-based cognitiv e and behav ioural interv entions, in order to address problems such as impulsiv ity , interpersonal difficulties and antisocial behav iour. 7 .2.1 8.2. For people with antisocial personality disorder with a history of offending behav iour who are in community and institutional care, consider offering group-based cognitiv e and behav ioural interv entions (for ex ample, programmes such as Reasoning and Rehabilitation) focused on reducing offending and other antisocial behav iour.

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

10/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

7 .2.1 8.3. When prov iding cognitiv e and behav ioural interv entions: assess the lev el of risk and adjust the duration and intensity of the programme accordingly (participants at all lev els of risk may benefit from these interv entions) prov ide support and encouragement to help participants to attend and complete programmes, including people who are legally mandated to do so. 7 .2.1 8.4. For people in community and institutional settings who meet criteria for psy chopathy or DSPD, consider cognitiv e and behav ioural interv entions (for ex ample, programmes such as Reasoning and Rehabilitation) focused on reducing offending and other antisocial behav iour. These interv entions should be adapted for this group by ex tending the nature (for ex ample, concurrent indiv idual and group sessions) and duration of the interv ention, and by prov iding booster sessions, continued follow-up and close monitoring.

7.2.19 Clinical evidence for the treatment of offending behaviour in young people
In addition to looking at adult offenders, the rev iew also included y oung offenders up to the age of 1 7 y ears. Elev en trials on cognitiv e behav ioural interv entions met the inclusion criteria of the rev iew where all but two trials were of interv entions deliv ered in prison; OSTROM1 97 1 and PULLLEN1 996 were interv entions deliv ered in a probation setting. Eight trials were of cognitiv e and behav ioural interv entions (GUERRA1 990, LEEMAN1 993, OSTROM1 97 1 , PULLEN1 996, ROHDE2004, SCHLICHTER1 981 , SHIV RATTAN1 988, SPENCE1 981 ) and three were multi-component interv entions (DEMBO2000, ELROD1 992, GREENWOOD1 993). Summary study information and ev idence from the included trials are shown in Table 39, Table 40 and Table 41 . Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . T able 39 Study information table for trials of interv entions targeted at adolescents in the criminal justice sy stem. T able 40 GRADE ev idence summary for cognitiv e behav ioural interv entions for adolescents in the criminal justice sy stem. T able 41 GRADE ev idence summary for multi-component interv entions v ersus control for adolescent offenders. The ev idence suggests that cognitiv e behav ioural interv entions deliv ered primarily in groups in institutional settings are more effectiv e than control for reducing offending for both intent to treat data (RR = 0.62; 0.39 to 0.98) and completer only data (RR = 0.65, 0.45 to 0.95). All studies included only males, ex cept for GUERRA1 990, which had both male and female participants. Three trials on multi-component interv entions for adolescent offenders were included in the rev iew. Two (DEMBO2000; ELROD1 992) tested the efficacy of interv entions deliv ered in the community and one (GREENWOOD1 993) ex amined interv entions prov ided in prison, which included an aftercare component in the community . Multi-component interv entions comprised family therapy , parenting skills and cognitiv e problem-solv ing skills training (DEMBO2000); group-based cognitiv e and behav ioural interv entions and parent training (ELROD1 992); and group-based cognitiv e and behav ioural interv entions and family therapy (GREENWOOD1 993). These studies found the interv ention to hav e a modest but non-significant effect on re-offending (RR 0.87 ; 0.65 to 1 .1 6). ELROD1 992 and DEMBO2000 inv olv ed both male and female participants while GREENWOOD1 993 included only male participants. ELROD1 992 was the least effectiv e trialin addition to group-based cognitiv e and behav ioural interv entions and parent training, there was a wilderness ex perience programme.

7.2.20 Clinical evidence summary for the treatment of offending behaviour in young people
There appears to be modest but statistically significant ev idence for the effectiv eness of group-based cognitiv e and behav ioural interv entions deliv ered in institutional settings in reducing offending for adolescents inv olv ed in the criminal justice sy stem. Multi-component interv entions were less effectiv e than the more focused group-based cognitiv e and behav ioural interv entions. This is consistent with the ev idence found for multisy stemic therapy . There is ev idence from studies of implementation of multisy stemic therapy , and other complex multimodal interv entions, that maintaining fidelity to the model is strongly associated with a positiv e outcome. It

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

11/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

could be that the diminished effectiv eness of the multi-component interv entions for offending behav iour reflected a lack of ov erall fidelity to or integration of the interv ention.

7.2.21 Health economic evidence for the treatment of offending behaviour in young people
Four US-based studies were identified in the sy stematic ev idence search that presented economic ev aluations of interv entions for y oung offenders (Caldwell et al. , 2006; Robertson et al. , 2001 ; My ers et al. , 2000; Dembo et al. , 2000a). Details on the characteristics and results reported in the studies are prov ided in the form of ev idence tables in Appendix 1 4. Details on the methods used for the sy stematic rev iew of the economic ev idence are prov ided in Chapter 3. Caldwell and colleagues (2006) compared an intensiv e juv enile correctiv e serv ice treatment programme with usual juv enile correctiv e serv ice treatment in a secured juv enile facility . The initial costs of the intensiv e programme were offset by improv ed treatment progress and lowered v iolent recidiv ism. The intensiv e treatment programme dominated usual treatment, resulting in lower net costs per offender and better outcomes in terms of a reduction in felony and v iolent offences. Robertson and colleagues (2001 ) performed a cost-benefit analy sis, ex amining local justice sy stem ex penditures associated with intensiv e superv ision and monitoring or CBT in comparison with regular probation. They demonstrated that, relativ e to those on probation, the CBT programme resulted in a net sav ing in ex penditure of $1 ,435 per offender during the 1 8-month inv estigation. No significant difference in justice sy stem ex penditures were demonstrated by the intensiv e superv ision and monitoring group. The study by My ers and colleagues (2000) was a simple cost comparison study of a multi-component interv ention programme for early -career juv enile offenders. The initial costs of the programme, total costs and differences in crime rates were compared with respectiv e costs and outcomes of an untreated community control group. Ov er 1 2 months, the programme resulted in net sav ings of $1 ,800 per y oung person due to lower crime rates compared with the untreated group. Dembo and colleagues (2000a) compared the criminal justice costs of a family empowerment interv ention programme v ersus an ex tended serv ices interv ention programme for juv enile offenders and their families. Ov er 2 y ears, the family empowerment interv ention programme resulted in significant net sav ings mainly as a result of lower arrest rates.

7.2.22 From evidence to recommendations


There was consistent ev idence that cognitiv e and behav ioural interv entions were effectiv e for the treatment of offending behav iour in y oung people. In addition, these interv entions may be cost effectiv e, according to ev idence deriv ed from US settings. The use of such interv entions for y oung people with offending behav iour is supported.

7.2.23 Recommendations
7 .2.23.1 . For y oung offenders aged 1 7 y ears or y ounger with a history of offending behav iour who are in institutional care, offer group-based cognitiv e and behav ioural interv entions aimed at y oung offenders and that are focused on reducing offending and other antisocial behav iour.

7.3 TREATMENT OF COMORBID DISORDERS IN PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER


7.3.1 Introduction
As highlighted in Chapter 2, people with antisocial personality disorder commonly present with comorbid mental disorders including significant drug and alcohol problems, other personality disorders and a range of common mental health problems, including depression and anx iety . The presence of these comorbidities will increase the burden of illness and may directly contribute to the ex acerbation of the problems associated with the antisocial personality disorder. Unfortunately people with antisocial personality disorder often reject treatment (Ty rer et al. , 2003), and ev en where they seek treatment for their comorbid disorders may find themselv es unable to assess treatment. Current practice The current treatment of comorbid mental health problems falls under three broad categories: that prov ided by general mental health serv ices in primary and secondary care, that prov ided or funded by specialist mental health serv ices in secondary and tertiary care, and that prov ided within the criminal justice sy stem. The ex tent of treatment for comorbid disorders for common mental health problems such as anx iety and depression in primary and secondary mental health serv ices is not well known. It is likely , giv en what is known about the epidemiology of antisocial personality disorder (for ex ample, Robins et al. , 1 991 ; Swanson et al. , 1 994) that a significant number of people do seek help but their comorbid

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

12/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

problem may not be recognised, or if they are offered treatment they may be more likely to drop out of it or not adhere to it (ESMHCG, 2005). The position with regard to the treatment of drug and alcohol problems is somewhat different, with a significant proportion of people with drug or alcohol misuse disorders receiv ing treatment from specialist substance misuse serv ices prov ided by or funded by the NHS. This is important because alcohol misuse is associated with increased v iolence in people with antisocial personality disorder (Y ang & Coid, 2007 ). An important issue is whether sufficient adaptation of drug and alcohol treatment programmes is undertaken to engage and retain people with antisocial personality disorder. Within specialist mental health serv ices, a small but growing number of units offer treatment specifically for personality disorder (Crawford & Rutter, 2007 ). In principle these units hav e a remit to treat antisocial personality disorder (Department of Health, 2003), but in practice few do (Crawford et al. , 2007 ), with a much greater focus on the treatment of borderline personality disorder. Tertiary or forensic mental health serv ices do treat people with antisocial personality disorder and their associated comorbidities, but as noted in Chapter 4 the percentage of people with antisocial personality disorder in the care of forensic serv ices is approx imately 50% (Singleton et al. , 1 998). Within the criminal justice sy stem, there is considerable treatment of comorbid mental disorders, primarily in prison settings, which comprises two aspects. First, inmates general mental health is managed through prison-based mental health teams (often linked to local mental health serv ices). These serv ices hav e seen significant inv estment in recent y ears in recognition of the historically poor mental healthcare of prisoners (ESMHCG, 2005), but it is likely that for many serv ices the concentration is on psy chosis and other sev ere mental disorders. The second major area of activ ity in addressing comorbid mental health problems in prison is the treatment of drug and alcohol misuse, with many prisons now hav ing specialist drug treatment serv ices (usually prov ided by the NHS or tertiary sector serv ices). Definition and aim of interv ention This rev iew was limited to the following comorbid mental health problems: a. drug and alcohol misuse in people with antisocial personality disorder b. common mental disorders in people with antisocial personality disorder. As there was limited ev idence from indiv idual trials or sy stematic rev iews of reasonable quality for other personality disorders in people with antisocial personality disorder, this rev iew makes no further comment on this. The rev iew acknowledges that the presence of comorbid personality disorder in people with antisocial personality disorder may hav e an ov erall consequence on treatment and would need to be taken into consideration when formulating a treatment plan. Psy chotic disorders were ex cluded from the rev iew in large part because where antisocial personality disorder and a psy chotic disorder co-ex ist, the primary focus of treatment would be on the psy chotic disorder. Interv entions were broadly defined to include all interv entions for common mental health disorders cov ered by the current NICE guidelines for those disorders (for ex ample, NCCMH, 2005a). For drug and alcohol misuse interv entions NICE guidelines were also used (NCCMH, 2007 a, 2007 b) along with other authoritativ e guidance (for ex ample, Department of Health, 2007 b).

7.3.2 Databases searched and inclusion/exclusion criteria


Information about the databases searched and the inclusion/ex clusion criteria used for this section of the guideline can be found in Table 42. T able 42 Databases searched and inclusion/ex clusion criteria for clinical ev idence.

7.3.3 Studies considered


The rev iew team conducted a new sy stematic search that assessed the efficacy of the treatment of comorbid disorders for people with antisocial personality disorder. Only one psy chosocial trial reporting data relating to the treatment of comorbid substance misuse in antisocial personality disorder met the eligibility criteria set by the GDG, prov iding data on 1 08 participants with dependence on cocaine (Messina et al. , 2003). This trial compared contingency management, cognitiv e behav ioural therapy with one another and treatment as usual. In addition, there were four RCTs that assessed in post hoc analy ses the impact of antisocial personality disorder (compared with absence of an antisocial personality disorder diagnosis) on the outcomes of psy chosocial interv entions. Two studies looked at these effects on participants with drug misuse disorders (Woody , 1 983; McKay et al. , 2000) and a further two trials on alcohol dependence (Wlwer et al. , 2001 ; Hesselbrock, 1 991 ). Fiv e studies were ex cluded from the analy sis. The most common reason for ex clusion was either treatment or control group did not hav e antisocial personality

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

13/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

disorder.

7.3.4 Clinical evidence for psychological interventions for the treatment of comorbid substance misuse
Messina and colleagues (2003) reported on a subgroup analy sis of people with antisocial personality disorder receiv ing either contingency management, CBT, a combination of CBT and contingency management, or control. In addition, all participants were receiv ing methadone maintenance treatment. Contingency management was particularly effectiv e for the treatment of drug misuse (RR 4.40; 1 .20 to 1 6.1 7 ) in the antisocial personality disorder population. These results were largely consistent with those found in a sy stematic rev iew on psy chosocial interv entions for drug misuse (see NCCMH, 2007 a). Brooner and colleagues (1 998) compared contingency management with control in opioid dependent people with antisocial personality disorder. Contingency management included contingent increases in methadone dose, scheduling of methadone, therapy sessions that were more conv enient for the participant, and so on. There appeared to be a reduction in drug use for the treatment group compared with control but this was not statistically significant. This study had a number of limitations: first, urinaly sis data were reported in a manner that could not rule out double counting of indiv iduals therefore it was difficult to interpret the results; second, this study used a v ery different method of reinforcement (v ouchers which could be ex changed for goods and serv ices) in comparison with Messina and colleagues (2003), which may hav e contributed to the lack of positiv e effect. Woody (1 983) compared supportiv e-ex pressiv e psy chotherapy with cognitiv e behav ioural psy chotherapy for the treatment of opioid dependence. Woody reported that participants with antisocial personality disorder had worse outcomes, whereas participants with depression and no antisocial personality disorder generally showed better outcomes. Participants with antisocial personality disorder and depression generally fell in between the two groups on a broad range of drug misuse outcomes. McKay and colleagues (2000) compared group therapy with indiv idualised relapse prev ention for cocaine dependence and found no significant differences between cocaine users with and without antisocial personality disorder for any substance misuse outcome (including cocaine and alcohol). Wlwer and colleagues (2001 ) compared CBT with coping skills training and treatment as usual for alcohol dependence and found no significant differences between subgroups of patients with or without antisocial personality disorder, as measured by abstinence at 3 or 6 months after detox ification. In contrast, Hesselbrock (1 991 ) in a study of inpatient alcoholism treatment reported worse outcomes (as measured by mean daily alcohol consumption and alcohol-related problems at 1 y ear) for participants with antisocial personality disorder.

7.3.5 Clinical evidence summary for psychological interventions for the treatment of comorbid substance misuse
The ev idence on psy chological interv entions for drug misuse indicates that people with antisocial personality disorder can benefit from treatment. There was a particularly large effect found when using contingency management to treat drug misuse in people with antisocial personality disorder. Although there was some inconsistency , in that another trial did not show such positiv e effects, this appears to be partly ex plained by the method of contingency management used in the latter trial and is consistent with a rev iew of the drug misuse literature that suggests that contingency management has the strongest ev idence for effectiv eness (see NCCMH, 2007 a, 2007 b). While the other studies rev iewed abov e do not report such positiv e effects, the picture of generally poor outcomes for people with antisocial personality disorder, which is commonly assumed to be the case, was not confirmed. People with antisocial personality disorder may be able to benefit as much from these interv entions as people without antisocial personality disorder.

7.3.6 Health economic evidence on the treatment of comorbid substance misuse and alcohol dependence
No ev idence on the cost effectiv eness of treatments of comorbid substance misuse and alcohol dependence was identified by the sy stematic search of the literature. Details on the sy stematic search of the economic literature are prov ided in Chapter 3.

7.3.7 From evidence to recommendations


The limited ev idence rev iewed abov e suggests that people with antisocial personality disorder can benefit from treatments for drug and alcohol misuse and that this benefit could be of the same order as those without a personality disorder. The encouraging results for contingency management are in line with the ex pectation that people with antisocial personality disorder may respond well to positiv e reinforcement. It was also the judgement of the GDG that such findings could generalise to people who meet criteria for DSPD.

7.3.8 Recommendations

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

14/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

7 .3.8.1 . For people with antisocial personality disorder who misuse drugs, in particular opioids or stimulants, offer psy chological interv entions (in particular, contingency management programmes) in line with recommendations in the relev ant NICE clinical guideline [NICE, 2007 ]. 7 .3.8.2. For people with antisocial personality disorder who misuse or are dependent on alcohol, offer psy chological and pharmacological interv entions in line with ex isting national guidance for the treatment and management of alcohol disorders. 7 .3.8.3. For people who meet criteria for psy chopathy or DSPD, offer treatment for any comorbid disorders in line with ex isting NICE guidance. This should happen regardless of whether the person is receiv ing treatment for psy chopathy or DSPD because effectiv e treatment of comorbid disorders may reduce the risk associated with psy chopathy or DSPD.

7.3.9 T he psychological treatment of comorbid depression and anxiety disorders


There is considerable ev idence that a personality disorder may hav e a negativ e impact on the course of a common mental disorder (for ex ample, Massion et al. , 2002) and that a common mental disorder may be associated with a poorer outcome in personality disorder (for ex ample, Y ang & Coid, 2007 ). It is also the case that adults with antisocial personality disorder often hav e multiple comorbidities. For ex ample, those with comorbid anx iety and antisocial personality disorder also had significantly higher lev els of comorbid depression, alcohol dependence and substance dependence and higher rates of suicide attempts compared with adults with antisocial personality disorder or anx iety disorders alone (Goodwin & Hamilton, 2003). This suggests that effectiv e treatment for common mental disorders in antisocial personality disorder may be challenging but potentially important. A sy stematic search identified no high-quality trials focused on the treatment of depression or anx iety disorders comorbid with antisocial personality disorder. Therefore the GDG and rev iew team searched for high-quality sy stematic rev iews that addressed the question of the treatment of comorbid depression and anx iety disorders. The GDG took the v iew that as the initial search for sy stematic rev iews had failed to identify a significant numbers of rev iews focused solely on the issue of comorbidity with antisocial personality disorder that they should consider (1 ) rev iews of a broad range of personality disorders and their impact on the treatment of depression and anx iety and, (2) rev iews of personality v ariables (such as trait anx iety , impulsiv ity and aggression) that might hav e an impact on treatment outcomes. The GDG also agreed to rev iew the ex isting NICE guidelines for common mental disorders to determine if any recommendations had been made about comorbid common mental health problems and antisocial personality disorder or indeed any other personality disorder. A number of sy stematic rev iews were identified and quality assessed. The following rev iews were considered (Dreessen & Arntz, 1 998; Mulder et al. , 2003; Newton-Howes et al. , 2006). In addition, the following NICE guidelines were also rev iewed (NCCMH, 2005a, 2005b, 2006, 2009a). From these rev iews a number of common themes emerged. First, there is no consistent ev idence that demonstrates people with antisocial personality disorder do not benefit from ev idence-based psy chological interv entions for common mental health problems or that they may be harmed by such interv entions (see for ex ample the rev iews by Mulder and colleagues [2003] on personality disorder and depression). (It should be noted there is some ev idence to suggest that brief interv entions may hav e little benefit for borderline personality disorder; NCCMH, 2009b.) Second, there is ev idence from post hoc analy ses of indiv idual trials that the presence of a personality disorder, or dev elopmental or social factors that are commonly associated with a personality disorder, may lead to a diminution of effectiv eness. This was commonly addressed in the treatment trials by ex tending the duration of treatment (for ex ample, Fournier et al. , 2008). There was also some ev idence that more ex perienced therapists were better able to deal with Ax is II comorbidity (Hollon, personal communication, 2008). Nemeroff and colleagues (2003), in a post hoc analy sis of the Keller and colleagues (2000) trial of nefazodone and a cognitiv e behav ioural-analy sis sy stem of psy chotherapy for chronic depression, found that patients with a significant history of childhood trauma obtained better outcomes with psy chological treatment, while those with no history of abuse obtained better outcomes with pharmacological treatments.

7.3.10 Clinical evidence summary for the psychological treatment of comorbid depression and auxiety disorders
People with antisocial personality disorder hav e high lev els of comorbid common mental health problems, which are associated with poorer long-term outcomes. Ev idence from clinical trials relating directly to this issue is lacking, but post hoc analy sis of data drawn from indiv idual trials and from sy stematic rev iews across a range of personality disorders suggest that effectiv e treatment of common mental health disorders is possible, but may require the ex tension of the duration of the treatment and/or high lev els of clinical skill and ex perience.

7.3.11 Health economic evidence on the treatment of comorbid depression and anxiety disorders
No ev idence on the cost effectiv eness of treatments of comorbid depression and anx iety disorders was

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

15/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

identified by the sy stematic search of the literature. Details on the methods adopted in the sy stematic search of the economic literature are prov ided in Chapter 3.

7.3.12 From evidence to recommendations


The ev idence rev iewed suggested that the treatment of common mental disorders in antisocial personality disorder is possible, but that caution is required in dev eloping any recommendations because the ev idence base is drawn from trials inv olv ing a wider range of personality disorders than just antisocial personality disorder. There is a clear indication in the ev idence rev iewed that consideration should be giv en to ex tending the duration of treatment. In addition, staff should be mindful of the need to take steps to address the increased likelihood that people with antisocial personality disorder will drop out of treatment.

7.3.13 Recommendations
7 .3.1 3.1 . People with antisocial personality disorder should be offered treatment for any comorbid disorders in line with recommendations in the relev ant NICE clinical guideline, where av ailable. This should happen regardless of whether the person is receiv ing treatment for antisocial personality disorder. 7 .3.1 3.2. When prov iding psy chological interv entions for comorbid disorders to people with antisocial personality disorder, consider lengthening their duration or increasing their intensity .

7.4 THERAPEUTIC COMMUNITY INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS
7.4.1 Introduction
In the history of psy chological treatments for personality disorder the therapeutic community has play ed an important role (Rapoport, 1 960). The therapeutic community mov ement had a significant impact on mental healthcare in the mid to late 20 t h century (Lees et al. , 2003) with dev elopments in the prison serv ice (Snell, 1 962), drug serv ices and for other personality disorders (Lees et al. , 2003). Howev er, in healthcare there has been a recent mov e away from therapeutic communities, in part influenced by high costs in the absence of conv incing ev idence for efficacy (Lees et al. , 2003). Therapeutic communities differ from other treatment approaches in the use of the residential community as the key agent for change. Peer influence is used to help indiv iduals acquire social skills and learn social norms, and so take on an increased lev el of personal and social responsibility within the unit (Smith et al. , 2006). In addition to therapeutic communities based on social learning theory , there are rehabilitation centres that emphasise more behav ioural, hierarchical principles that positiv ely and negativ ely reinforce a range of behav iours. Residential therapeutic communities inv olv e therapeutic group work, one-to-one key working, the dev elopment of practical skills and interests, education and training. The intensiv e nature of their approach means that such programmes tend to be longer in duration (6 to 1 2 months) (Greenwood et al. , 2001 ). In the UK, the Community of Communities project (Keenan & Paget, 2006) has dev eloped standards of good practice for therapeutic communities. Current practice Therapeutic communities are found within health, education and social care and prison settings in the UK and often work with people with sy mptoms and behav iours associated with the antisocial personality disorder construct. There are a number of therapeutic communities specialising in the treatment of substance misuse, with ov er half of residential serv ices in the National Treatment Agency for Substance Misuse online directory 1 2 describing themselv es as therapeutic communities. In addition, of the 56 therapeutic communities surv ey ed by the Community of Communities, 1 5 were in prison settings (Roy al College of Psy chiatrists, 2008b).

7.4.2 Definition and aim of review


The rev iew assessed therapeutic communities for people with antisocial personality disorder, people with sy mptoms and behav iours associated with this diagnostic construct, and people with comorbid substance misuse.

7.4.3 Databases searched and inclusion/exclusion criteria


Information about the databases searched and the inclusion/ex clusion criteria used for this section of the guideline can be found in Table 43.

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

16/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

T able 43 Databases searched and inclusion/ex clusion criteria for clinical ev idence.

7.4.4 Studies considered13


The rev iew team conducted a new sy stematic search for RCTs that assessed the efficacy of therapeutic communities for people with antisocial personality disorder or sy mptoms and behav iours associated with antisocial personality disorder. A sy stematic search for non-RCTs that assessed the efficacy of therapeutic communities for offenders was also conducted. There were no trials of therapeutic communities for people with antisocial personality disorder that met the eligibility criteria of the GDG. Howev er, three trials that assessed therapeutic communities for offenders who misused drugs (NIELSEN1 996; SACKS2004; WEXLER1 999) met the eligibility criteria set by the GDG, prov iding data on 1 ,682 participants. All were published in peer-rev iewed journals. As there was only one RCT for therapeutic communities for offenders without substance misuse problems (Lamb & Goentzel, 1 97 4), the rev iew team conducted a sy stematic search for non-RCTs that assessed the efficacy of therapeutic communities in this population; two non-RCTs (Marshall, 1 997 ; Robertson & Gunn, 1 987 ) were identified. In addition, sev en studies were ex cluded from the analy sis. The most common reason for ex clusion was the lack of relev ant outcomes (further information about both included and ex cluded studies can be found in Appendix 1 5).

7.4.5 Clinical evidence on therapeutic communities for offenders with substance misuse problems
Three RCTs hav e been conducted in institutional settings ev aluating the ev idence for therapeutic communities in substance misuse offenders. In two trials the interv ention included treatment within prison followed by release to a residential community of 6 months duration (SACKS2004; WEXLER1 999). The third trial (NIELSEN1 996) assessed a work-release therapeutic community programme. Summary study information and ev idence from the included trials are shown in Table 44 and Table 45. Full ev idence profiles and forest plots can be found in Appendices 1 5 and 1 6. T able 44 Study information table for trials of therapeutic communities for offenders with substance misuse problems. T able 45 GRADE ev idence summary for therapeutic communities for offenders with substance misuse problems. Therapeutic community prison and aftercare programmes for offenders who misused drugs (many of whom had antisocial personality disorder) were associated with relativ ely large reductions in offending (RR = 0.62; 0.49 to 0.7 8). At 5-y ear follow-up the difference was still statistically significant (RR = 0.93; 0.87 to 0.99).

7.4.6 Health economic evidence on therapeutic communities for offenders with substance misuse problems
Four US-based studies that reported on the cost-effectiv eness of therapeutic communities for offenders with substance abuse problems were identified by the sy stematic search of economic literature (McCollister et al. , 2003, 2003a and 2004; Griffith et al. , 1 999). One study by McCollister and colleagues (2003 McCollister and colleagues (2004) ev aluated the short and long-term costeffectiv eness (1 2 months and 5 y ears respectiv ely ) of a Californian in-prison therapeutic community and aftercare programme for male prisoners with history of substance misuse. Cost data included inprison and aftercare treatments, hospital inpatient and outpatient episodes, methadone treatments and other self-help programmes. The measure of effectiv eness was the number of incarceration day s av oided during follow-up. In the comparison with no treatment, the ICER was $80 per av oided incarceration day after 1 2 months, which came down to $65 after 5 y ears. A similar study based in Delaware ev aluated a work-release therapeutic community and aftercare programme for male prisoners with history of substance misuse (McCollister et al. , 2003a). Only costs of the in-prison and after-care treatment programmes were included and follow-up was 1 8 months. The ICER v ersus no treatment was $65 per incarceration day av oided. Another study ev aluated the cost effectiv eness of in-prison therapeutic community treatment for male

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

17/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

offenders with a history of substance misuse in Tex as (Griffith et al. , 1 999). A retrospectiv e analy sis was undertaken ov er 3 y ears, comparing treated offenders parole and aftercare costs, as well as reincarceration rates, with respectiv e costs and outcomes in an untreated comparison group. Separate analy ses were conducted for low-risk and high-risk offenders. For the low-risk group analy sis, the ICER was $494 per 1 % reduction in re-incarceration; for the high-risk group analy sis, the ICER fell to $1 65. This was largely ex plained by the higher re-incarceration rates ex perienced by the high-risk untreated group compared with the treated group, while for the low-risk group analy sis, re-incarceration rates were similar in the two cohorts (treated and untreated). Details on the study characteristics and results are prov ided in the form of ev idence tables in Appendix 1 4. The methods adopted for the sy stematic rev iew of economic literature are discussed in Chapter 3.

7.4.7 Clinical evidence on therapeutic communities for adult offenders


There were three trials that inv estigated the efficacy of therapeutic communities for general offenders in institutional and community settings. Of these, one was an RCT (Lamb & Goentzel, 1 97 4) and two were non-RCTs (Marshall, 1 997 ; Robertson & Gunn, 1 987 ). The RCT inv estigated a community alternativ e to prison in the US and the two non-RCTs inv estigated the effects of therapeutic communities for prisoners treated in HMP Grendon in the UK. For general offenders a meta-analy sis was not conducted as these studies differed in study design; instead these studies were narrativ ely rev iewed. Lamb & Goentzel (1 97 4) randomised participants to regular prison serv ices or to a therapeutic community as an alternativ e to prison in a community setting. The therapeutic community comprised three phrases. In phases one and two, the participants were giv en more responsibility and priv ileges within each phase. Phase three continued while the participant was on probation. The participant returned to the therapeutic community to v isit their assigned probation officer and to participate in social activ ities. The study found the therapeutic community to hav e a harmful effect on re-offending at 1 -y ear follow-up for 31 participants in the treatment group in comparison with 31 participants in the control group (RR 1 .22; 0.59, 2.53). Robertson & Gunn (1 987 ) conducted a 1 0-y ear prospectiv e cohort study of participants released from HMP Grendon in comparison with a matched control; there were some differences between the two groups, such as the treated group hav ing more desire for psy chiatric help compared with the control group. The study found no significant differences between participants treated in a therapeutic community compared with regular prison serv ices (93% and 85% respectiv ely , x 2 = 1 .37 , d.f. 1 , NS). Marshall (1 997 ) conducted a retrospectiv e cohort study of participants who stay ed in HMP Grendon (N = 7 02) from 1 984 to 1 989. These participants were compared with participants who were selected for Grendon in the same period but who did not actually go there (N = 1 42). The retrospectiv e study found no effect on the therapeutic community for participants who attended Grendon v ersus the comparison group who did not (RR 0.92; 0.82 1 .03).

7.4.8 Health economic evidence on therapeutic communities for adult offenders


No economic ev idence on therapeutic communities for adult offenders was identified in the literature.

7.4.9 Clinical evidence summary on therapeutic communities


The majority of RCT ev idence av ailable on therapeutic communities was on people who misuse drugs in the criminal justice sy stem. These samples had a fair proportion of people diagnosed with antisocial personality disorder (between 39 and 51 %) in addition to all participants reporting behav iour or sy mptoms associated with the antisocial personality disorder diagnostic construct. There was found to be a relativ ely large reduction in offending. The economic ev idence suggests that in-prison therapeutic communities for offenders with history of substance abuse may be cost effectiv e in terms of reducing future re-offending. In contrast the ev idence for therapeutic communities for general offenders is limited and based on weaker study design. There is no ev idence to suggest that therapeutic communities are effectiv e for general offenders.

7.4.10 From evidence to recommendations


The GDG concluded that therapeutic communities appeared to be effectiv e for people in prison or on probation who misuse drugs, many of whom were diagnosed with antisocial personality disorder. Therefore their judgement was that therapeutic communities targeted specifically at drug misuse are likely to be effectiv e in people with antisocial personality disorder who misuse drugs. Howev er, the GDG concluded there was insufficient ev idence to apply these findings to therapeutic communities targeting general offenders.

7.4.11 Recommendations
7 .4.1 1 .1 . For people with antisocial personality disorder who are in institutional care and who misuse or are dependent on drugs or alcohol, consider referral to a specialist therapeutic

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

18/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

community focused on the treatment of drug and alcohol problems.

7.5 PHARMACOLOGICAL INTERVENTIONS FOR ANTISOCIAL PERSONALITY DISORDER


7.5.1 Introduction
A rationale for pharmacological approaches in antisocial personality disorder is that many of the behav ioural traits of personality disorder may hav e a biological basis and are associated with neurochemical abnormalities of the central nerv ous sy stem (Coccaro et al. , 1 996a, 1 996b; Hollander et al. , 1 994). Howev er, a major problem in study ing the effects of medication is that it is difficult to map drug action on the personality disorders as they are listed in DSM. The reason for this is that they are so heterogeneous that it may be more fruitful to focus on behav ioural clusters (Markov itz, 2001 ). Soloff (1 998) has been influential by introducing a sy mptom-orientated approach. Ignoring the specific DSM Ax is II disorders, he grouped personality psy chopathology into the following sy mptom domains: cognitiv e-perceptual, affectiv e, impulse-behav ioural and anx ious-fearful. Affectiv e sy mptoms in turn were subdiv ided into dy sregulation of (a) mood and (b) anx iety . He suggested that since these domains were mediated by the same neurotransmitter sy stems as Ax is I disorders, albeit in an attenuated form, this approach could lead to more rational prescribing. Apply ing this approach, Soloff found ev idence that conv entional antipsy chotic drugs in low doses were effectiv e in reducing the cognitiv e perceptual abnormalities (Soloff et al. , 1 986a; Goldberg et al. , 1 986). For dy sregulation of mood, there was some ev idence for the use of SSRIs (Cornelius et al. , 1 990; Markov itz et al. , 1 991 ), tricy clic antidepressants (Soloff et al. , 1 986b), v enlafax ine (Markov itz & Wagner, 1 995) and monoamine ox idase inhibitors (MAOIs) (Parsons et al. , 1 989). For impulsiv e behav ioural dy scontrol, most attention had been focused on the SSRIs (Cornelius et al. , 1 990; Kav ouissi et al. , 1 994), but lithium (Tupin et al. , 1 97 3; Links, 1 990) and anticonv ulsants such as carbamazepine (Cowdry & Gardner, 1 989), v alproate (Stein et al. , 1 995) and div alproex sodium (Wilcox , 1 995) had also shown some positiv e outcomes. V arious features of antisocial personality disorder might be targets for a pharmacological interv ention. Paranoia, for instance, emerges from factor analy sis and hence might be a target of low-dose antipsy chotic medication. Similarly , impulsiv e dy scontrol and aggressiv e behav iour are important features of antisocial personality disorder and might usefully be targeted with SSRIs or mood stabilisers. This section therefore rev iews the ev idence on the use of drugs for those with antisocial personality disorder. As with assessing the effectiv eness of psy chological interv entions, there are three difficulties that need to be considered. First, antisocial personality disorder is often comorbid with Ax is I conditions and, as it may often be the presence of the latter that causes the indiv idual to present for treatment, it is not alway s clear whether it is the Ax is I or Ax is II condition that is being targeted when medication is used. Second, use of alcohol and other illicit substances, which is common in people with antisocial personality disorder, may diminish response rates to pharmacotherapy (Markov itz, 2001 ). Third, with complex conditions such as antisocial personality disorder, it is likely that multiple neurotransmitter sy stems are at play in producing, for ex ample, the affectiv e dy sregulation (Soloff, 1 998). This again makes drug selection difficult. Current practice The state of current practice in relation to the use of pharmacological interv entions to treat antisocial personality disorder is unclear, but it is likely that pharmacological interv entions are used in this population to treat sy mptoms rather than as an interv ention for the disorder itself. The reported lev el of prescription in the prison population does not suggest that pharmacological interv entions are used at a generally high lev el in offender populations (Christina Rowlands, presentation to the GDG, December 2007 ).

7.5.2 Databases searched and inclusion/exclusion criteria


Information about the databases searched and the inclusion/ex clusion criteria used for this section of the guideline can be found in Table 46. T able 46 Databases searched and inclusion/ex clusion criteria for clinical ev idence.

7.5.3 Studies considered14


Ten trials relating to clinical ev idence met the eligibility criteria set by the GDG, prov iding data on 7 49 participants (BARRATT1 997 , COCCARO1 997 A, GOTTSCHALK1 97 3, HOLLANDER2003, LEAL1 994, MATTES2005, MATTES 2008, NICKEL2005B, POWELL1 995, SHEARD1 97 6, STANFORD2005). Of these, all were published in peer-rev iewed journals between 1 97 3 and 2008. In addition, 1 6 studies

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

19/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

were ex cluded from the analy sis. The most common reasons for ex clusion were non-random allocation of participants to treatment and control and populations that would not meet the GDGs inclusion criteria, for ex ample, participants with schizophrenia (further information about both included and ex cluded studies can be found in Appendix 1 5). There was one trial prov iding ev idence for pharmacological interv entions for antisocial personality disorder (BARRATT 1 997 ). The purpose of the study was to look at the effects of anticonv ulsants on aggression among offenders in prison, howev er all participants at baseline met DSM-III-R criteria for antisocial personality disorder. Two trials were found that inv estigated pharmacological interv entions for a sub-population of antisocial personality disorder with comorbid substance misuse. (LEAL1 994, POWELL1 995) One trial compared amantadine and desipramine with placebo for participants with cocaine dependence (LEAL1 994) and one trial compared nortripty line and bromocroptine with placebo for participants with alcohol dependence (POWELL1 995). For the rev iew of pharmacological ev idence for antisocial personality disorder and associated sy mptoms or behav iour, eight trials were included (COCCARO1 997 A, GOTTSCHALK1 97 3, HOLLANDER2003, MATTES2005, MATTES2008, NICKEL2005, SHEARD1 97 6, STANFORD2005). Six trials compared anticonv ulsants with placebo (GOTTSCHALK1 97 3, HOLLANDER2003, MATTES2005, MATTES2008, NICKEL2005, STANFORD2005), one compared antidepressants with placebo (COCCARO1 997 A) and one compared lithium with placebo (SHEARD1 97 6). The population in all the trials had an elev ated lev el of impulsiv e aggression and/or anger while two trials looked specifically at offenders (SHEARD1 97 6, GOTTSHALK1 993). The age range for the trials were 1 9 to 67 y ears.

7.5.4 Clinical evidence for antisocial personality disorder


There was one trial (see Table 47 and Table 48) that looked at the effects of anticonv ulsants on aggression among prison inmates who all met DSM-III-R criteria for antisocial personality disorder (BARRATT1 997 ). Using the modification of the Ov ert Aggression Scale (OAS), the study found the anticonv ulsant pheny toin to hav e a small but non-significant effect on aggression compared with placebo (SMD 0.26; 0.61 , 0.09). Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . T able 47 Study information on pharmacological interv entions for antisocial personality disorder. T able 48 GRADE ev idence summary table on pharmacological interv entions for antisocial personality disorder.

7.5.5 Clinical evidence for antisocial personality disorder and comorbid substance misuse
Two trials (LEAL1 994, POWELL1 995) studied the effects of antidepressants in people with antisocial personality disorder and comorbid substance misuse compared with placebo (see Table 49). It was not possible to meta-analy se the data so there is no GRADE ev idence summary table. Summary study information and ev idence from the included trials are shown in Table 43 and Table 44. Full study characteristics can be found in Appendix 1 5. T able 49 Study information for pharmacological interv entions for antisocial personality disorder with comorbid substance misuse. For antidepressants v ersus placebo there was a small effect for leav ing the study early (RR 0.90; 0.52, 1 .55) for participants with cocaine dependence (LEAL1 994) and alcohol dependence (POWELL1 995), and a moderate effect on abstinence (RR 0.7 2; 0.530.97 ) for participants with alcohol dependence. Howev er, the effect on abstinence was small and based on only one study (POWELL1 995). The two trials also looked at the effects of dopaminergic drugs v ersus placebo (LEAL1 994, POWELL1 995). No significant differences were found between drop out for both treatment and placebo groups (RR 1 .1 8; 0.7 2, 1 .94) and a small but non-significant difference was found in abstinence for participants with alcohol dependence (RR 0.91 ; 0.7 5, 1 .1 0). This effect was small and based on sparse data.

7.5.6 Clinical evidence for antisocial personality disorder and associated symptoms or behaviour
Table 50 summarises the study information for trials concerned with pharmacological interv entions for

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

20/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

aggression in people with antisocial personality disorder. The GRADE ev idence summaries can be found in Table 51 . T able 50 Study information for the trials of pharmacological interv entions for aggression. T able 51 GRADE ev idence summary for pharmacological interv entions for aggression. Full study characteristics and forest plots can be found in Appendices 1 5 and 1 6 respectiv ely . Anticonv ulsants v ersus placebo Six trials inv estigated the effects of a number of anticonv ulsants on impulsiv e aggression and found a small and non-significant effect on aggression at end of treatment (SMD 0.1 3; 0.35 to 0.09). The quality of ev idence was v ery low with high heterogeneity (I 2 = 7 4.4%). SSRIs v ersus placebo One trial compared the SSRI fluox etine with placebo for reducing aggression in a population with elev ated aggression and found the effects of treatment to be medium to large (SMD 0.7 3; 1 .41 to 0.04). Howev er, this is based on one study of low quality . Lithium v ersus placebo There was only one trial that inv estigated lithium v ersus placebo in a population with elev ated lev els of the antisocial personality disorder construct aggression that met the eligibility criteria. The trial showed a medium effect for treatment, which was, howev er, non-significant and of low quality (SMD 0.60; 1 .23, 0.03).

7.5.7 Clinical evidence summary for antisocial personality disorder and associated symptoms or behaviour
There was no consistent ev idence, including from uncontrolled studies, that supported the use of any pharmacological interv ention to treat antisocial personality disorder or to treat the behav iour and sy mptoms that underline the specific diagnostic criteria for antisocial personality disorder.

7.5.8 Health economic evidence on pharmacological interventions for antisocial personality disorder
No ev idence on the cost effectiv eness of pharmacological interv entions for antisocial personality disorder with or without comorbid substance misuse and associated sy mptoms of behav iour was identified by the sy stematic search of the literature. Details on the methods adopted for the sy stematic rev iew of economic literature are prov ided in Chapter 3.

7.5.9 From evidence to recommendations


The ev idence did not support the generation of recommendations for the routine use of pharmacological interv entions for the treatment of people with antisocial personality disorder.

7.5.10 Recommendations for pharmacological interventions


7 .5.1 0.1 . Pharmacological interv entions should not be routinely used for the treatment of antisocial personality disorder or associated behav iours of aggression, anger and impulsiv ity . 7 .5.1 0.2. Pharmacological interv entions for comorbid mental disorders, in particular depression and anx iety , should be in line with recommendations in the relev ant NICE clinical guideline. When starting and rev iewing medication for comorbid mental disorders, pay particular attention to issues of adherence and the risks of misuse or ov erdose.

7.5.11 Recommendations on general issues in the treatment of adults with antisocial personality disorder
7 .5.1 1 .1 . When prov iding psy chological or pharmacological interv entions for antisocial personality disorder, offending behav iour or comorbid disorders to people with antisocial personality disorder, be aware of the potential for and possible impact of:

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

21/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

poor concordance high attrition misuse of prescribed medication drug interactions (including with alcohol and illicit drugs).

7.6 RESEARCH RECOMMENDATIONS


Through identify ing research limitations from the ev idence based rev iews, the guideline dev elopment group has formulated the following research recommendations.

7.6.1.1 Severity as a potential moderator of effect in group-based cognitive and behavioural interventions
Does the pre-treatment lev el of the sev erity of disorder/problem hav e an impact on the outcome of group-based cognitiv e and behav ioural interv entions for offending behav iour? A meta-analy sis of indiv idual participant data should be conducted to determine whether the lev el of sev erity assessed at the beginning of the interv ention moderates the effect of the interv ention. The study (for which there are large data sets that include ov er 1 0,000 participants) could inform the design of a large-scale RCT (including potential modifications of cognitiv e and behav ioural interv entions) to test the impact of sev erity on the outcome of cognitiv e and behav ioural interv entions. Why this is im portant Research has established the efficacy of cognitiv e and behav ioural interv entions in reducing reoffending. Howev er, the effects of these interv entions in a range of offending populations are modest. The impact of sev erity on the outcome of these interv entions has not been sy stematically inv estigated, and post hoc analy ses and meta-regression of risk as a moderating factor hav e been inconclusiv e. Ex pert opinion suggests that sev ere or high-risk indiv iduals may not benefit from cognitiv e and behav ioural interv entions, but if they were to be of benefit then the cost sav ings could be considerable.

7.6.1.2 Group-based cognitive and behavioural interventions for populations outside criminal justice settings
Are group-based cognitiv e and behav ioural interv entions effectiv e in reducing the behav iours associated with antisocial personality disorder (such as impulsiv ity , rule-breaking, deceitfulness, irritability , aggressiv eness and disregard for the safety of self or others)? This should be tested in an RCT that ex amines medium-term outcomes (including cost effectiv eness) ov er a period of at least 1 8 months. It should pay particular attention to the modification and dev elopment of the interv entions to ensure the focus is not just on offending behav iour, but on all aspects of the challenging behav iours associated with antisocial personality disorder. Why this is im portant Not all people with antisocial personality disorder are offenders but they ex hibit a wide range of antisocial behav iours. Howev er, the ev idence for the treatment of these behav iours outside the criminal justice sy stem is ex tremely limited. Following publication of the Department of Healths policy guidance, Personality Disorder: No Longer a Diagnosis of Ex clusion (2003), it is likely that there will be an increased requirement in the NHS to offer treatments for antisocial personality disorder.

7.6.1.3 T reatment of comorbid anxiety disorders in antisocial personality disorder


Does the effectiv e treatment of anx iety disorders in antisocial personality disorder improv e the longterm outcome for antisocial personality disorder? An RCT of people with antisocial personality disorder and comorbid anx iety disorders that compares a sequenced treatment programme for the anx iety disorder with usual care should be conducted. It should ex amine, ov er a period of at least 1 8 months, the medium-term outcomes for key sy mptoms and behav iours associated with antisocial personality disorder (including offending behav iour, deceitfulness, irritability and aggressiv eness, and disregard for the safety of self or others), as well as drug and alcohol misuse, and anx iety . The study should also be designed to ex plore the moderators and mediators of treatment effect which could help determine the role of anx iety in the course of antisocial personality disorder. Why this is im portant Comorbidity with Ax is I disorders is common in antisocial personality disorder, and chronic anx iety has been identified as a particular disorder that may ex acerbate the problems associated with antisocial personality disorder. There are effectiv e treatments (psy chological and pharmacological) for anx iety disorders but they are often not offered to people with antisocial personality disorder. Current treatment guidelines set out clear pathway s for the stepped or sequenced care of people with anx iety disorders. An RCT to test the benefit of this approach in the treatment of anx iety would potentially lead to a significant reduction in illness burden but a reduction in antisocial behav iour would hav e wider

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

22/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

societal benefits. The study should prov ide important information on the challenges of deliv ering these interv entions for a population that has ty pically both rejected and been refused treatment.

7.6.1.4 Using selective serotonin reuptake inhibitors to increase cooperative behaviour in people with antisocial personality disorder in a prison setting
Although there is ev idence that selectiv e serotonin reuptake inhibitors (SSRIs), such as parox etine, increase cooperativ e behav iour in normal people and do so independently of the lev el of subsy ndromal depression, this has y et to be tested in other settings. Giv en that people with antisocial personality disorder are likely to hav e difficulties cooperating with one another (because of a host of personality traits that include persistent rule-breaking for personal adv antage, suspiciousness, grandiosity , and so on), an RCT should be conducted to find out whether these reported changes of behav iour with an SSRI in normal people generalises to clinical populations in different settings. Why this is im portant There is little ev idence in the literature on the pharmacotherapy of antisocial personality disorder to justify the use of any particular medication. Howev er, multiple drugs in v arious combinations are used in this group either to control aberrant behav iour or in the hope that something might work. Current interv entions lack a clear rationale. This recommendation has the potential to adv ance the field in that (a) it is linked to a clear hy pothesis (that cooperativ e behav iour is linked to a dy sregulation of the serotonin receptors for which there is substantial ev idence) and (b) that it is feasible to obtain an answer to this question, giv en that there are a large number of indiv iduals detained in prison settings who would meet antisocial personality disorder criteria. Constructing an ex perimental task that requires cooperativ e activ ity would not be difficult in such a setting, since all of those who might be willing to participate are already detained. The successful ex ecution of this research would be important in that it (a) would establish the feasibility of conducting such a trial in a prison setting with this group, and (b) prov ide a clear and sensible outcome measure of antisocial behav iour that might be generalised to other settings.

7.6.1.5 A therapeutic community approach for antisocial personality disorder in a prison setting
Is a therapeutic community approach in a prison setting more clinically and cost effectiv e in the treatment and management of antisocial personality disorder than routine prison care? There should be a large-scale RCT comparing the clinical and cost effectiv eness of the therapeutic community approach for adults with antisocial personality disorder with routine care. It should ex amine the medium-term outcomes (for ex ample, offending behav iour, mental state and v ocational outcomes) ov er a period of at least 1 8 months following release from prison. The study should also be designed to ex plore the moderators and mediators of treatment effect, which could help to determine the factors associated with benefits or harms of the therapeutic community approach. Why this is im portant There is ev idence from RCTs that the therapeutic community approach is of v alue with drug and alcohol misusers in a prison setting at reducing the incidence of offending behav iour on release. Howev er, there are no equiv alent studies of a programme in the prison sy stem on antisocial personality disorder populations that do not hav e significant drug or alcohol problems. Data that do ex ist are from non-UK settings. Answering this question is of importance because outcomes for adults with antisocial personality disorder are poor and there are already considerable resources dev oted to a therapeutic community approach in the UK prison sy stem (for ex ample, HMP Grendon Underwood). The study could inform policy and resources decisions about the management of antisocial personality disorder in the criminal justice sy stem.

Footnotes
1 1 Her e a n d elsew h er e in t h e g u idelin e, ea ch st u dy con sider ed for r ev iew is r efer r ed t o by a st u dy ID in ca pit a l let t er s (pr im a r y a u t h or a n d da t e of st u dy pu blica t ion , ex cept w h er e a st u dy is in pr ess or on ly su bm it t ed for pu blica t ion , t h en a da t e is n ot u sed). T h e r efer en ces for st u dies ca n be fou n d in A ppen dix 1 5 . 1 2 See h t t p://w w w . n t a .n h s.u k /a bou t _t r ea t m en t /t r ea t m en t _dir ect or ies /r esiden t ia l /r esdir ect or y _f.a spx 1 3 Her e a n d elsew h er e in t h e g u idelin e, ea ch st u dy con sider ed for r ev iew is r efer r ed t o by a st u dy ID in ca pit a l let t er s (pr im a r y a u t h or a n d da t e of st u dy pu blica t ion , ex cept w h er e a st u dy is in pr ess or on ly su bm it t ed for pu blica t ion , t h en a da t e is n ot u sed). T h e r efer en ces for st u dies ca n be fou n d in A ppen dix 1 5 . 1 4 Her e a n d elsew h er e in t h e g u idelin e, ea ch st u dy con sider ed for r ev iew is r efer r ed t o by a st u dy ID in ca pt ia l let t er s (pr im a r y a u t h or a n d da t e of st u dy popu la t ion , ex cept w h er e a st u dy is in pr ess or on ly su bm it t ed for pu blica t ion , t h en a da t e is n ot u sed). T h e r efer en ces for st u dies ca n be fou n d in A ppen dix 1 5 .

Copy right 201 0, The British Psy chological Society & The Roy al College of Psy chiatrists.

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

23/24

3/27/13

INTERVENTIONS FOR PEOPLE WITH ANTISOCIAL PERSONALITY DISORDER AND ASSOCIATED SYMPTOMS AND BEHAVIOURS - Antisocial

A ll r ig h t s r eser v ed. No pa r t of t h is book m a y be r epr in t ed or r epr odu ced or u t ilised in a n y for m or by a n y elect r on ic, m ech a n ica l, or ot h er m ea n s, n ow k n ow n or h er ea ft er in v en t ed, in clu din g ph ot ocopy in g a n d r ecor din g , or in a n y in for m a t ion st or a g e or r et r iev a l sy st em , w it h ou t per m ission in w r it in g fr om t h e pu blish er s. En qu ir ies in t h is r eg a r d sh ou ld be dir ect ed t o t h e Br it ish Psy ch olog ica l Societ y .

Pu bMed Hea l t h Hom e | A bou t Pu bMed Hea l t h | Copy r i gh t | Di scl a i m er |

Fol l ow u s |

A dd u s | Con t a ct Us

www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015247/

24/24