Transcript What do we know about the treatment for antisocial

What do we know about the
treatment for antisocial
personality disorder?
Personality Disorder: A Risky Business?
Glasgow. 13 June, 2008
Professor Kate Davidson
NHS GG&C / University of Glasgow
Number of studies by diagnostic category up to 2006.
Duggan et al. (2007) Personality and Mental Health, 1, 95-125
16
14
12
10
total n studies by
diagnosis
8
6
4
2
0
BPD
mixed
aspd
avoid
mixed
B
mixed
C
Why we need to treat ASPD
• Antisocial personality disorder - same
prevalence as major mental illnesses such as
schizophrenia and bipolar disorder
• Prevalence of ASPD in prisons is 48%
• Estimated ¼ of all violent incidents in UK are
committed by people with ASPD.
• ASPD major public health implications in terms
of its association with drug abuse, suicide, early
unnatural death, violent crime, unemployment,
homelessness, and family violence.
Crawford and Rutter, 2007
• Recent evaluation of services for people
with personality disorder in England
• People with ASPD are generally excluded
because of concerns about whether the
service provided would be of value to
people with this disorder.
• We don’t know what to do!
Economic impact of violence on
Scotland
• Those affected by violence costs an
estimated 3-6% of the NHS budget (Burns
2006). Circa £400 million
• Each murder investigation costs the justice
system an estimated £1.3 million.
• Serious assault costs an average £19k.
Psychological treatment trials
• 2 published
• 1 submitted
• There are also 3 drug RCTs
• NICE guideline due August 2008
ASPD Trials
Treatment
Brooner et al.,
1998
Drug abusers (ASPD)
on methadone
maintenance (n=40)
Contingency
No difference
management vs between groups
control
Messima et al., CBT
vs Contingency
2003
Cocaine dependent
with/without ASPD*
(n=108) * n=48
outcome
Manag (CM) vs
CBT+CM
vs methadone
management
No difference
between groups
but ASPD patients >
non ASPD in active
conditions vs MM in
terms of cocaine
abstinence
MASCOT
University of Glasgow, Imperial College, London & NHS
Kate Davidson
David Cooke
Andrew Gumley
Ian Ford
Andrew Walker
Mike Crawford
Peter Tyrer
Philip Tata
Helen Seivewright
Fiona Macaulay (trial administrator)
CBT therapists (n=7);
Research assistants Natalie Coombs, Helen Robertson
Funding: MRC
Trial registration: ISRCTN89922377
Aims of trial
 Feasibility of an RCT in antisocial PD men
who are aggressive
 Assess the impact of treatment from a
user, family member, and referring agent
perspective.
 Chart treatment as usual.
Antisocial Personality Disorder:
MASCOT trial 2005-2007
• Randomised controlled trial – pilot
• Centres: Glasgow and London
• CBT vs Usual Treatment (TAU)
• Men with ASPD who are verbally and physically
aggressive n=52
information not for dissemination
Patient inclusion criteria
Included
 Adult men with diagnosis of ASPD (SCID-II)
 Endorsed any physical or verbal aggression
on Amended MacArthur Community Violence
Screening Instrument (MCVSI) interview in 6
months prior to baseline.
 Able to provide written informed consent.
Demographic & other details
(n=52)
Mean
Current Age
38
Age left school
16
Age 1st trouble with law (n=27)
14
Age when 1st received MH services
(n=27)
20
After randomisation
 If TAU
TAU
 If CBT
TAU + CBT
Assessed
N=77
Did not meet study criteria
N=25
Randomised
N=52
CBT
N=25
TAU
N=27
Followed up every 3 months
RA blind to treatment allocation
12 month follow-up
N=20 (80%)
12 month Follow-up
N=21 (77%)
• Will men with ASPD in the community
attend CBT?
Attendance at CBT sessions
(n=25) 66% attended
12
10
8
6
4
2
0
0 sessions
1
2 to 9
10 or more
• Can CBT change aggression?
% reporting any act of verbal or
physical aggression
physical
verbal
100
80
60
baseline
1 year
40
20
0
CBT
TAU
90
80
70
60
50
40
30
20
10
0
CBT
TAU
• Can CBT change harmful drinking?
Harmful alcohol use (AUDIT)
p=0.08
12
10
8
CBT
TAU
6
4
2
0
Baseline
1 year
• Does CBT improve social functioning?
Social functioning
CBT vs TAU, P=0.08* cbt 6 months
14
12
10
8
TAU
CBT all
CBT 6 mnths
6
4
2
0
baseline
1 year
Problems faced by therapists?
• Increased empathy may interfere with
therapist insight into past and ongoing risk
• Habituation to accounts of violence
• May threaten therapist’s ‘moral compass’
• eg ‘forget’ the risk
• Lots of ranting at the beginning
• Poor comprehension/ literacy levels
Views of therapists and men with
ASPD
• Supervision
-
Necessary to maintain alliance
Keep risk aware
Improve therapy outcomes
Men can usefully engage in therapy
- Possible to change behaviour and social
functioning
- When asked for feedback at end of therapy, both
participants and partners wanted more
What are the costs?
Average NHS cost per patient:
• £1,133 in TAU
• £1,295 with CBT.
If include social services and criminal justice (contacts with
police and nights in custody) (total costs)
• £31,097 for TAU
• £38,004 for CBT
CBT therapy cost an average of £1,300 per patient.
Conclusion
• Dearth of data on treatment effectiveness
• CBT for ASPD shows promise
• Pressing need for rigorous trials
Further information
[email protected]
0141 211 3908