4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The relatively large number of recommendations made reflects the paucity of research in this area.

4.1 Severity as a potential moderator of effect in group-based cognitive and behavioural interventions

Does the pre-treatment level of the severity of disorder/problem have an impact on the outcome of group-based cognitive and behavioural interventions for offending behaviour? A meta-analysis of individual participant data should be conducted to determine whether the level of severity assessed at the beginning of the intervention moderates the effect of the intervention. The study (for which there are large data sets that include over 10,000 participants) could inform the design of a large-scale RCT (including potential modifications of cognitive and behavioural interventions) to test the impact of severity on the outcome of cognitive and behavioural interventions.

Why this is important

Research has established the efficacy of cognitive and behavioural interventions in reducing reoffending. However, the effects of these interventions in a range of offending populations are modest. The impact of severity on the outcome of these interventions has not been systematically investigated, and post hoc analyses and meta-regression of risk as a moderating factor have been inconclusive. Expert opinion suggests that severe or high-risk individuals may not benefit from cognitive and behavioural interventions, but if they were to be of benefit then the cost savings could be considerable.

4.2 Group-based cognitive and behavioural interventions for populations outside criminal justice settings

Are group-based cognitive and behavioural interventions effective in reducing the behaviours associated with antisocial personality disorder (such as impulsivity, rule-breaking, deceitfulness, irritability, aggressiveness and disregard for the safety of self or others)? This should be tested in an RCT that examines medium-term outcomes (including cost effectiveness) over a period of at least 18 months. It should pay particular attention to the modification and development of the interventions to ensure the focus is not just on offending behaviour, but on all aspects of the challenging behaviours associated with antisocial personality disorder.

Why this is important

Not all people with antisocial personality disorder are offenders but they exhibit a wide range of antisocial behaviours. However, the evidence for the treatment of these behaviours outside the criminal justice system is extremely limited. Following publication of the Department of Health's policy guidance, 'Personality disorder: no longer a diagnosis of exclusion' (2003), it is likely that there will be an increased requirement in the NHS to offer treatments for antisocial personality disorder.

4.3 Effectiveness of multisystemic therapy versus functional family therapy

Is multisystemic therapy or functional family therapy more clinically and cost effective in the treatment of adolescents with conduct disorders? A large-scale RCT comparing the clinical and cost effectiveness of multisystemic therapy and functional family therapy for adolescents with conduct disorders should be conducted. It should examine the medium-term outcomes (for example, offending behaviour, mental state, educational and vocational outcomes and family functioning) over a period of at least 18 months. The study should also be designed to explore the moderators and mediators of treatment effect, which could help to determine the factors associated with benefits or harms of either multisystemic therapy or functional family therapy.

Why this is important

Multisystemic therapy and functional family therapy are two interventions with a relatively strong evidence base in the treatment of adolescents with conduct disorders, but there have been no studies directly comparing their clinical and cost effectiveness. Their use in health and social care services in the UK is increasing. Both interventions target the same population, but although they share some common elements (that is, work with the family), multisystemic therapy is focused on both the family and the wider resources of the school, community and criminal justice systems, and through intensive individual case work seeks to change the pattern of antisocial behaviour. In contrast, functional family therapy focuses more on the immediate family environment and uses the resources of the family to change the pattern of antisocial behaviour. The study should be designed to facilitate the identification of sub-groups within the conduct disorder population who may benefit from either multisystemic therapy or functional family therapy.

4.4 Interventions for infants at high risk of developing conduct disorders

Do specially designed parent-training programmes focused on sensitivity enhancement (a set of techniques designed to improve secure attachment behaviour between parents and children) reduce the risk of behavioural disorders, including conduct problems and delinquency, in infants at high risk of developing these problems? An RCT comparing parent-training programmes focused on sensitivity enhancement with usual care should be undertaken. It should examine the long-term outcomes over a period of at least 5 years, but with consideration given to the possibility of a further 10-year follow-up. The study should also be designed to explore the moderators and mediators of treatment effect that could help determine the factors associated with benefits or harms of the intervention.

Why this is important

There is limited evidence from non-UK studies that interventions focused on developing better parent–child attachment can have benefits for infants at risk of developing conduct disorder. Determining the criteria and then identifying children at high risk (usually via parental risk factors) is difficult and challenging. Even when these factors are agreed, engaging parents in treatment can be difficult. It is important that a range of effective interventions is developed to increase the treatment choice and opportunities for high-risk groups. Several interventions, such as Nurse–Family Practitioners, are being developed and trialled in the UK. It is important for this group of children to have an alternative, effective intervention.

4.5 Treatment of comorbid anxiety disorders in antisocial personality disorder

Does the effective treatment of anxiety disorders in antisocial personality disorder improve the long-term outcome for antisocial personality disorder? An RCT of people with antisocial personality disorder and comorbid anxiety disorders that compares a sequenced treatment programme for the anxiety disorder with usual care should be conducted. It should examine, over a period of at least 18 months, the medium-term outcomes for key symptoms and behaviours associated with antisocial personality disorder (including offending behaviour, deceitfulness, irritability and aggressiveness, and disregard for the safety of self or others), as well as drug and alcohol misuse, and anxiety. The study should also be designed to explore the moderators and mediators of treatment effect which could help determine the role of anxiety in the course of antisocial personality disorder.

Why this is important

Comorbidity with Axis I disorders is common in antisocial personality disorder, and chronic anxiety has been identified as a particular disorder that may exacerbate the problems associated with antisocial personality disorder. There are effective treatments (psychological and pharmacological) for anxiety disorders but they are often not offered to people with antisocial personality disorder. Current treatment guidelines set out clear pathways for the stepped or sequenced care of people with anxiety disorders. An RCT to test the benefit of this approach in the treatment of anxiety would potentially lead to a significant reduction in illness burden but a reduction in antisocial behaviour would have wider societal benefits. The study should provide important information on the challenges of delivering these interventions for a population that has typically both rejected and been refused treatment.

4.6 Using selective serotonin reuptake inhibitors to increase cooperative behaviour in people with antisocial personality disorder in a prison setting

Although there is evidence that selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, increase cooperative behaviour in normal people and do so independently of the level of sub-syndromal depression, this has yet to be tested in other settings. Given that people with antisocial personality disorder are likely to have difficulties cooperating with one another (because of a host of personality traits that include persistent rule-breaking for personal advantage, suspiciousness, grandiosity, etc.). An RCT should be conducted to find out whether these reported changes of behaviour with an SSRI in normal people generalises to clinical populations in different settings.

Why this is important

There is little evidence in the literature on the pharmacotherapy of antisocial personality disorder to justify the use of any particular medication. However, multiple drugs in various combinations are used in this group either to control aberrant behaviour or in the hope that something might work. Current interventions lack a clear rationale. This recommendation has the potential to advance the field in that (a) it is linked to a clear hypothesis (that cooperative behaviour is linked to a dysregulation of the serotonin receptors – for which there is substantial evidence) and (b) that it is feasible to obtain an answer to this question, given that there are a large number of individuals detained in prison settings who would meet ASPD criteria. Constructing an experimental task that requires cooperative activity would not be difficult in such a setting, since all of those who might be willing to participate are already detained. The successful execution 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) provide a clear and sensible outcome measure of antisocial behaviour that might be generalised to other settings.

4.7 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 effective 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 effectiveness of the therapeutic community approach for adults with antisocial personality disorder with routine care. It should examine the medium-term outcomes (for example, offending behaviour, mental state and vocational outcomes) over a period of at least 18 months following release from prison. The study should also be designed to explore 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 important

There is evidence from RCTs that the therapeutic community approach is of value with drug and alcohol misusers in a prison setting at reducing the incidence of offending behaviour on release. However, there are no equivalent studies of a programme in the prison system on antisocial personality disorder populations that do not have significant drug or alcohol problems. Data that do exist 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 devoted to a therapeutic community approach in the UK prison system (for example, HMP Grendon Underwood). The study could inform policy and resources decisions about the management of antisocial personality disorder in the criminal justice system.

  • National Institute for Health and Care Excellence (NICE)