What is the Evidence for Psychological Interventions for Antisocial Personality Disorder?

Research Paper Title

Psychological interventions for antisocial personality disorder.


Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties.

This review updates Gibbon 2010 (previous version of the review).

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.


The researchers searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. They also searched reference lists and contacted study authors to identify studies.

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment.

The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

The researchers used standard methodological procedures expected by Cochrane.


  • This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called ‘standard Maintenance'(SM) in some studies).
  • Eight of the 18 psychological interventions reported data on the primary outcomes.
  • Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD.
  • Data were available from only 10 studies involving 605 participants.
  • Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands.
  • Study duration ranged from 4 to 156 weeks (median = 26 weeks).
  • Most participants (75%) were male; the mean age was 35.5 years.
  • Eleven studies (58%) were funded by research councils.
  • Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%.
  • Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention.
  • One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention.
  • Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence).
  • One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up.
  • Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. ‘Driving whilst intoxicated’ programme (DWI) + incarceration versus incarceration.
  • One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months.
  • Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years.
  • The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19).
  • The certainty of the evidence for all outcomes was very low.
  • Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants’ level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention.
  • Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU.
  • Psychosocial risk management (PSRM; ‘Resettle’) versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison.
  • It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).


There is very limited evidence available on psychological interventions for adults with AsPD.

Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition.

No intervention reported compelling evidence of change in antisocial behaviour.

Overall, the certainty of the evidence was low or very low, meaning that the researchers have little confidence in the effect estimates reported.

The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies.

This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.


Gibbon, S., Khalifa, N.R., Cheung, N.H-Y., Vollm, B.A. & McCarthy, L. (2020) Psychological interventions for antisocial personality disorder. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007668.pub3.

Substance Use & Intervention Programmes: Remember to Address Social Issues Regardless of Deployment History

Research Paper Title

Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers.


The effects of negative social interactions/experiences on substance use have largely been studied in civilian populations, but less is known about United States Army Reserve/National Guard (USAR/NG) soldiers-a high-risk group.


The researchers examined the associations between problems with social acceptance, social victimisation, and substance use among USAR/NG soldiers, and examined potential differences by deployment history.

The sample consisted of soldiers who completed baseline and 1-year follow-up assessments (N = 445) of Operation: SAFETY, an ongoing study of USAR/NG soldiers.

They examined the effects of baseline problems with social acceptance/social victimization on nonmedical use of prescription drugs (NMUPD), illicit drug use, frequent heavy drinking (FHD), and alcohol problems at follow-up.


Significant effects were small in magnitude but consistent in direction.

Greater problems with social acceptance were associated with higher odds of NMUPD and illicit drug use.

Greater social victimisation was associated with higher odds of NMUPD and illicit drug use.

There were no differences by deployment history.


Problems with social acceptance/social victimisation were not associated with FHD or alcohol problems.

Problems with social acceptance/social victimisation may contribute to drug use among USAR/NG soldiers.

Intervention programmes should address social issues, regardless of deployment history.


Hoopsick, R.A., Vest, B.M., Homish, D.L. & Homish, G.G. (2020) Problems With Social Acceptance and Social Victimization Predict Substance Use Among U.S. Reserve/Guard Soldiers. Stress and Health. doi: 10.1002/smi.2934. Online ahead of print.

Components & Principles of Effective Treatments in Mental Health

For interventions (to at least be perceived) to be effective in the treatment of mental health conditions, from the perspective of the service user, there are a range of components that one must understand and appreciate.

  • Facilitative service environment(s):
    • Understand how the environment can affect a service user’s experience of treatment.
    • Prioritise good relationships between staff/volunteers and those using the services.
    • Taking a genuine interest in the service user.
    • Being respectful.
    • Helps service users feel at ease and prevent relapse.
  • Access to appropriate treatment(s).
  • Compassionate and non-judgemental support.
    • This can include peer, practical, and emotional support.
  • Interventions that are long enough in duration:
    • Treatment needs to be long enough in duration for the service user to avoid relapse and/or move into recovery.
    • Need for ongoing support.
    • Aftercare programme as a way of ensuring a supportive network to prevent relapse.
  • Interventions that offer stability.
  • Choices (in terms of treatment).
    • Service users like to feel they have a choice in their treatment.
    • Want to be treated as individuals.
    • Individualised care means provider must have flexibility in service delivery.
  • Opportunities to learn (or relearn) how to live.
    • Treatment should be seen as providing opportunities for service users to learn (vocational/life) skills to support them to live their lives.
    • This can aid service users to steer away from problematic patterns of behaviour by providing structure and purpose, alleviating boredom, and distraction from their condition.

The above should be provided with the following three principles in mind:

  1. Within the context of good relationships.
    • You are not there to be the service user’s best friend, but good/positive relationships aid effectiveness of treatment and perceptions of service.
  2. Person-centred care.
    • Where appropriate and practicable, the service/treatment should fit around the service user, not the service user around the service/treatment.
  3. Understanding the complexity of the service user’s (both personal and professional) circumstances.
    • Understanding of the service user’s circumstances can aid adherence to treatment and their journey through their condition.

Finally, remember that the way in which services and treatment are delivered, is considered by many service users, to be more important than the type of treatment provided.

College Students & Substance Use: Do They Require different Strategies for Prevention & Intervention?

Research Paper Title

Cumulative Risk of Substance Use in Community College Students.


Substance use in community college students has been explored in only a handful of studies.

Differences in population characteristics and substance use between 2- and 4-year students suggest that different factors may promote and thwart this behaviour.

Cumulative risk is a parsimonious methodology that provides better model stability and more statistical power, yet it has only been recently used in substance use research.

The aim of this study is to investigate multiple aspects of substance use risk in a population in need of substance use prevention and intervention services.


The researchers conducted a cross-sectional study of community college students (N = 288; 75% female) examining the relative contributions of different domains of cumulative risk (eg, life stressors, academic stressors, and mental health diagnoses) to develop different profiles of risk across substance use classes (ie, alcohol, cigarette, marijuana, and hard drug use).


Cumulative risk analyses indicated that alcohol and tobacco use were associated with the domains of life stressors and peer/family substance use, marijuana use with peer/family substance use and stressful childhood experiences, and hard drug use with peer/family substance use, lack of social support, low access to care, and stressful childhood experiences.


Different strategies for prevention and intervention may be necessary to effectively address different forms of substance use in this population.

Scientific Significance

The risk domain profiles related to specific drugs may lead to targeted interventions to reduce substance use in community college students.


Salgado García, F., Bursac, Z. & Derefinko, K.J. (2020) Cumulative Risk of Substance Use in Community College Students. The American Journal on Addictions. 29(2), pp.97-104. doi: 10.1111/ajad.12983. Epub 2020 Jan 3.

Suicide in Older Adults: Intervention Required

Research Paper Title

Suicide in Older Adults.


Suicide in older adults is a critical problem that nurses and other health professionals need to address.

Evidence-based interventions for prevention of late-life suicide are urgently needed, as well as increased availability of health care professionals with knowledge and skills to recognise suicide risks and intervene to provide effective care for this vulnerable population.


Sorrell, J.M. (2020) Suicide in Older Adults. Journal of Psychosocial Nursing and Mental Health Services. 58(1), pp.17-20. doi: 10.3928/02793695-20191218-04.

What is the Sustainability of a Biobehavioural Intervention Implemented by Therapists & Sustainment in Community Settings?

Research Paper Title

Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings.


The ultimate aim of dissemination and implementation of empirically supported treatments (ESTs) in behavioural medicine is:

  • Sustainability of the therapist/provider’s EST usage; and
  • Sustainment of EST delivery in the setting.

Thus far, sustainability has been understudied, and the therapist and setting variables that may be influential are unclear.

The purpose of the study was to test the therapists’ sustainability of a cancer-specific EST using a prospective longitudinal design and examine its predictors.


Oncology mental health therapists (N = 134) from diverse settings (N = 110) completed training in the biobehavioural intervention (BBI) and were provided with 6 months of support for implementation, with no support thereafter. BBI usage (percent of patients treated) was reported at 2, 4, 6, and 12 months.

Using a generalised estimating equation with a logistic link function, 12-month sustainability (a non-significant change in usage from 6 to 12 months) was studied along with therapist, supervisor, and setting variables as predictors.


BBI usage increased through 6 months and, importantly, usage was sustained from 6 (68.4% [95% CI = 62.2%-73.9%]) to 12 months (70.9% [95% CI = 63.6%-77.3%]), with sustainment in 66 settings (60.0%).

Predictors of implementation-to-sustainability usage were therapists’ early intentions to use the BBI (p < .001) and from the setting, supervisors’ positive attitudes toward ESTs (p = .016).


Adding to the DI literature, a health psychology intervention was disseminated, implemented, and found sustainable across diverse therapists and settings.

Therapists and setting predictors of usage, if modified, might facilitate future sustainability/sustainment of ESTs.


Ryba, M.M., Lo, S.B. & Andersen, B.L. (2019) Sustainability of a biobehavioral intervention implemented by therapists and sustainment in community settings. Translational Behavioral Medicine. pii: ibz175. doi: 10.1093/tbm/ibz175. [Epub ahead of print].