Fonagy Peter, Simes Elizabeth, Yirmiya Karen, Wason James, Barrett Barbara, Frater Alison, Cameron Angus, Butler Stephen, Hoare Zoe, McMurran Mary, Moran Paul, Crawford Mike, Pilling Stephen, Allison Elizabeth, Yakeley Jessica, Bateman Anthony
Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
Research Department of Clinical, Educational and Health Psychology, University College London, London, UK; Anna Freud, London, UK.
Lancet Psychiatry. 2025 Mar;12(3):208-219. doi: 10.1016/S2215-0366(24)00445-0.
Antisocial personality disorder is a major health and social problem, but scepticism about its treatability has restricted development of the evidence base for psychological treatments. Mentalisation-based treatment (MBT) tailored for antisocial personality disorder (MBT-ASPD) can address problematic behaviours by improving the ability to understand and regulate the negative effects of thoughts and feelings. This study aimed to evaluate the clinical and cost-effectiveness of MBT-ASPD compared with probation as usual in reducing aggressive behaviours from baseline to 12 months of follow-up.
The Mentaliziation for Offending Adult Males (MOAM) trial was a multicentre, two-group, pragmatic, assessor-masked, randomised controlled superiority trial in England and Wales. Eligible participants were male, aged 21 years or older, convicted of an offence and under National Probation Service supervision at one of 13 sites, identified through the Community Personality Disorder Pathways Service, met DSM-5 criteria for antisocial personality disorder, and scored at least 15 on the Overt Aggression Scale-Modified (OAS-M). After a three-stage screening process, consenting participants were randomly allocated (1:1), stratified by site, age, probation order type, and remaining probation duration, to either MBT-ASPD plus probation as usual, or probation as usual alone. Participants in the MBT-ASPD group were offered 12 months of weekly 75-min group therapy sessions and monthly 50 min individual sessions. Probation as usual lasted up to 12 months, after which participants continued under National Probation Service supervision for the remainder of their term. Investigators and data collectors were masked to treatment allocation. The primary outcome was aggression measured by the OAS-M at 12 months after random allocation. Data were collected by a hybrid team of traditional researchers and researchers with lived experience of the criminal justice system. The primary analysis was conducted in the intention-to-treat population using a linear mixed-effects model, adjusted for baseline at each follow-up timepoint (months 3, 6, 9, 12, 15, 18, 21, and 24). This trial is registered with ISRCTN (ISRCTN 32309003), and all pre-planned follow-ups are complete.
Between Jan 2, 2016, and Aug 31, 2018, 1946 individuals were referred to the study; after the screening process, 313 participants were randomly allocated (156 [50%] to probation as usual and 157 [50%] to MBT-ASPD plus probation as usual). Participants had a mean age of 34·2 years (SD 9·3); the majority of participants (247 [79%]) identified as White British, Irish, or White Other; followed by Black British (Caribbean, African, or Other; 30 [10%]) or Mixed (29 [9%]). At 12 months after random allocation, mean OAS-M scores were significantly higher in the probation as usual group (mean score 186 [SD 153]) than in the MBT-ASPD group (90 [126]), with an adjusted mean difference between groups of -73·5 (95% CI -113·7 to -33·2); p<0·0001, with a medium-to-large effect size of 0·74. During the trial, seven participants died, and one presumed death occurred, all in the probation as usual group after random allocation, with none of the deaths deemed related to trial procedures.
MBT-ASPD holds promise as an effective intervention for individuals with antisocial personality disorder within a forensic population. Future research should explore these findings' generalisability and the sustainability of treatment gains.
National Institute for Health Research Health Technology Assessment programme.
反社会型人格障碍是一个重大的健康和社会问题，但对其可治疗性的怀疑限制了心理治疗证据基础的发展。为反社会型人格障碍量身定制的基于心智化的治疗（MBT-ASPD）可以通过提高理解和调节思想及情感负面影响的能力来解决问题行为。本研究旨在评估MBT-ASPD与常规缓刑相比，在从基线到随访12个月期间减少攻击行为方面的临床效果和成本效益。
“成年男性犯罪心智化”（MOAM）试验是在英格兰和威尔士进行的一项多中心、两组、实用、评估者盲法、随机对照优势试验。符合条件的参与者为21岁及以上的男性，因犯罪被定罪且在13个地点之一接受国家缓刑服务监督；通过社区人格障碍路径服务确定，符合反社会型人格障碍的DSM-5标准，且在修订的公开攻击量表（OAS-M）上得分至少为15分。经过三阶段筛选过程，同意参与的参与者被随机分配（1:1），按地点、年龄、缓刑令类型和剩余缓刑期限分层，分为MBT-ASPD加常规缓刑组或仅常规缓刑组。MBT-ASPD组的参与者接受为期12个月的每周75分钟小组治疗课程和每月50分钟个体治疗课程。常规缓刑最长持续12个月，之后参与者在国家缓刑服务监督下继续服刑剩余刑期。研究人员和数据收集者对治疗分配情况不知情。主要结局是随机分配后12个月时用OAS-M测量的攻击行为。数据由传统研究人员和有刑事司法系统亲身经历的研究人员组成的混合团队收集。主要分析在意向性分析人群中使用线性混合效应模型进行，在每个随访时间点（第3、6、9、12、15、18、21和24个月）根据基线进行调整。本试验已在国际标准随机对照试验编号注册中心（ISRCTN 32309003）注册，所有预先计划的随访均已完成。
在2016年1月2日至2018年8月31日期间，1946人被转介到该研究；经过筛选过程，313名参与者被随机分配（156名[50%]接受常规缓刑，157名[50%]接受MBT-ASPD加常规缓刑）。参与者的平均年龄为34.2岁（标准差9.3）；大多数参与者（247名[79%]）认定为英国白人、爱尔兰人或其他白人；其次是英国黑人（加勒比人、非洲人或其他人；30名[10%]）或混血（29名[9%]）。随机分配后12个月时，常规缓刑组的平均OAS-M得分（平均得分186[标准差153]）显著高于MBT-ASPD组（90[126]），两组调整后的平均差值为-73.5（95%置信区间-113.7至-33.2）；p<0.0001，效应大小为0.74，属于中到大型。在试验期间，7名参与者死亡，1例推定死亡，均发生在随机分配后的常规缓刑组，且所有死亡均被认为与试验程序无关。
MBT-ASPD有望成为对法医人群中反社会型人格障碍个体的有效干预措施。未来的研究应探讨这些结果的普遍性以及治疗效果的可持续性。
国家卫生研究院卫生技术评估项目。
