{
  "abstract": "Background Patients in forensic psychiatric care (FPC) are often treated with various psychotropic medications. However, evidence regarding their effectiveness in this setting is lacking.Objective The study aimed to estimate how different psychotropic medications are associated with the use of coercive measures and recidivism during FPC.Methods In this observational national register-based study, we included all patients newly registered as admitted to FPC in Sweden between January 2009 and August 2024. Exposures included major classes of psychotropic medication (typical antipsychotics, atypical antipsychotics, antidepressants, hypnotics and sedatives, antiepileptic medications, opioids, medications for addictive disorders and mood stabilisers), antipsychotic treatment strategies (no use, monotherapy, polypharmacy, long-acting injectables or clozapine) and specific antipsychotic agents. Outcomes were the use of coercive measures and recidivism into criminal behaviour. We performed a within-individual analysis using conditional generalised estimating equation models, where the risk of outcomes was compared between exposed and non-exposed time periods.Findings In total, 2690 patients were included, of which 25.1% experienced at least one occasion of coercion and 27.1% at least one event of recidivism during FPC. Atypical antipsychotics were associated with a reduced risk of subsequent use of coercive measures (OR 0.70, 95% CI 0.55 to 0.89) and recidivism (OR 0.79, 95% CI 0.63 to 0.99). Medication for addictive disorders was associated with a reduced risk of coercive measures by 34% (OR 0.66, 95% CI 0.47 to 0.93). Among antipsychotic agents, clozapine was associated with the largest risk reduction in the use of coercive measures (OR 0.48, 95% CI 0.33 to 0.69) and recidivism (OR 0.49, 95% CI 0.33 to 0.74). There was no significant difference between long-acting injectable, oral monotherapy or polypharmacy.Conclusions We observed that atypical antipsychotics, especially clozapine, were associated with a risk reduction for coercive measures and recidivism during FPC. Additionally, medications for addictive disorders were associated with a reduced risk of coercive measures.Clinical implications Our results can help inform decision-making processes in this clinical setting regarding pharmacotherapy but should be interpreted as one of many aspects influencing treatment success in FPC.",
  "authors": [
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden"
      ],
      "name": "Taalke Maria Sitter"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden",
        "School of Educational Sciences and Psychology, University of Eastern Finland, Joensuu, Finland"
      ],
      "name": "Suvi Savinen"
    },
    {
      "affiliations": [
        "Center for Ethics, Law and Mental Health, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden",
        "Department of Forensic Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden",
        "Department of Forensic Psychiatry, National Board of Forensic Medicine, Stockholm, Sweden"
      ],
      "name": "Peter Andiné"
    },
    {
      "affiliations": [
        "Center for Ethics, Law and Mental Health, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden",
        "Department of Forensic Psychiatry, National Board of Forensic Medicine, Stockholm, Sweden"
      ],
      "name": "Anja Fernqvist"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden",
        "Swedish Prison and Probation Service, Norrköping, Sweden"
      ],
      "name": "Hanna Edberg"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden",
        "Department of Biomedicine, Aarhus University, Aarhus, Denmark"
      ],
      "name": "Isabell Brikell"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden",
        "Department of Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, USA"
      ],
      "name": "Brian M D’Onofrio"
    },
    {
      "affiliations": [
        "Centre for Psychiatry Research, Region Stockholm, Stockholm, Sweden",
        "Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden"
      ],
      "name": "Tatja Hirvikoski"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden"
      ],
      "name": "Ralf Kuja-Halkola"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden"
      ],
      "name": "Agnieszka Szwajda"
    },
    {
      "affiliations": [
        "Department of Psychiatry, University of Oxford, Oxford, UK"
      ],
      "name": "Seena Fazel"
    },
    {
      "affiliations": [
        "Center for Ethics, Law and Mental Health, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden",
        "Department of Forensic Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden"
      ],
      "name": "Thomas Nilsson"
    },
    {
      "affiliations": [
        "Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden"
      ],
      "name": "Zheng Chang"
    }
  ],
  "title": "Association of psychotropic medications with the use of coercive measures and recidivism during forensic psychiatric care: a Swedish nationwide register-based study",
  "uid": "f240a910-9124-54b1-b53c-85be0c2bece8"
}