The conditions when using psychiatric medication differ slightly between forensic and general psychiatry. In this evaluation, SBU describes these differences and investigates their significance on pharmaceutical treatments. The evaluation addresses the benefits, risks and experiences of treatment, in addition to health economics and ethical considerations. The evaluation was made as part of a government assignment.
In Sweden, a person who has committed a crime under the influence of a severe mental disorder can be sentenced to forensic psychiatric care which is regulated partly by the Health and Medical Services Act and partly by penal law. “Severe mental disorder” is a legal term, not a medical, and the patients in forensic psychiatry are a clinically heterogeneous group. Psychotic disorders are the most common diagnoses, followed by autism spectrum disorder and personality disorders. Virtually all patients are treated with medication. Treatment is often long-term – in some cases lifelong.
The demographics of the patient groups and their pharmaceutical treatments were studied by comparing the Swedish National Forensic Psychiatric Register (RättspsyK) and the National Quality Registry for Psychosis Care (PsykosR) with the National Patient Register and the National Cause of Death Registry.
The evaluation includes systematic reviews of studies in forensic psychiatric care regarding 1) effects of pharmaceutical treatments; 2) the costzeffectiveness of the treatments and 3) patients’ and staff’s experiences of pharmaceutical treatments. We also mapped systematic reviews of pharmaceutical effects on comorbid conditions. To include the perspectives of patients and relatives, we collaborated with the national patients and relative association PAR. We estimated the cost of prescriptions of commonly used medications. Ethical aspects were discussed based on published literature.
Our review of pharmaceutical treatments in forensic psychiatry clearly indicates a neglected area of research. We can also note that forensic psychiatry – like general psychiatry – is limited by the lack of new antipsychotics. Forensic psychiatry would be helped by the development of novel antipsychotics that target the underlying biological causes of psychosis. Development of better treatments is of major significance to both patients and society.
Before new knowledge is achieved, forensic psychiatry should adopt the guidelines that exist for pharmaceutical treatment in general psychiatry. This particularly concerns the national guidelines for treatment with antipsychotics and treatment of substance abuse. Furthermore, it is important that these guidelines are viewed in relation to the special context of care in forensic psychiatry, and that consideration is taken to the comorbid conditions found in forensic psychiatry. Forensic psychiatry has existed for a long time and the experience of various pharmaceutical treatments should be comprehensive. However, this experience needs to be spread throughout forensic psychiatry units to ensure this knowledge is shared.
presents a comprehensive, systematic assessment of available scientific evidence. The certainty of the evidence for each finding is systematically reviewed and graded. Full assessments include economic, social, and ethical impact analyses.
SBU assessments are performed by a team of leading professional practitioners and academics, patient/user representatives and SBU staff. Prior to approval and publication, assessments are reviewed by independent experts, SBU’s Scientific Advisory Committees and Board of Directors.