The conditions for psychological and psychosocial interventions within forensic psychiatric care differ in many ways from non-compulsory psychiatry. This project focuses on the benefits and risks of interventions used in forensic psychiatry, including their health economic and ethical aspects, and the experiences of patients who have been remitted to forensic psychiatric care. The assignment to evaluate interventions in forensic psychiatric care came from The Ministry of Health and Social Affairs. An earlier mapping of systematic reviews pertaining to interventions used in forensic psychiatry (SBU 2017) indicate a substantial need for well conducted research.
These results demonstrate that there is a large need for research that can support the development of psychological and psychosocial interventions, as well as general healthcare and nursing, and help to improve how patients are met in forensic psychiatric care. The results also indicate that the way forensic psychiatry is conducted varies throughout Sweden.
Severe psychiatric illness is a legal term rather than a medical term. In Sweden, a person who commits a crime when they have an active severe psychiatric illness can be sentenced to receive forensic psychiatric care rather than incarceration. Approximately 300 individuals are remitted to forensic psychiatric care each year.
Forensic psychiatric care is regulated in part by the same laws that regulate all Swedish healthcare and in part by penal laws. Patients remitted to forensic psychiatric care have diverse diagnoses and the most common diagnosis is psychosis. Autism and personality disorders are also common. These patients often have a substantial need for healthcare. The care provided by forensic psychiatry resembles the care provided by other psychiatric care providers, often using the same treatments.
The project was conducted in accordance to the methods of SBU. This assessment consists of three systematic reviews. The first assessed the effects of psychological treatments and psychosocial interventions examined in controlled studies that were conducted in forensic psychiatric settings and considered transferable to the Swedish system. The second assessed the qualitative evidence regarding the experiences of patients remitted to forensic psychiatric care in Sweden. The third was a systematic review of health economic assessments; this was complemented with cost information associated with interventions, the over-all care and the legal process in the Swedish system. The systematic reviews were complemented with a survey of current clinical practices used in Swedish forensic psychiatric care and an ethical evaluation.
Five studies of effects of treatment met the inclusion criteria for the systematic review on psychological treatments and psychosocial interventions. All were cognitive behavioral therapies that had been adapted for use in forensic psychiatric settings. The studies were too heterogenous in treatment and outcome to allow meta-analysis. No studies on psychosocial interventions were identified.
Four qualitative studies on patient experiences from Swedish forensic psychiatry were identified. The studies suggest that these patients often feel vulnerable, that they lack autonomy and adequate influence over their care.
No economic evaluations which meet the inclusion criteria for the project were identified. The systematic review was complemented with an assessment of the related costs in Sweden that showed that the costs of interventions are very low in relation to the total cost of forensic psychiatric care.
Our assessment of psychological treatments and psychosocial interventions clearly indicates a lack of research in forensic psychiatric care; there are few effect studies in the field. It is promising that more interventions have been adapted for this population in the last few years, and that research into their efficacity has begun.
It should be noted that the lack of research does not imply that an intervention lacks effect, but rather that its effect has not been sufficiently researched.
Other aspects of care and how patients are treated in forensic psychiatry are also important for patient recovery. Initiatives to develop this work should be encouraged. Psychological treatments, psychosocial interventions, and general healthcare together with pharmacological treatment are all important elements of forensic psychiatric care; they depend on each other to achieve the best results.
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.