Effects and experiences of pharmacological interventions in forensic psychiatry – a health technology assessment

Hultcrantz M1, Andiné P2, Engberg G3, Howner K4, Hoxha Ekström E5, Lindström E6, Nilsson M5, Radovic S7
1Swedish Agency for Health Technology Assessment and Assessment of Social Services, Karolinska Institutet, 2University of Gothenburg, Sahlgrenska University Hospital, National Board of Forensic Medicine, 3Karolinska Institutet, 4Karolinska Institutet, National board of Forensic Medicine, 5Swedish Agency for Health Technology Assessment and Assessment of Social Services, 6Akademiska University hospital, 7University of Gothenburg

Background: Pharmacological interventions are of utmost importance in forensic psychiatry and the vast majority of patients are treated with medicine. However, since these patients may differ from those in general psychiatry, e.g. with regard to violent behavior, aggression, drug abuse and comorbidity, it is unclear whether also the therapeutic efficacy of medication may differ.

Objectives: The aim was to assess effects of pharmacological interventions, describe patient experiences, and discuss health economical and ethical aspects for patients with severe mental illness within forensic psychiatry.

Methods: We conducted three systematic reviews on studies performed within forensic psychiatry, assessing: 1) effects of pharmacological interventions; 2) cost-effectiveness of these interventions; and 3) experiences of pharmacological interventions among patients and staff. In addition, a systematic mapping was performed focusing on the effects of pharmacological interventions for patients with relevant comorbidities. Patient and family member experiences of medical treatment were sampled with the help of a non-profit patient organization (PAR).

Results: Only a limited number of pharmacological interventions have been evaluated in the context of forensic psychiatry, and the certainty of evidence for all outcomes were assessed as very low. Also, very little research has focused on the pattern of comorbidity relevant for these patients. Any improvements of pharmacological treatment that would shorten the time of inpatient care have a high probability of being cost-effective, since the costs for pharmaceuticals are very small in relation to the total cost of care. Patients request more information about their prescribed drugs and call for drugs with less side effects. Ethical considerations relate to prescription of medicines as well as further research in a coercive setting.

Conclusions: Using various approaches, this assessment gives a comprehensive picture of what is known about pharmacological treatments in forensic psychiatry and highlights the need of primary high-quality research specifically focusing on these patient groups.

Patient involvement: Our patient partners provided input on the protocol and contributed with their experiences of pharmacological interventions through a questionnaire.