Antipsychotic Prescriptions and Rehospitalizations in a Forensic Psychiatry Sample

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SPECIAL REPORT: FORENSIC PSYCHIATRY PART 2

As there is very little research examining antipsychotic prescriptions and their effectiveness in forensic psychiatry, a recent longitudinal, retrospective study aimed to examine antipsychotic prescribing and rehospitalization rates in a forensic psychiatric sample.

“Forensic psychiatric patients have unique challenges often due to their high-profile offences, public scrutiny, and legal requirements,” wrote the study authors. “Advancing treatment of the high-profile forensic population can reduce stigma toward people with mental illness and criminal justice involvement.”¹

Investigators examined a total of 153 adult participants with a psychotic illness who had a verdict of not criminally responsible on account of mental disorder (NCRMD), and were hospitalized at the forensic psychiatric hospital in British Columbia, Canada, then discharged from the hospital between January 1, 2010, to December 31, 2015. Participants had to have a diagnosis of a psychotic illness at the time of discharge and be treated with an antipsychotic. Of the 153 participants, a majority were male (85.6%), White (71.2%), middle aged (30s to 50s), and had schizophrenia or schizoaffective disorder (76.5%). The mean age was 40.9 years (SD = 12.6). Additionally, 62.1% of participants had a substance use disorder; however, substance use is strictly prohibited at the forensic psychiatric hospital, so all patients were considered in remission at the time of the study.

Most of the antipsychotic prescriptions were atypical antipsychotics (75.9%). Participants had an antipsychotic polypharmacy rate of 39.9%. The sample was divided into 4 primary antipsychotic formulation types: oral (34.0%), injection (39.2%), clozapine (19.0%), and subtherapeutic (7.8%). Approximately 52.9% participants were rehospitalized, with the average number of rehospitalizations being 1.2 (SD = 1.7). On average, participants taking clozapine spent about half of the time rehospitalized (~10% vs ~20%) compared with the oral and injection groups, but it was not statistically significant. The investigators noted that as clozapine only had a 19.0% prescription rate, it may be underutilized in this sample. Additionally, as clozapine potentially offers shorter custodial dispositions, reduced recidivism, and better quality of life in forensic patients, further research is needed on clozapine and rehospitalization in this population, potentially with a larger sample size.²

“We found that more than half of conditionally discharged patients had a rehospitalization during the follow up period, although the time patients spent in hospital varied significantly between patients. Many of these rehospitalizations were voluntary or preventive, often due to patient anxiety or deterioration of mental state, rather than new offences. Overall, we did not find a significant difference between the 4 groups regarding rehospitalization rates,” wrote the study authors.¹

Surprisingly, long-acting injectable (LAI) antipsychotics did not provide any advantage in terms of rehospitalization rates compared with prescribing only oral antipsychotics. This is significant, as LAIs have also been proposed as a preferred method for treating individuals with schizophrenia spectrum disorders or other psychotic disorder in forensic settings.^3-5

“Better treatments for forensic patients will help reduce the significant stigma and institutionalization that these patients face,” concluded the authors.¹

References

1. Goody J, Petersen K, Brink J, et al. Antipsychotic prescribing practices and their association with rehospitalization in a forensic psychiatric sample. Front Psychiatry. 2024:15:1474626.

2. Patchan K, Vyas G, Hackman AL, et al. Clozapine in reducing aggression and violence in forensic populations. Psychiatr Quarterly. 2018;89:157-168.

3. Machin A, McCarthy L. Antipsychotic prescribing of consultant forensic psychiatrists working in different levels of secure care with patients with schizophrenia. BJPsych Bull. 2017;41(2):103-108.

4.Remington G, Addington D, Honer W, et al. Guidelines for the pharmacotherapy of schizophrenia in adults. Can J Psychiatry. 2017;62(9):604-616.

5. Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 2020;177(9):868-872.