Prescription of psychotropic medication after prison release linked to lower rate of violent reoffending

Among released prisoners in Sweden, rates of violent reoffending were lower during periods when individuals were dispensed antipsychotics, psychostimulants, and drugs for addictive disorders, compared with periods in which they were not dispensed these medications, according to a study appearing in the November 1 issue of JAMA.

There were more than 10 million prisoners worldwide in 2015, with approximately 2.2 million in the United States alone. Despite reported decreases in violence in many countries, reoffending rates remain high. From 2005 through 2010, more than one-third of released prisoners in the United States and the United Kingdom were reconvicted of a new crime within 2 years. Most programs to reduce reoffending focus on psychosocial interventions, but their effect sizes are weak to moderate. As psychiatric and substance use disorders, which increase reoffending rates, are overrepresented among jail and prison populations, treatment with appropriate psychotropic medications offers an alternative strategy to reduce reoffending, although there is uncertainty about whether pharmacological treatments reduce reoffending risk.

Seena Fazel, M.D., of the University of Oxford, England, and colleagues examined the associations between major classes of psychotropic medications and violent reoffending. The study included all released prisoners in Sweden from July 2005 to December 2010, through linkage of population-based registers. Rates of violent reoffending during medicated periods (dispensed prescription of psychotropic medications [antipsychotics, antidepressants, psychostimulants, drugs used in addictive disorders, and antiepileptic drugs]) were compared with rates during nonmedicated periods. Prison-based psychological treatments were also included in the analysis.

The study included 22,275 released prisoners (average age, 38 years; 92 percent male). During follow-up (median, 4.6 years), 4,031 individuals (18 percent) had 5,653 violent reoffenses. The researchers found that three classes of psychotropic medications were associated with substantial reductions in violent reoffending: antipsychotics, a 42 percent reduction; psychostimulants, 38 percent; and drugs used in addictive disorders, a 52 percent reduction. In contrast, antidepressants and antiepileptics were not significantly associated with violent reoffending rates.

Analyses also demonstrated that completion of psychological treatments targeting general criminal attitudes and substance abuse was associated with reductions in violent reoffending. The associations with these psychological programs were not stronger than those for medications. "These findings may have implications for risk management, because prison psychological programs need appropriate facilities, require sufficiently trained and supervised therapists, and are likely to be relatively expensive. Provision of medication after prison release needs evaluation as a possibly cost-effective crime reduction alternative. Because prisoners with psychiatric disorders benefit from both pharmacological and psychological treatments, research should investigate whether combining therapies improves outcomes," the authors write.

"The absolute numbers of prisoners with psychiatric disorders are large worldwide, and most individuals who could benefit from psychotropic treatment do not receive it after prison release. The magnitudes of the associations reported in this study may warrant correctional services to review policies for released prisoners. Evidence-based provision of psychotropic medications to released prisoners may have the potential to make substantial improvements to public health and safety, particularly in countries that are undergoing decarceration [reducing the number of persons imprisoned or the rate of imprisonment]."