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Background: Patients in forensic psychiatric care (FPC) are commonly treated with a wide range of psychotropic medications. There is, however, a lack of understanding regarding how pharmacological treatment and psychotropic polypharmacy are used throughout care.

Method: This register-based cohort study included patients admitted to FPC in Sweden between 2009 and 2020. We estimated the prevalence of the use of major psychotropic medication, as well as psychotropic polypharmacy, at admission and discharge. We also examined the change in antipsychotic use after admission.

Results: In total, 1962 patients were included. Antipsychotics were the most used psychotropic medication class, with 86.2% (95%CI: 84.5 - 87.8) of patients receiving at least one typical or atypical antipsychotic at admission. Changes in the antipsychotic regime were more common in the beginning of FPC, compared to later time points. Within the subgroup of patients discharged during the study period (n=561), there was a reduction in the use of typical antipsychotics (admission: 34.9%; discharge: 26.6%) and hypnotics and sedatives (admission: 37.4%; discharge: 28.1%). Other major medication classes remained relatively stable. The prevalence of psychiatric polypharmacy at admission was 70.6% (95%CI: 68.5 - 72.7) and remained similar during care.

Conclusions: Our study documented a high prevalence of antipsychotic use and psychotropic polypharmacy through FPC. Further, a high level of off-label antipsychotic use and antipsychotic polypharmacy was observed. Stronger evidence regarding the effectiveness and safety of those treatment strategies is needed.