Howner Katarina, Andiné Peter, Engberg Göran, Ekström Emin Hoxha, Lindström Eva, Nilsson Mikael, Radovic Susanna, Hultcrantz Monica
Department of Clinical Neuroscience, Centre of Psychiatry Research, Karolinska Institutet, Stockholm, Sweden.
Department for Forensic Psychiatry, National Board of Forensic Medicine, Stockholm, Sweden.
Front Psychiatry. 2020 Jan 16;10:963. doi: 10.3389/fpsyt.2019.00963. eCollection 2019.
Pharmacological treatment is of great importance in forensic psychiatry, and the vast majority of patients are treated with antipsychotic agents. There are several systematic differences between general and forensic psychiatric patients, e.g. severe violent behavior, the amount of comorbidity, such as personality disorders and/or substance abuse. Based on that, it is reasonable to suspect that effects of pharmacological treatments also may differ. The objective of this systematic review was to investigate the effects of pharmacological interventions for patients within forensic psychiatry. The systematic review protocol was pre-registered in PROSPERO (CRD42017075308). Six databases were used for literature search on January 11, 2018. Controlled trials from forensic psychiatric care reporting on the effects of antipsychotic agents, mood stabilizers, benzodiazepines, antidepressants, as well as pharmacological agents used for the treatment of addiction or ADHD, were included. Two authors independently reviewed the studies, evaluated risk of bias and assessed certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). The literature search resulted in 1783 records (titles and abstracts) out of which 10 studies were included. Most of the studies included were retrospective and non-randomized. Five of them focused on treatment with clozapine and the remaining five on other antipsychotics or mood stabilizers. Five studies with a high risk of bias indicated positive effects of clozapine on time from treatment start to discharge, crime-free time, time from discharge to readmission, improved clinical functioning, and reduction in aggressive behavior. Psychotic symptoms after treatment were more pronounced in the clozapine group. Mainly due to the high risk of bias the reliability of the evidence for all outcomes was assessed as very low. This systematic review highlights the shortage of knowledge on the effectiveness of pharmacological treatment within forensic psychiatry. Due to very few studies being available in this setting, as well as limitations in their execution and reporting, it is challenging to overview the outcomes of pharmacological interventions in this context. The frequent use of antipsychotics, sometimes in combination with other pharmacological agents, in this complex and heterogeneous patient group, calls for high-quality studies performed in this specific setting.
药物治疗在法医精神病学中至关重要，绝大多数患者接受抗精神病药物治疗。普通精神病患者和法医精神病患者之间存在一些系统性差异，例如严重暴力行为、合并症数量，如人格障碍和/或药物滥用。基于此，有理由怀疑药物治疗的效果也可能不同。本系统评价的目的是调查法医精神病学中药物干预对患者的影响。该系统评价方案已在国际前瞻性注册系统（PROSPERO，注册号：CRD42017075308）中预先注册。2018年1月11日使用六个数据库进行文献检索。纳入了法医精神病护理中的对照试验，这些试验报告了抗精神病药物、心境稳定剂、苯二氮䓬类药物、抗抑郁药以及用于治疗成瘾或注意力缺陷多动障碍的药物的效果。两位作者独立审查了这些研究，评估偏倚风险并使用推荐分级的评估、制定与评价（GRADE）方法评估证据的确定性。文献检索产生了1783条记录（标题和摘要），其中纳入了10项研究。大多数纳入的研究是回顾性的且非随机的。其中五项研究聚焦于氯氮平治疗，其余五项研究聚焦于其他抗精神病药物或心境稳定剂。五项存在高偏倚风险的研究表明氯氮平对从治疗开始到出院的时间、无犯罪时间、从出院到再次入院的时间、改善临床功能以及减少攻击行为有积极作用。治疗后氯氮平组的精神病症状更为明显。主要由于高偏倚风险，所有结局证据的可靠性被评估为非常低。本系统评价凸显了法医精神病学中药物治疗有效性方面的知识短缺。由于在此背景下可用的研究极少，以及研究实施和报告方面的局限性，在这种情况下概述药物干预的结果具有挑战性。在这个复杂且异质性的患者群体中频繁使用抗精神病药物，有时还与其他药物联合使用，这就需要在这个特定背景下开展高质量的研究。
