Abstract
Preliminary evidence suggests that adherence to antipsychotic medication reduces criminal recidivism among patients diagnosed with schizophrenia. However, existing studies operationalize antipsychotic adherence as a binary variable (usually using a threshold of ≥80%), which does not reflect the prevalence of suboptimal adherence in real-world settings. The purpose of the current analysis was to investigate the association between successive ordinal levels of antipsychotic adherence and criminal recidivism in a well-defined sample of offenders diagnosed with schizophrenia (n = 11462). Adherence was measured using the medication possession ratio (MPR) and analyzed as a time-dependent covariate in multivariable regression models. Data were drawn from linked, comprehensive diagnostic, pharmacy and justice system records, and individuals were followed for an average of 10 years. Adjusted rate ratios (ARR) and confidence intervals (CI) are reported. Overall mean MPR was 0.41. Increasing levels of antipsychotic adherence were not associated with progressively lower rates of offending. However, when compared to the reference group (MPR ≥ 80%) all lower adherence levels were significantly associated (P < .001) with increased risk of violent (ARR = 1.58; 95% CI = 1.46–1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33–1.50) offenses. Significance was replicated in separate sensitivity analyses. Previously published studies reporting reductions in crime may have been influenced by antipsychotic adherence ≥80%. Binary operationalization of adherence is an inaccurate predictor of recidivism. Future research addressing functional outcomes of antipsychotic adherence should conceptualize adherence as an incremental independent variable.
Highlights
Antipsychotic medication is the cornerstone of treatment for schizophrenia and considered instrumental in the management of violent behavior
Between January 1998 and March 2015, 39 591 offenders convicted under BC provincial jurisdiction received at least one antipsychotic prescription
The current study is the first to examine the full range of antipsychotic medication adherence in an offender population spanning multiple years and found that adherence above 80% was associated with a significantly reduced risk of offending compared to all lower levels of adherence
Summary
Antipsychotic medication is the cornerstone of treatment for schizophrenia and considered instrumental in the management of violent behavior. A groundbreaking study in a general population (published in 2014) reported a 45% reduction in violent crime among patients when they received antipsychotic medication compared to when they did not.[1] A more recent analysis concluded that pharmacological treatment of schizophrenia significantly delayed time to violence by 18% among offenders released from prison.[2] the relationship linking violence and psychosis is unclear.[3]. Previous research addressing violent offending[1] applied an innovative within-participant analytic approach, but investigated adherence in binary terms, concluding that any adherence (at least one prescription within 120 days) was superior to none
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