What leads to high antipsychotic dosing in forensic patients with schizophrenia? Branimir Margetić, * Branka Aukst Margetić, Dragutin Ivanec, and Tija Žarković Palijan Earlier findings suggest that forensic schizophrenia patients are treated with higher doses of antipsychotics. This practice-based specificity is insufficiently studied, and clinicians’ motives regarding this practice remain poorly understood. In this editorial, the authors provide their data on treatment of forensic schizophrenia patients and identify characteristics of psychopathology and previous types of behaviors, including suicidal attempts, as potential reasons for the practice. They also emphasize that “these previous acts” often took place years ago, and suggest that current or recent aggression is unlikely the main reason for dosing, but rather the clinicians’ intention to maintain “must remain unaggressive” condition. Therefore, the authors suggest new ideas that may contribute to a better understanding of the specific prescribing patterns in the forensic population and hope that these ideas would be implemented in further well-designed prospective studies. Received 30 August 2016; Accepted 8 September 2016; First published online 19 April 2017 Key words: Forensic psychiatry, antipsychotic drugs, suicide, aggression. Forensic schizophrenia patients are often treated with higher doses and with more than one antipsychotic. 1-5 It is assumed that the fundaments of this practice are the lack of responses to the usual doses and the attempts to control violent behavior, though the approach is assumed to be often unnecessary and supporting evidence for its use is weak. 1 The main topic of “forensic psychopharmacology” is the treatment of aggression. However, the questions of a standardized definition and, consequently, clinical approaches to aggression remain unresolved. Moreover, typical forensic schizophrenia inpatients (at least in Croatia) are too treatment-resistant to have good insight into their condition and the need for continuous treatment, but they take medications and are rarely violent. The situation is further complicated by the fact that violence may be differently motivated, and that approaches to different types of aggression should differ. 6 For instance, psychotically motivated offense is probably the main reason for hospitalization of forensic schizophrenia patients, while studies imply that impul- sive violence is the main type exhibited by hospitalized patients. 6,7 Do we then treat current aggression, reasons for past aggression, or “future danger to self or others”? This unresolved question is what motivates clinicians to prescribe certain dosages. Thus far, we have reported that forensic patients’ histories of mechanical restraint are associated with more intensive positive symptoms and also with the character- istics of personality that may predispose the patients to impulsive reactions. 8 It is worth noting that the great majority of these patients had been restrained in previous years and none in the 3 months prior to the study. As the use of restraints is dominantly linked with aggression, the findings suggest that the patients’ current doses of antipsychotics may be related to aggressive behavior that took place in the past, and which was not only a consequence of symptoms but also associated with the characteristics of their personality. 8 Moreover, the find- ings are in accordance with some previous findings that indicated that violence is generally more common in treatment-resistant psychotic patients. 9-11 It is logical to expect that those patients “need” higher doses. However, we had conducted a larger study, and one of the aims was to assess the relationships between treatment strategies and different behaviors in this population. There are no reports related to a possible association of the doses with the seriousness of offense or suicidality that occurs more frequently in aggressive schizophrenia patients. 12-14 Thus, it would be valuable * Address for correspondence: Dr. Branimir Margetić, Neuropsychiatric Hospital, Jelengradska 1, 44317 Popovača, Croatia. (Email: branimir.margetic@zg.t-com.hr) CNS Spectrums (2017), 22, 435–438. © Cambridge University Press 2017 doi:10.1017/S1092852916000675 EDITORIAL https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852916000675 Downloaded from https://www.cambridge.org/core. IP address: 181.214.120.16, on 06 May 2020 at 00:58:54, subject to the Cambridge Core terms of use, available at