| Summary: | <p><b>Background:</b> Despite limited evidence for service benefit, the demand for forensic psychiatric beds is growing. Some studies have reported rates of serious adverse outcomes post-discharge, however, the role of psychiatric diagnosis as a determinant of these outcomes needs to be clarified to ensure patients are managed in the most appropriate way.</p> <p><b>Aims:</b> The first aim of this thesis is to summarize evidence on key adverse outcomes, and to provide comparative information for public health and policy. The second aim of this thesis is to elucidate the role of diagnosis and comorbidity in the risk of some adverse outcomes.</p> <p><b>Methods:</b> The first study is a systematic review and a meta-analysis of investigations that followed patients discharged from secure hospitals, and reported data on key adverse outcomes after discharge. The second is a historical cohort study of forensic patients discharged from Swedish secure hospitals between 1972 and 2009, which examines the role of psychiatric diagnosis in risk of some adverse outcomes.</p> <p><b>Results:</b> Thirty-six studies from 10 countries were included. Mortality rates were lower in studies from England and Wales (crude rate=1,239, 95% CI 932-1,547) compared to other countries (2,331; 1,738-2,925). Readmission rates were higher in samples with a bigger proportion of patients with a diagnosis of mental illness (β=105.57, [se(β)]=54.90, p=0.070) as opposed to personality disorder (β=-181.45, [se(β)]=90.59, p=0.070). Reoffending rates were lower in more recent studies (β=-101.15, [se(β)]=43.34, p=0.026). Compared with different cohorts of discharged prisoners matched on gender, age, and type of offence, reoffending rates were lower for the forensic psychiatric samples (UK prevalence ratios 1.4-7.7 in UK studies)</p> <p>In the Swedish study, substance use was associated with increased risk of death (HR=1.783, 95% CI=1.556-2.044, p&LT;.000) and violent offending (HR=1.980, 95% CI=1.740-2.254, p&LT;.000). Schizophrenia increased the risk of readmission. Bipolar disorder (HR=1.461, 95% CI=1.196-1.785, p&LT;.000 and personality disorder (HR=1.496, 95% CI=1.345-1.663, p&LT;.000) were associated with increased risk of violent offending.</p> <p><b>Conclusions:</b> Treatment and post-discharge support strategies should take into account primary and comorbid diagnosis. Services should provide better overall care to improve patients' general health aiming to reduce premature mortality. Better health could also improve social functioning of these patients reducing readmissions and post-discharge offending in the long-term.</p>
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