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Background Patients in forensic psychiatric care (FPC) are often treated with various psychotropic medications. However, evidence regarding their effectiveness in this setting is lacking.Objective The study aimed to estimate how different psychotropic medications are associated with the use of coercive measures and recidivism during FPC.Methods In this observational national register-based study, we included all patients newly registered as admitted to FPC in Sweden between January 2009 and August 2024. Exposures included major classes of psychotropic medication (typical antipsychotics, atypical antipsychotics, antidepressants, hypnotics and sedatives, antiepileptic medications, opioids, medications for addictive disorders and mood stabilisers), antipsychotic treatment strategies (no use, monotherapy, polypharmacy, long-acting injectables or clozapine) and specific antipsychotic agents. Outcomes were the use of coercive measures and recidivism into criminal behaviour. We performed a within-individual analysis using conditional generalised estimating equation models, where the risk of outcomes was compared between exposed and non-exposed time periods.Findings In total, 2690 patients were included, of which 25.1% experienced at least one occasion of coercion and 27.1% at least one event of recidivism during FPC. Atypical antipsychotics were associated with a reduced risk of subsequent use of coercive measures (OR 0.70, 95% CI 0.55 to 0.89) and recidivism (OR 0.79, 95% CI 0.63 to 0.99). Medication for addictive disorders was associated with a reduced risk of coercive measures by 34% (OR 0.66, 95% CI 0.47 to 0.93). Among antipsychotic agents, clozapine was associated with the largest risk reduction in the use of coercive measures (OR 0.48, 95% CI 0.33 to 0.69) and recidivism (OR 0.49, 95% CI 0.33 to 0.74). There was no significant difference between long-acting injectable, oral monotherapy or polypharmacy.Conclusions We observed that atypical antipsychotics, especially clozapine, were associated with a risk reduction for coercive measures and recidivism during FPC. Additionally, medications for addictive disorders were associated with a reduced risk of coercive measures.Clinical implications Our results can help inform decision-making processes in this clinical setting regarding pharmacotherapy but should be interpreted as one of many aspects influencing treatment success in FPC.