Background: The aim was to assess incidence, prevalence and risk factors of medication-induced tremor in African-Caribbean patients with severe mental illness (SMI). Method: A prospective study of SMI patients receiving care from the only mental health service of the previous Dutch Antilles. Eight clinical assessments, over 18 years, focused on movement disorders, medication use, and resting tremor (RT) and (postural) action tremor (AT). Risk factors were modeled with logistic regression for both current (having) tremor and for tremor at the next time point (developing). The latter used a time-lagged design to assess medication changes prior to a change in tremor state. Results: Yearly tremor incidence rate was 2.9% and mean tremor point prevalence was 18.4%. Over a third of patients displayed tremor during the study. Of the patients, 5.2% had AT with 25% of cases persisting to the next time point, while 17.1% of patients had RT of which 65.3% persisted. When tremor data were examined in individual patients, they often had periods of tremor interspersed with periods of no tremor. Having RT was associated with age (OR = 1.07 per year; 95% confidence interval 1.03–1.11), sex (OR = 0.17 for males; 0.05–0.78), cocaine use (OR = 10.53; 2.22–49.94), dyskinesia (OR = 0.90; 0.83–0.97), and bradykinesia (OR = 1.16; 1.09–1.22). Developing RT was strongly associated with previous measurement RT (OR = 9.86; 3.80–25.63), with previous RT severity (OR = 1.22; 1.05–1.41), and higher anticholinergic load (OR = 1.24; 1.08–1.43). Having AT was associated with tremor-inducing medication (OR = 4.54; 1.90–10.86), cocaine use (OR = 14.04; 2.38–82.96), and bradykinesia (OR = 1.07; 1.01–1.15). Developing AT was associated with, previous AT severity (OR = 2.62 per unit; 1.64–4.18) and tremor reducing medication (OR = 0.08; 0.01–0.55). Conclusions: Long-stay SMI patients are prone to developing tremors, which show a relapsing–remitting course. Differentiation between RT and AT is important as risk factors differ and they require ...