'Locked-Door Policy' in Psych Hospitals Makes No Difference to Patient Safety

Nancy A. Melville

August 03, 2016

A large comparison study of psychiatric hospitals, both those with and those without locked-door policies, showed no significant difference between the two groups in rates of suicide, suicide attempts, and unauthorized absence with or without return, suggesting little benefit from this common practice.

"These findings suggest that locked-door policies may not help to improve the safety of patients in psychiatric hospitals and are not generally successful in preventing people from absconding," first author Christian Huber, PhD, of the Universitäre Psychiatrische Kliniken Basel, in Switzerland, said in a press statement.

"In fact, a locked-door policy probably imposes a more oppressive atmosphere, which could reduce the effectiveness of treatments, resulting in longer stays in hospital. The practice may even lend motivation for patients to abscond," Dr Huber added.

The study was published online July 28 in Lancet Psychiatry.

Open-Door Policy Better?

The study, which included data from 21 German hospitals, spanned the period 1998 to 2012 and included four hospitals without a locked-door policy and 16 hospitals with a locked-door policy.

The data were drawn from 145,738 patient cases. Diagnoses included dementia, substance use disorders, schizophrenia spectrum disorders, mood and stress-related disorders, and personality disorders.

Propensity score matching of cases showed that open-door facilities had no statistically significant increases compared with locked-door facilities in rates of suicide (odds ratio [OR], 1.32; P = .24), suicide attempts (OR, 1.05; P = .71), absconding with return (OR, 1.28; P = .21), and absconding without return (OR, 1.09; P = .69).

Treatment in open wards was associated with a decreased probability of suicide attempts (OR, 0.658; P = .003) and of absconding with return (OR, 0.629; P < .0001) and without return (OR, 0.707; P = .01), but not in completed suicides (OR, 0.823; P = .63), compared with treatment in locked wards.

Although locked-door policies are designed to keep patients in, the findings support research suggesting that restriction may have the opposite effect and may increase patients' desire to leave.

In one study, when patients were asked why they absconded, 19% described being disturbed by other patients as a reason for leaving the ward.

"These data suggest that the restriction of personal freedom in locked ward settings might increase absconding behaviour and prevent patients from returning," the investigators note.

Other research has indicated that "opening the doors of an acute psychiatric ward led to a reduction in absconding and increased adherence after acute treatment."

Importantly, differences in mental health systems around the world, particularly in the availability of psychiatric beds, complicate the translation of the findings beyond Germany, the authors note.

Germany has about 1.1 psychiatric care beds per 1000 inhabitants; in comparison, rates are higher in Belgium (1.8 beds per 1000) and are even greater in Japan (2.8 beds per 1000).

In the United Kingdom, the rates are about half those of Germany (0.5 per 1000). They are even less in the United States (0.3 beds per 1000). These data suggest that beds in those countries go to patients with more severe illness, the authors report.

Open-door settings may provide for an improved therapeutic atmosphere and improved relationships between staff and patients, allowing for less restriction, but this may not be in the case in more severely ill patient populations.

"It is unclear whether these advantages can still be realized on wards with higher proportions of severely ill and endangered patients, and whether short hospital stays still allow for sufficient therapeutic relationships to be built to retain patients in treatment," the authors write.

Barrier to Trust

In an accompanying commentary, Tom Burns, CBE, DSc, FRCPsych, chair of social psychiatry, University of Oxford, United Kingdom, agreed that in addition to likely indicating more severe illness, fewer psychiatric beds can indicate higher involuntary admissions, and with substance abuse common, some facilities may be locked because of the additional need to "keep undesirables out."

But with the primary justification for locked doors being to protect patients from the risk for suicide and absconding, the new study calls into question the true benefits of such policies.

"The study does, of course, need replicating, but the authors are surely justified in concluding that locked doors do not seem to provide the anticipated protection," Dr Burns writes.

"Throughout western psychiatry we are witnessing a shift to ever more compulsion and control. National variations seem to reflect local customs and tradition, rather than any demonstrated differences in patient characteristics and needs."

The trend reflects an increased tendency to replace efforts at building "trusting relationships" with locked doors.

"If we lose the emphasis on this core skill from our training and practice, it could be very difficult to re-establish. Therapeutic engagement and continuity of care need to move back up our profession's priorities," Dr Burns writes.

The study's authors and Dr Burns have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online July 28, 2016. Abstract, Commentary

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