“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,” said lead study author Christian Huber, MD, of the Universitäre Psychiatrische Kliniken Basel in Switzerland, in a 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.”
Many hospitals that care for the mentally ill use locked-door policies that restrict freedom of movement in the name of safety.
The study examined 145,738 admissions to 21 German inpatient psychiatric hospitals from 1998 to 2012. The most common diagnoses included dementia, substance use disorders, schizophrenia, affective disorders, stress related disorders, and personality disorders. The four measured outcomes were suicide, suicide attempts, absconding with return, and absconding without return.
Huber and colleagues found, in comparing overall outcomes in hospitals that used locked wards with those that had none, that suicide (OR 1.326, 95% CI 0.803-2.113; P=0.24), suicide attempts (OR 1.057, CI 0.787-1.412; P=0.71), absconding with return (OR 1.288, CI 0.874-1.929; P=0.21), and absconding without return (OR 1.090, CI 0.722-1.659; P=0.69) all were not significantly greater under open-door policies.
In a separate analysis comparing patients in locked wards to those in unlocked units, the latter had lower probabilities of suicide attempts (OR 0.658, 95% CI 0.504-0.864; P=0.003), absconding with return (OR 0.629, 0.524-0.764; P<0·0001), and absconding without return (OR 0.707, CI 0.546-0.925; P=0.01).
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“It could be supposed that in completely open hospitals, patients at higher risk of suicide might be more able to leave and die by suicide,” the authors wrote. “However, locked wards might not adequately address this issue: about 13%-38% of patients leave a locked unit without the permission of staff. Indeed, patients seem to wait until they have their first chance to leave as soon as coercive measures are ceased. Thus, the safety of locked wards for the prevention of suicide might be overestimated, and patients at high-risk might be lost from treatment.”
Huber and colleagues called for more studies to determine whether their findings are applicable in different countries and circumstances, but noted that “the large sample size and naturalistic study design, the inclusion of a large number of hospitals, and the availability of data over an extended observation period all enhance the generalisability of our findings.”
In an accompanying commentary, Tom Burns, from the University of Oxford’s psychiatry department, questioned some of the study authors’ interpretations but agreed that “the authors are surely justified in concluding that locked doors do not seem to provide the anticipated protection.”
Burns commented that, in developed countries, “compulsion and control” in psychiatric care is becoming more common, without any basis in actual patient behavior but instead derives from “local customs and traditions.” This trend, he suggest, reflects “a neglect of attention to establishing trusting relationships” with psychiatric patients that needs to be reemphasized.