Locking the doors of mental health hospitals does not reduce the risk of suicide or of patients leaving without permission, according to a study published in The Lancet Psychiatry.
People with mental health problems have a higher risk of suicide than the general population. Some hospitals that offer psychiatric care lock their wards to try to reduce this risk, while others leave rooms open.
Researchers in Germany have compared outcomes for locked and unlocked accommodation in a 15-year study of around 145,000 patients. The authors believe that an open door policy may be preferable, as it can promote a better therapeutic atmosphere and more positive health outcomes.
Authorities around the world are increasingly using locked-door policies to keep patients safe from harm, but locked doors also restrict personal freedom.
European countries tend to follow traditional approaches in caring for patients in psychiatric care, because there has been little evidence so far that one method is better than another.
Similar outcomes whether doors are open or locked
The current study examined data from 21 German hospitals between 1998 and 2012 to see how locked and open door policies might correlate with rates of suicide, attempted suicide, and absconding.
Of 349,574 patients, they selected 72,869 cases from each hospital type, or 145,738 cases altogether. Creating matched pairs enabled a direct comparison between hospitals.
Most of the patients had brain disorders relating to dementia, substance use, schizophrenia, and affective disorders, including mood disorders, such as depression, stress-related, and personality disorders.
They looked at the numbers of completed suicides, attempted suicides, leaving and then returning, and absconding without return.
They then factored in whether the hospital had an open door policy or not, and whether the wards were locked, partly locked, open, or if they were day clinic wards.
Patients attending open and day clinic wards were less likely to abscond, either with or without returning, compared with locked and partly locked wards.
The number of attempted suicides was also lower among those staying in an open ward, compared with a locked ward, but rates of completed suicide were similar.
Do locked doors unnecessarily create a sense of oppression?
Given the similarity of outcomes between the two types of hospital, the researchers propose that an open door policy might be preferable.
"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. 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. Christian Huber, of the Universitäre Psychiatrische Kliniken Basel, Switzerland
Since each hospital serves a specific location, there was no chance of higher-risk patients being allocated to hospitals with locked wards. This reduced the risk of bias.
The authors warn that an open door strategy might not be appropriate everywhere, as mental health care provision differs in other ways, too, for example, how many beds are available, the percentage of acutely ill patients, and how long they are treated for.
Germany has around 1.1 psychiatric care beds for every 1,000 people, compared with 0.5 beds per 1,000 in the United Kingdom and 0.3 in the United States. Where there are fewer beds, patients who receive treatment are more likely to be severely ill and more at risk.
Nevertheless, the authors believe that the findings raise important questions, not just in Germany but beyond, and they call for further studies to confirm the applicability of their findings to mental health services elsewhere.
The study did not look at suicide, self-harm, or harm to others among people who absconded and did not return, since data for these patients were not available.
Co-author Professor Undine E Lang points out, however, that: "Most people with mental health disorders are at greater risk of suicide and self-harm than of harming others." Other studies have suggested that "very few" people who abscond go on to harm themselves or others.
Losing sight of the need for a trusting relationship?
In a linked comment, Prof. Tom Burns, of the Department of Psychiatry at the Warneford Hospital, University of Oxford in the U.K., notes that psychiatric care is shifting toward exercising a greater degree of control. He notes that traditional approaches do not necessarily match patients' needs and situations.
This, he says, raises issues of patients' rights and is at odds with the stated aims of national strategies to use the least restrictive option.
A core skill in mental health care practice, he says, is to develop trusting relationships with patients, and particularly with those who are most troubled and severely ill. A control-oriented approach can lose sight of this key principle.
If this skill is lost, says Prof. Burns, it could be very difficult to get back. He calls for the re-establishment of therapeutic engagement and continuity of care as priorities in mental health care.
If you need someone to talk to, you can call the National Suicide Prevention Lifeline toll-free on 1-800-273-8255, or chat with a skilled, trained counselor through the website.