Psychiatry: Day of the Unlocked Door

27. September 2016
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Locked wards in psychiatry are supposed to protect patients. Yet suicide attempts and absconding are more common with locked wards than in hospitals with "open doors". A new study makes it clear: coercive measures tend to jeopardise therapy.

Locked wards in psychiatry are controversial among physicians and patients. Patients are accommodated there when they endanger themselves or others – for example, are in acute danger of suicide or impulsive aggressive behaviour. Admission can be made by law or quasi-judicial decision, but patients may also voluntarily decide to enter a locked ward.

Such risk patients represent a challenge for mental health institutions. The justification for locked wards goes as follows: Only when patients are kept away from behaving as a threat to themselves or to outsiders are they able to be adequately protected and to receive adequate therapy.

Comparison between hospitals with and without locked wards

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Christian Huber is a senior physician at the Centre for Psychotic Disorders of the University Psychiatric Clinics (UPK) Basel © Christian Huber

Now a new study has however shown that the risk that patients make suicide attempts or commit suicide or abscond from the treatment is no greater in open psychiatric hospitals than in psychiatric hospitals with locked wards. The research team led by Christian Huber and Undine Lang of the University of Basel and the University Psychiatric Clinics (UPK) Basel evaluated a total of around 350,000 patient cases from the period 1998 to 2012 – ie. over a period of 15 years. The researchers have now published their findings in the journal “The Lancet Psychiatry”.

The data was derived from 21 German hospitals, five of which pursued a practice of open doors, in other words managed to do without locked wards. 16 hospitals in addition to open wards also had temporarily or permanently locked wards. The diagnoses of the patients included organic brain disorders such as dementia, substance abuse, conditions within the schizophrenic spectrum, mood disorders and personality disorders. All hospitals were legally therein obliged to admit all persons of a particular catchment area – regardless of the severity of their illness or self-endangering behaviour. Problematic cases were thus not more likely to be admitted to a hospital with a closed ward.

Suicide attempts and absconding more frequent in locked wards

The analysis of the data showed: suicide attempts and suicide occur in hospitals without locked wards no more frequently than in hospitals with locked wards. What’s more, absconding was not more frequently observed in hospitals with “open doors”. Instead, the likelihood of suicide attempts and absconding (with and without patient return) was even significantly lower for clinics without locked wards – although this wasn’t true in relation to successful suicide attempts.

“The effect of the closed hospital doors is being overestimated”, says Christian Huber, lead author of the study. “Being retained did not in our study improve the safety of patients and sometimes even counters the prevention of suicide and absconding”. An atmosphere of control, restricted personal freedoms and coercive measures rather jeopardises successful treatment, says the researcher.

Results could promote “open door policy”

“The results indicate that locked wards are not a “need to have” in a general psychiatric hospital in order to protect patients who demonstrate self-endangering potential and to prevent them from absconding”, says Huber. Instead, it is important to create an appreciative environment and an open, good therapeutic atmosphere in which reaching joint decisions with the patient is encouraged. “An open-door policy requires that the treatment team be active especially in interaction with patients, that it involve them more in the therapy, and that this therapy go together with a sustainable alliance with the patient”, says the researcher. “In the wards there should be a well-developed range of treatments that covers timely, adequate drug treatment and specific psychotherapeutic offers”.

Measures involving compulsory treatment and safety measures – such as medication without consent, fixation or isolation – should be able to be implemented within the scope of regulations relating to acute self or external threat, says Huber. “However, such measures represent a significant limitation of freedom and should be applied only when less restrictive alternatives are not available. Moreover, they should only relate to the people at risk”.

The results of the study could also influence legal issues that arise at the opening of clinics. “[These results] provide already fully openly operating clinics with an important argument to oppose the demands for safety through custody”, says Huber. “They also enable other hospitals to evolve towards an open-door policy”.

Creating an atmosphere where patients remain voluntarily

Overall, the results correspond to his experience in practice, says Mazda Adli, chief physician of the psychiatry based Fliedner-Klinik Berlin and researcher at the Department of Psychiatry and Psychotherapy, Charité – Universitätsmedizin Berlin. “However, it must be made clear that in the study only suicide attempts and suicide entered into calculations, and not behaviour endangering others”, says Adli. “Suicidality often occurs with patients having depression and is only rarely, typically in cases involving very difficult to interpret courses of progress, used to justify admission to a protected station.”

By contrast, there are in reality patients for whom a protected station can be temporarily useful, according to Adli. “These include for example acute manic patients who are not restrainable, or delusional patients who are plagued by strong fears. “However, the ward doors should be closed for an ever so brief period as possible and be reviewed at frequent intervals as to whether this is still necessary. The same applies in situations of acute danger to others – for example with patients who during periods of acute mania incorrectly interpret their environment, meaning others could be jeopardised.

“Regardless of whether there is or isn’t a protected station in a clinic: it is important to create a positive therapeutic atmosphere in which patients feel safe and are willing to volunteer to stay in the clinic”, says Adli. That also means, especially in hospitals with “open doors”, more work for doctors and nurses – for example, through the close supervision and monitoring of patients. “For this, adequate time resources are needed”, says the psychiatrist. “It is therefore crucial that the proportion of closed doors is not increased by economic pressures to achieve the shortest possible treatment times in the hospitals.”

Trend toward more control in psychiatry

Overall there is in psychiatry in the Western world a trend towards more coercive measures and control, writes Tom Burns of the Department of Psychiatry at the University of Oxford in a comment on the current study. “Such measures are exercised differently from country to country – and regional customs and traditions tend to be reflected more than demonstrated differences in the characteristics of the patients”, says Burns. It is therefore very important to ensure that such measures ought not be used arbitrarily – and to continue exploring how these measures affect the behaviour and well-being of patients.

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Medicine, Psychiatry, Research

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Dit maakt het recente advies van de HGR over dwanginterventies in psychiatrie alleen maar relevanter

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