Speak to older mental health service users or senior mental health professionals and many of them will tell you about their experiences of mental health inpatient wards with open-door policies. This was quite common 30 years ago but increasingly we see modern mental health units being kept permanently locked.

The reason usually given for wards being locked is that the people within them need to be kept safe; safe from harming themselves and safe from committing harm to others. Of course these are very real fears, but they are often wrongly magnified by a still sadly stigmatising media and public perception of severe mental illness.

There is certainly an uneasy tension between the Mental Health Act Code of Practice and the reality of locking up severely ill mental health patients, which is brought into sharp focus when we consider the lack of evidence for locked wards. The literature is primarily made up of expert opinion that insists safety is paramount, but fails to provide any compelling evidence that locking people up actually increases safety.

Today, The Lancet Psychiatry has published an important new 15-year naturalistic observational study, which compares locked and open wards in German hospitals, to see what impact different policies had on suicide, suicide attempts and absconding (Huber et al, 2016).

Methods

The researchers had a big data set to work with: 349,574 admissions to 21 German psychiatric hospitals over a 15 year period (1/1/1998-31/12/2012). Four of the hospitals had open wards, 16 had locked wards, and 1 changed practice during the study.

They used propensity score matching and selected 72,869 pairs of admissions to hospitals with and without locked wards. This ingenious approach allowed for ‘causal inference’ on the effect that locked or open wards had on suicide, suicide attempts and absconding.

They used generalised linear models to analyse the data.

There were only minor differences in baseline characteristics of patients in locked versus open wards. There’s a clear table of these differences in the paper and the authors describe the main differences at the beginning of the results section. They also say that “all variables were accounted for in the propensity score-matched analyses to ensure optimum correction of the main analyses for these potential confounders”.

Outcomes

The primary outcome was completed suicide. Secondary outcomes were suicide attempt during treatment, absconding with return, and absconding without return.

Results

Locked wards saw no reduction in the rates of suicide, suicide attempts or absconding.

Compared to locked wards, open wards were associated with:

• Decreased probability of suicide attempts (OR 0·658, 95% CI 0·504 to 0·864; p=0·003)
• Decreased probability of absconding with return (0·629, 0·524 to 0·764; p<0·0001)
• Decreased probability of absconding without return (0·707, 0·546 to 0·925; p=0·01)
• But no decreased probability of completed suicide (0·823, 0·376 to 1·766; p=0·63)

Conclusions

The authors summarised the implications of their work quite simply:

Locked doors in psychiatric hospitals do not seem to improve the safety of patients.

Structural and practical changes are needed to promote open-door hospital policies and should be assessed in future research.

Strengths and limitations

The main strengths of this study are the sample size, the 15 year length of the study, and the minimisation of admission bias (hospitals were legally obliged to admit patients at risk of self-harm and absconding, irrespective of their locked/open status).

It’s generally accepted that prospective study designs are more likely to result in reliable data than this kind of observational research. The authors argue in this case that the quality of routinely collected German psychiatric data has been shown to be of sufficient quality, and indeed that a number of systems were put in place to ensure that the material collected was suitable for analysis.

This is a novel and compelling study, conducted in Germany, but very relevant to any Western country that has a secure system for mentally ill inpatients.

Discussion

Suicide rates in inpatients units are disturbingly high, with up to 0·4% of psychiatric inpatients reported to die by suicide (Walsh et al, 2015). Given this, we need to do everything we can to organise our care system in such a way that these risks are minimised.

Our obsession with security and safety in an ever more dangerous world is justified if you watch the TV news channels for any prolonged period of time. The world is after all full of war, terrorism, violent crime, child abuse; or so we’re led to believe.

Trends in recent years have moved our mental healthcare system towards fear and control. Surely this position clashes with the well-documented national commitment to the least restrictive means, or are we saying one thing in the codes of practice and doing something else quite different in the real world?

I spent a very enjoyable day at City University last week, participating in the #COCAPPimpact discussions, which included some rich and very constructive conversations about therapeutic relationships. It doesn’t take much to appreciate that relationships (therapeutic or otherwise) are stronger and more equitable on open wards. The COCAPP study reminds us that these skills are fundamental to high quality mental healthcare, but we risk losing them completely if we go any further down the route of compulsion and control.

If you need help

If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.

If you live elsewhere, we recommend finding a local Crisis Centre on the IASP website.

We also highly recommend that you visit the Connecting with People: Staying Safe resource.

Links

Primary paper

Photo credits

• Sascha Kohlmann CC BY 2.0
• Matt Brown CC BY 2.0