When I started working in acute mental health units in the mid-1990s, the ward doors on my unit were never locked, nurses were sometimes placed over the door if there was a particularly high risk of a patient wanting to leave the ward. self-injury, the rest of the time staff were anxiously alert (Bowers et al., 2008). Over time, events, polls and politicians in England have locked doors. The doors were broken and they were reinforced with airlocks, making the wards more and more secure.

There has long been suspicion that locking doors and other cover restrictions on wards have led to an increasingly coercive nature of care, with less emphasis on the treatment environment. Despite the debate, the evidence for or against door locking is largely weak (Steinert et al., 2019) and, as with many things related to acute mental health care, more research is needed, as most previous studies have been largely based on observational data. . For example, see Hubers et al., (2016). wrote a blog By Mental Elf in 2016.

The current study by Indregard et al., (2024) is a unique pragmatic, randomized controlled trial of the effect of an open-door policy versus a locked-door (care as usual) on patient adherence rates.

Evidence for or against locking doors in acute mental health wards is largely weak.

Methods

This was a pragmatic, randomized, non-inferiority trial (based on the assumption that opening ward doors is no worse than locking them). He compared two wards with an open-door policy to three locked wards (treatment as usual – TAU) in a psychiatric unit in Norway.

An open door policy was co-created and preparatory activities included workshops and the introduction of peer support workers to enhance therapeutic dialogue. The gates were open from 9 am to 9 pm unless locking provided security.

The allocation sequence was a simple binomial list, allocating participants to both groups in a 2:3 ratio for the open-door policy and TAU (respectively). It is clear that staff and patients are not blinded to the intervention. The authors analyzed the data based on an intention-to-treat analysis.

The primary outcome focused on coercive measures, including coercive medication, seclusion or isolation, and physical and mechanical restraints. Secondary outcome measures included the Experience of Coercion Scale (ECS) and the Essen Climate Rating Scale (EssenCES). To see ISRCTN16876467 for the registry.

Results

Over approximately one year, 556 patients were randomized to open-door wards (n=245) or TAU (n=311). Patients were broadly matched for demographics, and approximately three-quarters of both groups were present involuntarily. About half of the patients were diagnosed with psychotic disorders.

• In the two open-door wards, the doors remained open 73% of the time.

The open-door policy was non-inferior to (not worse than) conventional treatment on all outcomes, mainly focused on coercion:

• The proportion of patients exposed to coercion was 65 (26.5%) on open-door wards and 104 (33.4%) on TAU wards (risk difference 6.9%; 95% CI -0.7 to 14.5);
• Reported incidents of violence against staff were 0.15 per patient in open-door wards and 0.18 per patient in regular treatment wards;
• There were no suicides during the trial period;
• Median length of stay was significantly shorter in the open door policy group (16 days; IQR 7–31) than in TAU wards;
• Patients on open-door wards rated their experiences of coercion significantly lower than those on TAU wards (mean difference in EKS 0.5 (95% CI 0.8 to -0.2; range 0–4));
• Those admitted to open wards reported significantly higher scores on therapeutic retention (mean difference 2.4; 95% CI 1.2 to 3.5) and experienced safety (3.5; 95% CI 1.8 to 5.2).

This Norwegian study of acute psychiatric wards found that an open-door policy can be implemented safely without the use of coercive measures.

The result

The authors concluded that:

An open door policy could be safely implemented without the use of coercive measures. Our results highlight the need for more reliable and relevant randomized trials to investigate how a complex intervention such as an open-door policy can be effectively implemented across health systems and contexts.

Discussion

According to this study, it appears that you can open the doors to acute mental health wards without seeing an increase in coercion, but many unanswered questions remain. For example, escape data (despite being in the original protocol) were not reported, the design of the trial meant that certain conclusions could not be drawn, and there were no serious incidents that would have stopped the trial.

Interestingly, this was not just a trial of an open-door policy, the intervention appeared to be multifaceted with a focus on increasing therapeutic dialogue, the addition of peer support workers, and the outcome of a 12-month follow-up. even the doors opened. This can make replication difficult. All wards had two patients per staff member during the day and evening, and four patients per staff member at night, plus an additional receiving ward and PICU supporting five trial wards. I suspect that the unit includes more beds per population than in the UK context, but it remains elusive as there is no robust measure of acuity comparison.

It is an important milestone for the authors to be able to conduct a trial in this area, as we need more evidence to support clinical and management decisions in mental health services. I believe that such a study would be funded in the UK and that the required ethical and governance procedures could be agreed. There remains a lack of evidence on how to deliver interventions to patients in inpatient and community services that have real benefits and take into account service designs.

We need more evidence to support clinical and management decisions made in UK mental health services.

Statement of interest

None.

Connections

Primary paper

Indregard A, Nussle H, Hagen M, Vandvik P, Tesli M, Gather J, Kunøe N (2024) Open-door policy versus usual treatment in urban psychiatric inpatient wards: a pragmatic, randomized controlled, non-inferiority trial Norway. Lancet Psychiatry, Published: March 06, 2024 DOI:https://doi.org/10.1016/S2215-0366(24)00039-7

Other references

Bowers L, Allan T, Haglund K, Mir-Cochrance E, Nijman H, Simpson A, Van Der Merwe M, (2008) The City 128 extension: locked doors, outcome and acceptability in acute psychiatry. National Focal Point for NHS Service Implementation and Organizational R&D (NCCSDO ).

Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE. (2016) Suicide risk and abstinence in psychiatric hospitals with and without open-door policies: a 15-year observational study. Lancet Psychiatry 2016, Published online July 28, 2016 http://dx.doi.org/10.1016/ S2215-0366(16)30168-7

Steinert, T., Schreiber, L., Metzger, FG and b. Open doors in psychiatric clinics. Neurologist 90680–689 (2019). https://doi.org/10.1007/s00115-019-0738-y