A new article published in The Lancet Psychiatry finds that implementing an open-door policy in inpatient psychiatric wards results in less exposure to coercive practices such as restraints and involuntary medication for service users.
The research, led by Anne-Marthe Rustad Indregard of Oslo Metropolitan University, additionally finds that instances of violence against staff were essentially the same in open-door wards compared to treatment-as-usual wards. The authors write:
“The results confirmed our main hypothesis and are consistent with observational studies that open-door policies cause no increase in coercive measures. The absence of an increase in suicides and aggressive incidents was also consistent with the open-door policy literature. Our results on patient feedback confirm previous survey data indicating that open-door policies generate more treatment support and a greater sense of safety. In addition, we found that an open-door policy can reduce patientsâ subjective experience of coercion, which supports the hypothesis that the underlying mechanism of the open-door policy is a strengthened alliance between patients and staff.”
In the context of the current research, an open-door policy in an inpatient psychiatric setting means collaborating with service users to reduce coercive measures and leaving the ward door unlocked “as much as possible.” In this setting, coercive measures are only used to prevent imminent harm after exhausting voluntary and collaborative solutions.
The goal of the current study was to compare rates of coercive measures, including involuntary medication, isolation, seclusion, and physical/mechanical restraints, in open-door psychiatric wards to treatment-as-usual wards.
To accomplish this goal, the researchers randomly assigned adult service users at the Lovisenberg Diaconal Hospital in Oslo, Norway, to either an open-door or treatment-as-usual ward. Between February 10, 2021, and February 1, 2022, the researchers measured the number of coercive measures implemented on each service user. Service users were also given a chance to respond to a questionnaire measuring their experience of the ward upon discharge.
During the study, 245 service users were admitted to the open-door ward, 180 of whom (73%) were admitted involuntarily. Three hundred eleven service users were admitted to the treatment-as-usual ward, 233 of whom (75%) were admitted involuntarily. Service users were excluded from the present research if they were currently in criminal justice custody or if they had “a documented history of persistent violence.”
Coercive measures were used on 65 of 245 (26.5%) service users admitted to the “open door” ward compared to 104 of 311 (33.4%) service users admitted to the treatment-as-usual ward. This equates to a risk difference of 6.9%. The “open-door” ward also had less risk of coercive measures when examining coercion based on the length of stay for each service user. Those who stayed between 0 and 7 days had a risk difference of 1.5%, those staying 0 to 14 days had a 5.4% risk difference, and those staying between 0 to 21 days had a 4.6% risk difference.
The risk of coercion was lower in the open-door wards for every type of coercion measured.
- 8 service users (3.3%) in the “open door” wards had mechanical restraints used on them compared to 15 (4.8%) in the treatment-as-usual wards.
- 25 service users (10.2%) in the “open door” wards had physical restraints used on them compared to 40 (12.9%) in the treatment-as-usual wards.
- 13 (5.3%) service users in the “open door” ward were forced into isolation/seclusion compared to 17 (5.5%) in the treatment-as-usual wards.
- 14 (5.7%) service users in the “open door” wards were forced to take short-term medication against their will compared to 27 (8.7%) in the treatment-as-usual wards.
- 52 (21.2%) service users in the “open door” wards were forced to take long-term medication against their will compared to 84 (27%) in the treatment-as-usual wards.
The median length of stay was significantly shorter in the open-door wards, at 16 days, compared to 21 days in the treatment-as-usual wards. Service users’ experience of coercion was lower in the “open-door” wards.
Service users admitted to the open-door wards reported an experience of coercion score of 1.3 out of 4 compared to 1.8 in the treatment-as-usual wards. Service users also reported feeling significantly safer (12.2 out of 20) in the open-door wards than in the treatment-as-usual controls (8.7 out of 20).
Instances of violence against staff were essentially the same on both wards, with 37 cases (.15 per service user stay) in the “open door” wards compared to 56 (.18 per service user stay) in the treatment-as-usual wards.
The authors acknowledge several limitations to the current work. As the research took place entirely in one hospital in Oslo, Norway, the results may not be generalizable to other populations, especially those with fewer resources dedicated to psychiatric care.
Due to the nature of open-door interventions, staff working in the wards could not be blinded, meaning they knew whether service users were receiving treatment as usual. This could alter staff behaviors in the open-door wards towards less coercive practices. As the study was a non-inferiority trial, conclusions about the possible superiority of open-door wards cannot be drawn. The low number of responses on the feedback questionnaire about service users’ experience of the ward limits generalizability.
The authors conclude:
“Overall, open-door policies can be safely implemented with no increase in coercive measures in an inner-city setting with patients who are predominantly involuntarily admitted.”
Experts have argued that coercion in mental healthcare is damaging to service users. One author with first-hand experience of coercive and abusive practices reports that these coercive practices in mental healthcare disproportionately affect minorities.
Research has shown that involuntary hospitalization for psychiatric issues increases suicide risk and makes youth less likely to seek mental healthcare. According to the UN Special Rapporteur, involuntary psychiatric interventions “may well amount to torture.”
One study found that areas with low rates of involuntary hospitalization for psychiatric issues did not see more adverse events or increased patient harm compared to places that more frequently utilize involuntary hospitalization. In addition, experts have also said that involuntary treatment is burdened by a lack of evidence.
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Indregard, A. R. et. al. (2024). Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: a pragmatic, randomized controlled, non-inferiority trial in Norway. The Lancet: Psychiatry. (Link)
This research is great to start moving in the right direction.
I wonder what “leaving the ward door unlocked ‘as much as possible'” and “coercive measures are only used to prevent imminent harm” mean here.
I am always skeptical of the language used because of how fraudulent practices have historically been.
For example, do they only lock the door to prevent people who say they are actively trying to leave to commit suicide, or do the workers claim to be locking the door in the name of “suicide prevention” regardless of what patients say?
I know I am being pedantic, but psychiatry is so full of bs as it stands. I have never seen someone try to leave a ward to harm themselves, but people who wanted freedom had their release withheld or pushed back regardless because of “suicide prevention” (insurance money).
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