Locked psychiatric wards may mean more suicide or escape attempts

(Reuters Health) - Psychiatric patients treated on unlocked wards may attempt escape or suicide less often than peers in locked facilities, a recent study suggests.

To see how security measures influenced outcomes, researchers examined data on almost 350,000 patients admitted to psychiatric hospitals in Germany over 15 years.

Compared with treatment in locked wards, receiving care in unlocked wards was associated with about 34 percent lower odds of a suicide attempt, 37 percent decreased chances of escaping temporarily and 29 percent reduced risk of escaping without coming back, the study found.

“We assume that providing locked wards in a psychiatric hospital does not per se improve patient safety in terms of better protection from suicide and absconding,” said lead study author Dr. Christian Huber, a psychiatry researcher at the University of Basel in Switzerland.

“This is important from our point of view, as it may mean that less restrictive treatment settings can be used without endangering patient safety,” Huber added by email. “Coercion in psychiatry constitutes an ethical challenge, should always be a last resort measure, and often impedes successful treatment.”

Researchers compared outcomes for patients who were similar in many respects but placed on different types of psychiatric wards including locked, partly locked or open residential facilities as well as day clinics.

The analysis included about 270,000 people treated in hospitals with locked wards and another 78,000 patients who received psychiatric care at facilities without locked wards.

Overall, more patients were treated with antipsychotics, antidepressants and mood stabilizers in hospitals with unlocked wards. At hospitals with locked wards, a greater proportion of patients were not given psychiatric medications.

Roughly 1 percent of patients in both care settings exhibited self-injuring behavior during treatment, researchers report in the Lancet Psychiatry.

The study team calculated the odds of suicides and escapes for a subset of about 147,000 patients who could be compared to others similar in age, mental health diagnosis and other medical conditions and were placed on different types of wards.

While the risk of death from suicide was lower in the unlocked wards, the difference wasn’t large enough to rule out the possibility that it was due to chance.

One limitation of the study is that researchers could only match about half the patients with similar people to compare the odds of suicide and escape, the authors note.

The study also didn’t include patients at university hospitals or private clinics, which typically can admit patients with even lower risks of suicide or escape than the general population, the authors point out. This means the study results might underestimate the value of unlocked doors, the researchers conclude.

“Hospitals without locked wards may be able to provide similar protection through improved focus on the patient-therapist relationship, therapeutic atmosphere and timely, sufficient pharmacotherapy,” Huber said.

This approach has its limits.

“There will always be situations where safety measures like intensive care, seclusion, restraint, or involuntary medication have to be used on an individual basis,” Huber added.

One advantage of unlocked doors, however, is that they convey a level of trust that can improve doctor-patient relationships and make therapy more effective, Tom Burns, a psychiatry researcher at the University of Oxford in the U.K. wrote in an accompanying editorial.

“An important aspect of psychiatric care is to help restore a patient’s confidence and self respect (as well as controlling symptoms) and this is not helped by them being locked up,” Burns said by email. “I think that the default position should be that patients are admitted to open wards and only moved to locked wards in the instances when they fail to settle.”

SOURCE: Lancet Psychiatry, online July 28, 2016.