Psychiatry on closed and open wards: The suicide risk remains the same

In psychiatric clinics with an exclusively open-door policy, the risk of patients committing suicide or absconding from treatment is no higher than in clinics with locked wards. This has been demonstrated in a large study by the University of Basel and the University Psychiatric Clinics of Basel (UPK), in which around 350,000 cases were analyzed over a period of 15 years. The results are published in the journal The Lancet Psychiatry.

Self-endangering behavior by patients, suicidality and absconding from treatment represent great challenges for all medical institutions. In many psychiatric clinics, therefore, high-risk patients are accommodated in locked wards. This is done on the grounds that patients can only receive adequate protection and appropriate therapy if they are prevented from attempting suicide or absconding, but there is no evidence that locked wards actually prevent self-endangering behavior. It is, however, known that such wards create a treatment climate that is not conducive to successful therapy and tends to increase motivation to escape.

A study period of 15 years

In their naturalistic observational study, PD Dr. Christian Huber and Prof. Dr. Undine Lang of the UPK and the University of Basel, together with colleagues, studied 349,574 cases in 21 German clinics over the period from 1998 to 2012. Some of these clinics practiced an open door policy, making do without any locked wards. Sixteen clinics also maintained intermittently or permanently locked wards in addition to open wards. All of the clinics were legally obliged to admit all individuals from a certain area, regardless of the severity of their illness or of self-endangering behavior on the part of the patient.

One of the study's findings is that the rate of suicide attempts and suicides is no lower in clinics with locked departments. Furthermore, institutions with open doors did not record a higher rate of absconding. "The effect of locked doors in clinics is overestimated," says first author Christian Huber. "According to our study, being locked in does not improve patient safety and, in some cases, actually hinders the prevention of suicide and absconding. An atmosphere of control, restricted personal freedoms and sanctions is more likely to be a risk factor impeding successful therapy."

Focus on ethical standards

"Our results are important for the destigmatization, participation and emancipation of patients, as well as for psychiatric care in general," comments last author Undine Lang, Director of the Adult Psychiatric Clinic at UPK Basel. The results will also have an influence on legal issues that arise when clinics adopt an open door policy. In future, treatment should focus more on ethical standards that ensure patients retain their autonomy as far as possible, says Undine Lang. Efforts should also be made to strengthen the therapeutic relationship and joint decision-making with patients.