Objective: Substance use treatment is often performed inside locked wards. We investigate the effects of adopting a policy of open-door treatment for a substance use treatment and dual diagnosis ward. Methods: This is a prospective open-label study investigating 3-month study periods before opening (P1), immediately after (P2), and 1 year after the first period (P3). Data on committed patients, coercion (seclusion, forced medication, absconding events with subsequent police search), violence, and substance use was collected daily. We applied generalised estimating equation models. Results: The mean daily number of patients with ongoing commitment changed from 2.64 (P1) to 2.12 (P2) to 0.96 (P3), corresponding to a reduction of relative risk (RR) for having an ongoing commitment by 20% in P2 (RR 0.80; 95% CI 0.66-0.98) and 67% in P3 (RR 0.33; 95% CI 0.25-0.42). The mean daily number of coercive events was 0.29, 0.13, and 0.05, corresponding to a risk for undergoing coercive measures reduced by 56% (RR 0.44; 95% CI 0.22-0.90) and 85% (RR 0.15; 95% CI 0.05-0.45). Substance use, violence or ward atmosphere did not differ significantly. Conclusions: Our results support findings from general psychiatric wards of reduced coercion after adopting a primarily open-door policy. However, coercive events were rare during all periods. The widespread practice of restricting the freedom of inpatients with substance use disorders by locking ward doors is highly questionable.

Haase E: Morphium Entziehungskuren im offenen Krankenhause [Morphium withdrawal cures in the open hospital]. Die Therapie der Gegenwart 1928;69:440-451.
Claren LH: Die deutschen Trinker-Asyle und ihre Leistungen [The German Drinker Asylums and Their Achievements]: Festschrift zur Feier der 50 Conferenz des Vereins der Medicinal-Beamten des Reg-Bezirks Düsseldorf am 19 October 1895. Düsseldorf, Dietz, 1895, p 248.
Levinstein E: Die Morphiumsucht. Eine Monographie nach eignen Beobachtungen [Morphium Addiction. A Monograph after Proper Observations]. Berlin, 1877.
Haglund K, van der Meiden E, von Knorring L, von Essen L: Psychiatric care behind locked doors. A study regarding the frequency of and the reasons for locked psychiatric wards in Sweden. J Psychiatr Ment Health Nurs 2007;14:49-54.
American Psychiatric Association (APA): Practice Guideline for the Treatment of Patients with Substance Use Disorders, ed 2. Washington, American Psychiatric Association, 2006.
Zentrale Ethikkommission bei der Bundesärztekammer [Central Ethics Committee of the German Chamber of Physicians]: Stellungnahme der Zentralen Kommission zur Wahrung ethischer Grundsätze in der Medizin und ihren Grenzgebieten (Zentrale Ethikkommission) bei der Bundesärztekammer. Zwangsbehandlung bei Psychischen Erkrankungen. Dtsch Arztebl Int 2013;110:1334-1338.
Lang UE, Hartmann S, Schulz-Hartmann S, Gudlowski Y, Ricken R, Munk I, von Haebler D, Gallinat J, Heinz A: Do locked doors in psychiatric hospitals prevent patients from absconding? Eur J Psychiatry 2010;24:199-204.
Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE: Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry 2016;3:842-849.
Jungfer HA, Schneeberger AR, Borgwardt S, Walter M, Vogel M, Gairing SK, Lang UE, Huber CG: Reduction of seclusion on a hospital-wide level: successful implementation of a less restrictive policy. J Psychiatr Res 2014;54:94-99.
Cibis ML, Wackerhagen C, Müller S, Lang UE, Schmidt Y, Heinz A: [Comparison of aggressive behavior, compulsory medication and absconding behavior between open and closed door policy in an acute psychiatric ward]. Psychiatr Prax 2016, Epub ahead of print.
Folkard S: Agressive behavior in relation to open wards in mental hospital. Ment Hyg 1960;44:155-161.
Bowers L, Allan T, Haglund K, Mir-Cochrane E, Nijman H, Simpson A, van Der Merwe M: The city 128 extension: locked doors in acute psychiatry, outcome and acceptability. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO), 2008.
Muir-Cochrane E, van der Merwe M, Nijman H, Haglund K, Simpson A, Bowers L: Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards. Int J Ment Health Nurs 2012;21:41-49.
Haglund K, von Essen L: Locked entrance doors at psychiatric wards - advantages and disadvantages according to voluntarily admitted patients. Nord J Psychiatry 2005;59:511-515.
Haglund K, von Knorring L, von Essen L: Psychiatric wards with locked doors - advantages and disadvantages according to nurses and mental health nurse assistants. J Clin Nurs 2006;15:387-394.
Tarrier N, Khan S, Cater J, Picken A: The subjective consequences of suffering a first episode psychosis: trauma and suicide behaviour. Soc Psychiatry Psychiatr Epidemiol 2007;42:29-35.
Driessen M, Wertz J, Steinert T, Borbe R, Vieten B, Diefenbacher A, Urban S, Kronmuller KT, Lohr M, Richter D, Hohagen F: Das Erleben der Aufnahme in eine psychiatrische Klinik [The experience of being admitted to a psychiatric clinic: part 2: comparative analyses of patient and hospital characteristics]. Nervenarzt 2013;84:45-54.
van der Merwe M, Bowers L, Jones J, Simpson A, Haglund K: Locked doors in acute inpatient psychiatry: a literature review. J Psychiatr Ment Health Nurs 2009;16:293-299.
Sinha R: Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci 2008;1141:105-130.
Sinha R, Garcia M, Paliwal P, Kreek MJ, Rounsaville BJ: Stress-induced cocaine craving and hypothalamic-pituitary-adrenal responses are predictive of cocaine relapse outcomes. Arch Gen Psychiatry 2006;63:324-331.
Breese GR, Chu K, Dayas CV, Funk D, Knapp DJ, Koob GF, Lê DA, O'Dell LE, Overstreet DH, Roberts AJ, Sinha R, Valdez GR, Weiss F: Stress enhancement of craving during sobriety: a risk for relapse. Alcohol Clin Exp Res 2005;29:185-195.
Theodoridou A, Schlatter F, Ajdacic V, Rössler W, Jäger M: Therapeutic relationship in the context of perceived coercion in a psychiatric population. Psychiatry Res 2012;200:939-944.
Blaesi S, Gairing SK, Walter M, Lang UE, Huber CG: [Safety, therapeutic hold, and patient's cohesion on closed, recently opened, and open psychiatric wards]. Psychiatr Prax 2015;42:76-81.
Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 1983;13:595-605.
Woods P, Almvik R: The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl 2002;412:103-105.
Schalast N: [A short questionnaire for assessing the social climate on forensic psychiatric wards]. Psychiatr Prax 2008;35:175-181.
Steinert T, Eisele F, Goeser U, Tschoeke S, Uhlmann C, Schmid P: Successful interventions on an organisational level to reduce violence and coercive interventions in in-patients with adjustment disorders and personality disorders. Clin Pract Epidemiol Ment Health 2008;4:27.
Nugteren W, van der Zalm Y, Hafsteinsdóttir TB, van der Venne C, Kool N, van Meijel B: Experiences of patients in acute and closed psychiatric wards: a systematic review. Perspect Psychiatr Care 2016;52:292-300.
Terkelsen TB, Larsen IB: The locked psychiatric ward: hotel or detention camp for people with dual diagnosis. J Ment Health 2013;22:412-419.
Ng B, Kumar S, Ranclaud M, Robinson E: Ward crowding and incidents of violence on an acute psychiatric inpatient unit. Psychiatr Serv 2001;52:521-525.
Teitelbaum A, Lahad A, Calfon N, Gun-Usishkin M, Lubin G, Tsur A: Overcrowding in psychiatric wards is associated with increased risk of adverse incidents. Med Care 2016;54:296-302.
Decaire MW, Bédard M, Riendeau J, Forrest R: Incidents in a psychiatric forensic setting: association with patient and staff characteristics. Can J Nurs Res 2006;38:68-80.
Baum A, Kagan I: Job satisfaction and intent to leave among psychiatric nurses: closed versus open wards. Arch Psychiatr Nurs 2015;29:213-216.
Rubio-Valera M, Luciano JV, Ortiz JM, Salvador-Carulla L, Gracia A, Serrano-Blanco A: Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence. BMC Psychiatry 2015;15:35.
Ashmore R: Nurses' accounts of locked ward doors: ghosts of the asylum or acute care in the 21st century? J Psychiatr Ment Health Nurs 2008;15:175-185.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.