Preventing Suicide in Locked vs. Unlocked Psychiatric Units
by Margaret Parish, PhD, Director of Patient Care
Locked psychiatric units are no better than open units at preventing suicide, according to a large 15-year observational study published this month in the British medical journal The Lancet Psychiatry. In addition, the results of the study suggest that patients in open units are less likely to attempt suicide or to run away from the hospital (with or without returning) than patients in locked units.
Open psychiatric hospitals are uncommon today, in both the US and the UK. Hospitalization is often a short-term restrictive intervention in situations of imminent risk, and uses locked doors to physically prevent people in distress from acting self-destructively. No doubt in some emergencies this is effective. However, physical intervention can bypass psychological experience, treating the patient more like a thing and less like a person, and leaving them feeling further alienated rather than understood. Many people react to restrictive environments by struggling for personal freedom, which can interfere with establishing collaborative relationships with clinicians to address the problems that contribute to self-destructiveness in the first place.
For this study, Christian G. Huber and colleagues at the University of Basel used data collected over a 15-year period from 349,574 admissions to 21 different psychiatric hospitals in Germany. While some of these hospitals were locked and some were not, each was obligated to treat everyone in their designated area, and they worked with a wide range of people with different psychiatric and substance use disorders. The rate of completed suicide was not lower for those on the locked units, nor was the rate of running away from the hospital. Not only did the locked doors not prevent suicide, they did not even reliably keep people from leaving the unit. In fact, it was the patients on open units who less often absconded from treatment, and also had a lower rate of unsuccessful suicide attempts. There was no difference in the rate of completed suicide.
The investigators were primarily interested in learning whether hospitalization on a locked unit is an effective way to prevent suicide. Since it was a naturalistic study – they could not randomly assign people to the different units – they used a method called “propensity score matching,” pairing patients in the study with similar characteristics, enabling researchers to make inferences about the effect of the different types of settings.
Suicide remains an enormously difficult challenge in any setting, impossible to accurately predict or control and tragic for any community in which it occurs. This study provides evidence that the movement toward curtailing individual liberties that has been so prevalent in recent years is not an effective solution. On the contrary, patients are more likely to remain in treatment and to refrain from attempting suicide in an open setting where their autonomy is preserved and respected.
To learn more about the open setting at the Austen Riggs Center: