The Lovisenberg study of Open-door policies in acute mental healthcare: developing and evaluating a service innovation to minimize coercion

In 2024, LOADS published results indicating that Open-door policy in mental healthcare wards was equally safe as 'best practice' with locked doors: admissions to Open-door policy wards showed no increase in dangerous incidents, or in use of coercive measures, or in length of stay or other resource use. Patients admitted to the Open-door policy wards stated that they were more satisfied with the treatment environment than those in regular treatment; this resulted in a greater feeling of security in the ward, and higher experienced support for recovery/treatment. Open-door policy wards had a lower proportion of patients who reported a high experience of coercion. Implementation of interventions and research designs are often criticized in clinical studies. In the LOADS project, we thus conducted analyses of whether implementation seemed satisfactory: During the project period, the main door of the Open door policy wards was open for more than 70% of the opening hours from 09:00 to 21:00. The patients who were admitted to the two types of wards were equally distributed (randomized), and analyses confirmed there were no differences between the study groups in how large a proportion were involuntarily admitted (around 75%), how many were assessed as having an increased risk of violence (around 50%), in the proportion of women (around half of patients in both groups), in the proportion with a diagnosis on the schizophrenia spectrum (around 50%) or in age (41.6 years average). The article was published in Lancet Psychiatry in March 2024 and the approved manuscript is openly archived at https://www.duo.uio.no/handle/10852/110648

Freedom of movement is a fundamental human right that is systematically restricted in acute psychiatry to address safety, prognosis and/or staffing concerns. The legitimacy and therapeutic impact of the current state-of-the art ‘locked door’ practice has recently been called into question by the United Nations, the WHO, user organisations, and the Norwegian Government. Lovisenberg Diaconal Hospital wishes to implement and test a new service model, open-door policies, to increase patient freedom and reduce coercion in their inner-city acute psychiatric wards. The Lovisenberg Open Acute Door Study (LOADS) RCT will randomly assign admitted acute psychiatric patients to two open-door policy wards or state-of-the-art locked-door wards for 12 months. The RCT will be followed by a 4-year observational period to report on data beyond the RCT. The hypothesis is that open-door care will be equivalent to - or better than locked-door care. The risk of insufficient involvement of staff and management is addressed via an action-based implementation model: The Clinic Director retains the psychological ownership of the project, and invests considerable resources and time in engaging and listening to the opinion of staff, users, and external collaborators in dialogue on the design and implementation of the open-door service model. This also reduces the risk of insufficient research management, as the project manager for the research component need not constantly pressure staff and management to contribute but can focus on study design, results analyses and dissemination. Ordinary risk of insufficient inclusion (selection bias) and incomplete data are addressed by the designation of LOADS as a health services research project that will utilise routinely collected data from all admitted patients rather than being based on acutely ill patients providing informed consent. The RCT addresses the risk of selection bias in comparing old and new service models.