Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: A pragmatic, randomised controlled, non-inferiority trial in Norway
Open accessAbstract
Background Open-door policy is a recommended framework to reduce coercion in psychiatric wards. However, existing observational data might not fully capture potential increases in harm and use of coercion associated with open-door policies. In this first randomised controlled trial, we compared coercive practices in open-door policy and treatment-as-usual wards in an urban hospital setting. We hypothesised that the open-door policy would be non-inferior to treatment-as-usual on the proportion of patients exposed to coercive measures.Methods We conducted a pragmatic, randomised controlled, non-inferiority trial comparing two open-door policy wards and three treatment-as-usual acute psychiatric wards at Lovisenberg Diaconal Hospital in Oslo, Norway. An exemption from the consent requirements enabled inclusion and random allocation of all patients admitted to these wards using an open list (2:3 ratio) administrated by a team of ward nurses. The primary outcome was the proportion of patient stays with one or more coercive measures, including involuntary medication, isolation or seclusion, and physical and mechanical restraints. The non-inferiority margin was set to 15%. Primary and safety analyses were assessed using the intention-to-treat population. The trial is registered with ISRCTN registry and is complete, ISRCTN16876467.Findings Between Feb 10, 2021, and Feb 1, 2022, we randomly assigned 556 patients to either open-door policy wards (n=245; mean age 41·6 [SD 14·5] years; 119 [49%] male; 126 [51%] female; and 180 [73%] admitted to the ward involuntarily) or treatment-as-usual wards (n=311; mean age 41·6 [4·3] years; 172 [55%] male and 138 [45%] female; 233 [75%] admitted involuntarily). Data on race and ethnicity were not collected. The open-door policy was non-inferior to treatment-as-usual on all outcomes: the proportion of patient stays with exposure to coercion was 65 (26·5%) in open-door policy wards and 104 (33·4%) in treatment-as-usual wards (risk difference 6·9%; 95% CI -0·7 to 14·5), with a similar trend for specific measures of coercion. Reported incidents of violence against staff were 0·15 per patient stay in open-door policy wards and 0·18 in treatment-as-usual wards. There were no suicides during the randomised controlled trial period.Interpretation The open-door policy could be safely implemented without increased use of coercive measures. Our findings underscore the need for more reliable and relevant randomised trials to investigate how a complex intervention, such as open-door policy, can be efficiently implemented across health-care systems and contexts.Funding South-Eastern Norway Regional Health Authority and The Research Council of Norway.
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Locked wards were significantly associated with higher perceived coercion compared to open-door policy wards.
“and were significantly associated with higher perceived coercion compared to open-door policy wards [157]”
From Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review (2025) · cites this paper as [157]
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Factors Associated with Perceived Coercion in Adults Receiving Psychiatric Care: A Scoping Review
Lessard-Deschênes, C., Pariseau-Legault, P., Billé, V., Sergerie-Richard, S., Hudson, E., Silva, B., Drouin, J.-S., Désilets, M., & Goulet, M.-H. (2025) · Healthcare · doi:10.3390/healthcare13151868 · Cited by 10 · see citing works
- Authors
- Indregard, A.-M. R., Nussle, H. M., Hagen, M., Vandvik, P. O., Tesli, M., Gather, J., & Kunøe, N.
- Affiliations
- OsloMet – Oslo Metropolitan University (NO)
- Oslo University Hospital (NO)
- University of Oslo (NO)
- Corresponding author
- Indregard, Anne-Marthe Rustad
- ORCID
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2024-05
- Volume
- 11
- Issue
- 5
- Pages
- 330-338
- ISSN
- 2215-0366 (ISSN-L)
- OpenAlex
- W4392501008
- Cited by
- 22
- References
- 24
- Citations by year
- 2026: 9 · 2025: 8 · 2024: 5
- FWCI
- 11.07
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Licence
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- NORA - Norwegian Open Research Archives (submittedVersion, cc-by-nc-nd)
- Funders
- Research Council of Norway
- South-Eastern Norway Regional Health Authority
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Medicine › Psychiatry and Mental health › Electroconvulsive Therapy Studies
- Keywords
- open door policy, psychiatric ward, coercion in mental health care, involuntary medication, non-inferiority, usual care, involuntary admission, psychiatric hospitalization, Norway, patient safety, Oslo, ward nurses
- MeSH terms
- Adult, Mental Disorders, Female, Hospitalization, Hospitals, Psychiatric, Humans, Inpatients, Male, Policy
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