The use of ‘locked wards’ in acute mental health services is not backed by evidence and is associated with greater risk of patient self-harm and increased violence and aggression, according to a new analysis by UTS researcher Jon Wardle.
Wardle suggests that Queensland Government support for locked wards policies may be in breach of the law in that State, and he also highlights concerns about the use of locked wards in other jurisdictions.
His paper raises plenty of questions for Queensland Health Minister Lawrence Springborg (pictured below), whom Wardle says “is guilty of increasing the stigmatisation of a vulnerable community group, fanning ill-informed community fears and demonising people urgently in need of help”.
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Jon Wardle writes:
On the election hustings recently, Queensland Health Minister Lawrence Springborg recommitted his government to ‘locked wards’ policies in acute mental health wards in that State.
Coincidentally, perhaps even serendipitously, a review of the case for and against locked door policies in acute mental health wards was published in the peer-reviewed journal Psychiatry, Psychology and Law the very same day.
Perhaps unsurprisingly, this review showed that the evidence of the effectiveness of locked door policies in acute mental health wards was severely wonting, but it also showed that the current guidelines may be inconsistent with Queensland law.
The Queensland Mental Health Commissioner understand this, and since the outset of the implementation of these policies has not only been vociferous in his condemnation of the policy, but has also been strongly advocating for more effective and less restrictive mechanisms through which to achieve the aims Springborg wants.
Reducing absconding and risk – it just doesn’t work
The primary justification for the introduction of blanket locked door policies across all mental health facilities in Queensland was the high rate of absconding, and the ‘risks’ this placed on the public and patients themselves, as well as the ‘burden’ on police, who would be tasked to bring them back to the facility.
About 2,200 people in Queensland had ‘absconded’ in 2012-13, the period of introduction. However, ‘absconding’ itself is a loose term. The Queensland Mental Health Commissioner noted that most ‘absconding’ cases were not ‘disappearances’, but late returns from approved weekend leave, or people living in the community failing to make appointments required by their orders of involuntary treatment.
Rather than nefarious intent, factors such as lover’s trysts, physical cravings for drugs of addiction, personal matters that need attending (often the care of children, parent’s or pets), fear, confusion, conflict with ward staff members – sometimes even assault by staff members – are all factors that have been identified as triggers of absconding where it is a deliberate event. None of these upstream factors are assisted by locked door policies.
Moreover, the evidence for claims that locked door policies reduces absconding rates remains equivocal. British evidence suggests that less restrictive measures such as facilitating contact (e.g. through phone calls), encouraging visits or using resources to encourage supervised leave are far more effective at reducing absconding rates than locked doors.
Australian evidence is even more damming. Retrospective analysis of absconding inpatients shows that locked doors appear unrelated to the number of absconding patients within all facilities, and that when limited to acute wards, locked wards experienced twice the rate of absconding patients than wards that were locked. This could be facility-dependent; however a German trial of alternating locked door and unlocked policies in the same facility showed that rates of absconding, as well rates of required coercive medication and aggressive incidents, were higher when locked door policies were in effect.
Not only is evidence starting to demonstrate that locked door policies may have a causative role in increasing absconding rates, they may increase the other risks the Queensland health minister is trying to reduce as well.
Meta-analyses, literature reviews and epidemiological studies show that locked wards are significantly associated with greater risk of patient self-harm, and increase the incidence of violent and aggressive acts. Aggression towards ward staff is both heightened and more frequent in locked wards, with nearly one-fifth of aggressive incidents taking place in front of the locked door.
The German experience shows that the incidence of required seclusion and restraint and incidence of dangerous and violent events is reduced significantly (85% and 50% respectively) when locked doors are removed and facilities converted to open wards, and Swiss research also shows better safety measures when blanket locked door policies are removed.
The principles of Queensland law don’t apply
Although much can (and should) be made of the ethical and international law issues raised by blanket use of locked door policies in Queensland, the directives may be in breach of Queensland law itself.
Section 9 of the Mental Health Act 2000 (Qld) is meant to be guided by clinical evidence. The implementation of blanket locked door policies in acute inpatient facilities across Queensland appear to be inconsistent with s 9 (a) of the Mental Health Act 2000 (Qld), as they restrict liberty without clear benefit to patients or the public – and in fact evidence suggests that may increase harms, and they are also inconsistent with Section 9 (b), as a number of less restrictive measures are available that demonstrate equal or better effectiveness at reducing absconding rates and harmful events among patients in acute mental health inpatient facilities.
Under s 493A of the Mental Health Act 2000 (Qld) it is stated that ‘if a policy or practice guideline is inconsistent with this Act, the policy or practice guideline is invalid to the extent of the inconsistency’. Clearly on this criteria such provisions are not valid.
It’s not only Queensland, people
One last point. Whilst Queensland has been the poster child of locked door policies in Australia, perhaps the Queensland government even deserves some credit, in that it actually admits to the practice (though not too much credit – admitting to doing the wrong thing still implies doing the wrong thing).
It happened in New South Wales well before being announced in Queensland – and still does. Although some publications noted ‘many or all’ New South Wales facilities had similar policies only after the Queensland announcement had been made, the truth is the Queensland Health itself identified that its change to a blanket locked door policy was done ‘to reflect legislative provisions in New South Wales, based on coronial recommendations’.
However, the coronial recommendation was not to institute blanket locked door policies, but rather institute such policies in a coordinated, consistent and audited way.
The fact that in Queensland this has become an election issue whilst this has not happened in New South Wales is not due to substantial differences in policies, but probably has far more to do with the Teflon-coated nature of what should be a scandal-ridden (by any normal standards) New South Wales Liberal government, and a Queensland Liberal National that can’t get a break and (usually deservedly) appears to invites controversy without even trying.
In other states too, locked door policies continue. However, the extent of ‘locked door’ implementation is extraordinarily difficult to gauge, as most States simply don’t audit or report it, and most facilities that do it have complete autonomy over what policies are implemented, and how they are implemented. However, most States are equally complicit.
Why Springborg, rightly regarded as one of the more honourable persons playing the political game (especially in Queensland), continues to defend a policy which cannot be defended clinically, ethically or legally is unknown.
By beating up mental health patients as a police and public risk issue and ignoring compelling public health arguments to reverse tack, Springborg is guilty of increasing the stigmatisation of a vulnerable community group, fanning ill-informed community fears and demonising people urgently in need of help. There is nothing less honourable.
Though in sad reflection of humanity, there is also probably no strategy more politically successful. Just ask Scott Morrison.
• Jon Wardle is a Chancellor’s Research Fellow at the Faculty of Nursing Midwifery and Health, University of Technology Sydney and holds visiting positions at the School of Medicine, University of Washington and the School of Population Health, University of Queensland. In addition to his academic roles Jon has clinical backgrounds in naturopathy and nursing.
You can track Croakey’s coverage of the Queensland election here.
