Patient Perspectives on Open-Door Policies in Psychiatry: Mixed Methods Study

Open-door policies in psychiatric wards are increasingly recommended as a means to reduce coercion and enhance patient autonomy. However, evidence that integrates patient perspectives on ward openness and related safety measures remains limited. Traditional qualitative approaches often lack the breadth to fully capture the complexity of these views. We hypothesized that patients would prefer open-door treatment and hold a critical view of locked-ward environments, emphasizing autonomy and dignity in care.

This study aims to systematically explore psychiatric patients' perspectives on open-door versus locked-ward treatment, identifying key themes and quantifying preferences within a large clinical sample.

A hybrid questionnaire survey was conducted in September 2023 at the University Psychiatric Clinics (UPK) Basel. The survey examined psychiatric service usage and integrated key factors from a meta-review, including ward relationships, environment, autonomy, legal status, coercion, care entitlement, and expectations at admission and discharge. The final sample comprised 604 patients (response rate 19.1%) drawn from an initial pool of 3212 former inpatients. A text mining approach using latent Dirichlet allocation, a Bayesian topic modeling technique, was applied to analyze open-ended responses and identify latent thematic structures.

The majority of respondents (347/544, 63.8%) rated open-door treatment as "very important" (10 out of 10 on a Likert scale). In contrast, only 21.0% (127/552) of participants were willing to accept voluntary treatment in locked wards, with 70.4% (425/552) explicitly rejecting this option. Logistic regression indicated that younger patients were significantly more likely to accept locked ward treatment (β=-.18, P=.04), while patients diagnosed with mood disorders (ICD-10 [International Statistical Classification of Diseases and Related Health Problems, Tenth Revision] F3) showed a trend toward lower acceptance (β=-.42, P=.08). Gender and other diagnoses were not significant predictors. Latent Dirichlet allocation identified 5 key topics within patient narratives, which hierarchical clustering grouped into 2 overarching themes: Restriction and Institutionalization, characterized by terms indicating confinement, loss of control, and social isolation; and Autonomy and Self-Determination, which emphasizes patients' desire for freedom, control over daily life, and access to nature and outdoor spaces.

This study provides robust evidence that psychiatric patients overwhelmingly prioritize open-door policies, linking them to enhanced autonomy, trust, and therapeutic engagement. The thematic analysis highlights the psychological and social costs of locked wards and the critical need for flexible, patient-centered care models. Younger age and diagnostic category influence willingness to accept locked settings, suggesting the need for tailored approaches. Institutions aiming to implement open-door policies should consider these preferences alongside adequate staffing, therapeutic programming, and environmental modifications to foster autonomy while maintaining safety. Integrating patient perspectives in policy design may enhance treatment satisfaction and clinical outcomes.