From Bed Counts to Open Doors: What Redefines Acute Psychiatric Care

Any serious attempt to redefine acute psychiatric inpatient care has to begin with an uncomfortable question: can the system actually deliver it? That is the framing behind a new editorial collection in Frontiers in Psychiatry, which gathers studies on bed capacity, coercion, ward environments and patient experience across continents. The editors, Alfonso Ceccherini-Nelli of the University of Alberta and Stefano Barlati of the University of Brescia, argue that the acute ward is shaped as much by what surrounds the patient — beds, staff, outdoor space, information, legal frameworks — as by what is prescribed inside it. Their through-line is coercion: what drives it, what predicts it, and what softens it.

The capacity question is addressed directly by a two-round Delphi survey of senior clinicians in Hong Kong’s public mental health system, reported by Ma and colleagues. The panel reached consensus on an optimal provision of 68 adult psychiatric beds per 100,000 population — 39 percent above the current level, which sits close to the panel’s agreed minimum of 50. The experts also endorsed a daytime nurse-to-patient ratio of 1:4 and target inpatient stays of around three weeks for psychotic and mood disorders. Notably, bed need was judged to depend chiefly on population needs rather than on the availability of community services alone, a finding that pushes back against the assumption that community care can simply absorb reductions in inpatient capacity.

Once patients reach the system, those with medical comorbidity are vulnerable from the very first contact. Mesbah and colleagues reviewed 507 emergency department encounters in Houston in which the presenting complaint was purely behavioural. A global statement such as “neurologically intact” appeared in 94.5 percent of the charts, but the underlying examinations told a different story: the Glasgow Coma Scale was documented in only 9.3 percent of encounters, deep tendon reflexes in 1.4 percent, and cognition and memory in 7.5 percent. Nothing had improved since a 2016 audit of the same department, a pattern the authors link to diagnostic overshadowing — the tendency to attribute physical findings to psychiatric illness — and to persistent inequity in the medical assessment of psychiatric patients.

Substance use disorder, another at-risk condition highlighted in the collection, is tightly bound to compulsory care. Among 5,887 admissions to a Turkish referral centre between 2019 and 2023, Akdag and colleagues found substance use in 27.5 percent of cases, mostly involving multiple substances. Involuntary admissions rose sharply over the period, from 15 percent in 2019 to between 36 and 40 percent in 2022 and 2023. In adjusted analyses, substance use disorder more than tripled the odds of involuntary admission (odds ratio 3.6), substance-induced psychosis nearly doubled them (odds ratio 2.3), and male sex and later calendar year were also independent predictors, while bipolar disorder predicted lower risk. Use of atypical and depot antipsychotics, clozapine and electroconvulsive therapy grew overall, yet patients with substance use disorders were less likely to receive clozapine, mood stabilisers or ECT — a treatment gap layered on top of their elevated coercion risk.

Preventing violence on the ward depends on recognising who is at risk, and Liu and colleagues looked for cheap, routine markers among 555 men hospitalised for alcohol dependence in Hefei, China. More than a third — 37.1 percent — had at least one documented aggressive incident, and a third of those had three or more. After adjusting for withdrawal severity, three factors were independently associated with aggression: shorter sleep, higher nurse-rated suicide risk, and lower haemoglobin, the last of these even within the normal laboratory range. The explained variance was modest, and the study is observational, so these markers cannot be treated as causal. But they are inexpensive, already collected at the bedside and potentially modifiable, which makes them practical candidates for risk screening in a population where aggression is common.

Cossu and colleagues take on the ethics of coercion directly, in the context of Article 12 of the UN Convention on the Rights of Persons with Disabilities. Rather than debating whether involuntary treatment is ever justified, they propose treating each instance as a sentinel event — the same status given to serious medical errors. Every episode of coercion would be reported, examined through root cause analysis conducted together with service users and families, and followed by a concrete action plan. The model deliberately locates the drivers of coercion in resources, training and power asymmetries within the service, not solely in the patient’s symptoms, shifting the accountability question from the individual to the system.

The physical ward environment is one of those system-level drivers, and it bears directly on restraint. Liu and colleagues exploited a natural experiment in New York: renovations closed the outdoor areas of two inpatient units for several months in 2024. On the general adult unit, the loss of outdoor access coincided with more intramuscular as-needed medication orders, more seclusion or restraint, and more constant observation. On the geriatric unit, only oral as-needed medication use increased. Confounding cannot be excluded in such a design, but the pattern suggests that outdoor space functions as a de-escalation resource rather than a mere amenity — something patients can use to discharge tension before staff must intervene.

Amann and colleagues extend this environmental argument to therapy itself, reviewing nature-based interventions on psychiatric wards, including forest walks, gardening and structured outdoor activity. The five inpatient studies they identified are mostly small, uncontrolled and focused on depression, but they report short-term mood gains and point to meaning, agency, belonging and calm as plausible mechanisms. A striking gap is that adverse events were never systematically recorded in any of the studies, so the authors call for adequately powered randomised trials with built-in safety monitoring before such interventions can be recommended with confidence.

Whether a hospital actually feels like a place of care is a question only patients can answer. Cuevas-Esteban and colleagues applied Patient Journey Mapping to a 14-bed unit near Barcelona that operates the Safewards model and opens its doors six hours a day; 60 percent of the participants had been admitted involuntarily. From focus groups with 18 patients and ratings from 32, two “moments of pain” emerged: waiting in the emergency department and group activities. Medical visits, door openings and discharge were the high points. Intriguingly, patients objected less to the duration of waiting than to insufficient or inconsistent information and to the public, communal nature of medication administration — both problems that are remediable at very low cost.

Treating admission as one phase of a continuing care project also means planning for what follows it. In a case-control study of 196 episodes in Málaga, García-Illanes and colleagues combined seven variables into a points-based index for 30-day readmission: previous admissions, personality disorder, social risk, emergency attendance in the prior year, legal capacity restriction, aggression towards others at admission, and being married or widowed. The index discriminated moderately well, with an area under the curve of 0.76, or 0.73 after optimism correction, and its three risk levels could guide the intensity of post-discharge follow-up, pending external validation. Finally, Wang and colleagues’ integrative review of 25 studies found moderate-to-high mental health stigma among nursing students, with wide cross-cultural variation; education, simulation, digital methods, peer support and clinical placements all helped, though contact benefits could fade or reverse after distressing first exposures, making multicomponent programmes combining contact with guided reflection and supervision the most promising approach. Read together, the editors conclude, these studies show that shorter stays and community alternatives cannot substitute for adequate beds and staffing, that most evidence remains single-centre and observational, that psychosocial functioning and personal recovery after discharge are still rarely measured, and that acute psychiatric care should ultimately be judged not only by safety and efficiency but by its respect for autonomy, dignity and the quality of the inpatient experience itself.

Subject of Research: Strategies for improving acute psychiatric inpatient care, including bed capacity, coercion, ward environment and patient experience

Article Title: Editorial: Redefining acute psychiatric care: strategies for improved inpatient experiences, vol II

Article References: Ceccherini-Nelli, A., & Barlati, S. (2026). Editorial: Redefining acute psychiatric care: strategies for improved inpatient experiences, vol II. Frontiers in Psychiatry, 17, 2032873. https://doi.org/10.3389/fpsyt.2026.2032873

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.2032873

Keywords: acute psychiatric care, inpatient experience, involuntary treatment, coercion, substance use disorder, readmission, ward environment, stigma, bed capacity, patient journey, restraint, mental health services