BACKGROUND: In 2018, Switzerland introduced a nationwide case-based prospective remuneration system (TARPSY), with decreasing daily rates for reimbursement of inpatient care in mental health facilities. Initially, there were concerns that declining daily rates could result in early discharges and increased readmission rates.

METHODS: We compared length of stay (LOS) and readmission rates for patients in adult and geriatric psychiatry treatment at four psychiatric hospitals between 2017 (the last year with the traditional remuneration system) and 2018 (the first year with TARPSY).

RESULTS: A total of 26,324 treatment episodes of 15,464 patients were analysed. The reduction of average LOS was not statistically significant in the first year after the implementation of TARPSY, neither in adult (mean –0.6 days, 95% confidence interval [CI] –1.6 to 0.4; p = 0.226) nor in geriatric psychiatry (mean −1.6 days, 95% CI −3.8 to 0.7; p = 0.178). When compared with the traditional remuneration system with fixed daily rates, the readmission risk was statistically significantly reduced by −9.1% (95% CI −4.9 to −13.1%; p <0.001) in adult psychiatry but not in geriatric psychiatry (−6.8%, 95% CI −19.2 to 7.4%; p = 0.329).

CONCLUSIONS: If being evident at all, the effects of the new remuneration system TARPSY on LOS and readmission rates seem to be small. Concerns that declining daily rates in TARPSY would result in early discharges and increased readmission rates did not prove true in adult and geriatric psychiatry.

How the brain performs higher cognitive functions such as learning and memory is traditionally studied by investigating how neurons work. However, over the past two decades, evidence has accumulated which suggests that components of the extracellular matrix contribute to the storing of information through learning processes. Thus, matrix regulation – either changes in the protein composition of the perineural network surrounding neurons or cleavage of this network by specific metalloproteases – could be relevant to the many psychiatric disorders that are shaped by previous experiences, i.e. by learning and plasticity. This includes disorders which are a direct consequence of past experiences and ones where previous experiences constitute a risk factor. Psychotherapy is one of the first-line treatments for most psychiatric conditions, and involves learning and plasticity. Here, we review selected publications pertaining to experience dependence in psychiatric conditions and summarise evidence of roles for the extracellular matrix in learning and memory. We then suggest how control of the extracellular matrix could be leveraged for innovative treatments and, more generally, discuss possible aetiological effects of extracellular matrix alterations in psychiatric disorders.

ABSTRACT

We introduce and present a psychotherapic technique initiated by Wilhelm Reich in the 1920's and thereafter expanded and refined with essential contributions by Elsworth Baker among others. We outline its theory and technical foundations and also provide an epistemologic interpretation of its peculiar body-mind representation based on character- and muscular armoring as a reaction to suffering; armoring of the ocular segment in the etiology of Bleuler's schizophrenic splitting; and finally the consequences of armoring on the energetic functions as the logical development of Freud's theory of libido, with significant theoretic, therapeutic and nosologic consequences.

AIMS OF THE STUDY: In daily clinical work, coercion continues to be highly prevalent, with rates differing between countries and sometimes even within countries or between wards of the same hospital. Previous research found inconsistent characteristics of individuals who underwent coercive measures during psychiatric treatment. Furthermore, there continues to be a lack of knowledge on the clinical course of people after being involuntarily committed. This study aimed to describe the rate and duration of different coercive measures and characterise a cohort of involuntarily committed patients regarding sociodemographic and clinical variables.

METHODS: In this observational cohort study, we analysed clinical data from the patients’ medical files, the use of coercive measures (seclusion, restraint, coercive medication) and other procedural aspects in involuntarily hospitalised patients (n = 612) at the University Hospital of Psychiatry Zurich. For analysis, we used cross-tabulation with chi-square tests for categorical variables and, owing to a non-normal distribution, the Mann-Whitney U-test for interval variables.

RESULTS: Coercive measures were documented in 170 patients (28% of those who were involuntarily hospitalised). The total number of seclusions was 344, with a mean duration of 9 hours per seclusion. A total of 89 patients (15%) received 159 episodes of coercive medication (oral and intramuscular). Also, 11 episodes of restraint were recorded in 7 patients (1%) with a mean duration of 12 hours per restraint. Patients subjected to coercion were significantly more often male, violent prior to admission, diagnosed with psychosis or personality disorder, and had a history of frequent hospitalisations with long durations of hospitalisation.

CONCLUSIONS: The prevalence of coercive measures is still high in involuntarily hospitalised patients. Seclusion was the most frequently used coercive measure, which may be based on cultural and clinical aspects and differs from findings in other countries where restraint is more frequently used. Some sociodemographic and clinical characteristics were associated with the use of coercion. This underlines the importance of developing treatment strategies for patients at risk to prevent situations in which the use of coercion is necessary. To enable comparison between different study sites, standardised protocols should be used to document frequency and duration of coercive measures.