Friday, October 30, 2026
Two papers, a psychopharmacology pearl, a psychotherapy pearl and the news.
AI-generated content. This briefing was written by Claude Opus 5.5 and may contain errors. Please verify against the primary source before acting clinically.
| The Paper |
| New research from the psychiatric journals |
GLP-1 Receptor Agonists and Risk of Kidney Replacement Therapy and Health Care Utilization in Bipolar Disorder With Chronic Kidney Disease
Singh B, Gonzalez Suarez ML, Ali HM, Baweja R. Journal of Clinical Psychiatry. October 2026.
People with bipolar disorder carry a heavy load of chronic kidney disease, driven by lithium exposure, metabolic syndrome from antipsychotics, diabetes and hypertension, yet they are rarely the focus of nephroprotection research. This Mayo Clinic group used the TriNetX network to run a new-user, active-comparator cohort study of adults with bipolar disorder and CKD (stage 3 or earlier) who started a GLP-1 receptor agonist, compared with those who started a DPP-4 inhibitor, and in a secondary analysis with new users of RAAS inhibitors, followed for five years with propensity-score matching.
Against DPP-4 inhibitors, GLP-1 RA use was associated with a lower risk of needing dialysis or transplant (kidney replacement therapy; aHR 0.56, 95% CI 0.50 to 0.64). In the matched cohorts (3,908 per group), five-year KRT-free survival was 87.9% versus 84.6%, and the advantage held against RAAS inhibitors (94.7% vs 89.8%). Results were consistent across sex, race, obesity status and psychotropic subgroups, including lithium users. The health care utilization findings were mixed, with a lower adjusted hazard but no difference in matched HCU-free survival.
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In practice
This is observational and the authors call it exploratory, but when a patient with bipolar disorder has both CKD and an indication for diabetes or weight treatment, it is a reason to favor a GLP-1 RA and to bring the nephrologist and primary care team in early. It does not license keeping lithium in declining kidney function without close eGFR monitoring. |
Full text doi:10.4088/JCP.26m16392
| Outside Psychiatry |
| A general-medicine paper that ends up in our clinic |
Comparative Effectiveness of Phenobarbital vs Diazepam for Alcohol Withdrawal Syndrome
Bradley T, Feeney M, Law AC, Peterkin AF, Fantasia KL, Walkey AJ, Bosch NA. JAMA Internal Medicine. October 2026.
Phenobarbital has spread quickly through US hospitals as an alternative to benzodiazepines for alcohol withdrawal, mostly on the strength of small trials and before-and-after studies. This study used the Premier Healthcare Database to emulate a randomized trial among 24,643 adults admitted with alcohol withdrawal to 754 US hospitals between 2022 and 2024, comparing those started on phenobarbital (48%) with those started on diazepam (52%) on the day of admission, with targeted maximum likelihood estimation to adjust for confounding.
Length of stay was nearly identical (4.1 vs 4.3 days; difference −0.21 days, 95% CI −0.42 to 0.00), and so was the rate of invasive mechanical ventilation (3.1% vs 2.7%; risk difference 0.4%, 95% CI −0.7% to 1.4%). Treatment escalation and complications of severe withdrawal did not differ. The one signal was self-directed discharge, which was more common with diazepam (12.6% vs 9.5%).
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In practice
For consult-liaison and addiction psychiatrists, this suggests phenobarbital and a long-acting benzodiazepine are close to therapeutically equivalent, so the choice can rest on local protocol, hepatic and respiratory risk, and monitoring capacity rather than superiority claims. The lower rate of leaving against medical advice is worth testing in a real trial, because a completed detox is the doorway to starting naltrexone, acamprosate, or other treatment for the use disorder. |
Full text doi:10.1001/jamainternmed.2026.4939
| Past the Boards |
| One advanced clinical point, usually pharmacology |
A normal CYP2D6 genotype stops meaning normal once paroxetine, fluoxetine or bupropion is on board
A pharmacogenomic report describes the gene, not the patient in front of you. Phenoconversion is the term for a genotypic CYP2D6 normal metabolizer who behaves like a poor metabolizer because a strong inhibitor is co-prescribed, and the three most common culprits are psychiatric: paroxetine, fluoxetine and bupropion (much of bupropion's inhibition comes from its metabolites). Duloxetine is a moderate inhibitor.
The labels already encode this. Aripiprazole is halved with a strong 2D6 inhibitor, exactly as for a genotypic poor metabolizer, and quartered when a strong 3A4 inhibitor is added too; vortioxetine is halved with bupropion or fluoxetine. The practical rule is to read every genotype result through the current medication list, and to remember that the effect outlasts the inhibitor: after fluoxetine stops, 2D6 inhibition fades only as norfluoxetine clears, over several weeks, so a dose cut made for the combination may need to be raised again later.
| In the Room |
| A psychotherapy technique, shown in a vignette |
When you prescribe and do therapy, the prescription joins the transference
Residents often hold both roles, prescriber and therapist, and it is tempting to keep them in separate compartments: medication talk at the end, therapy for everything else. But a dose request, a missed pill, or a sudden wish to stop a medication is also communication about the relationship, and it carries the same transference as anything else the patient brings. The pill can stand for the therapist's care, control, or rejection, and changes in the regimen can be used to manage closeness and separation. The technical move is to hold both questions at once: assess the symptom honestly, because a real relapse needs real treatment, and ask what the request means before acting on it. Reflexively adjusting the dose answers the wish without understanding it; reflexively refusing turns a clinical decision into a power struggle. Exploring first keeps the medication decision sound and often uncovers material the patient could not say directly.
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Vignette
A woman in twice-weekly therapy with a PGY-3, stable for months on sertraline, asks in the session after the resident announced a three-week vacation whether her dose could be raised, because she has been feeling "on edge." The resident first checks sleep, mood and safety and finds nothing has changed clinically. Instead of writing the order or declining it, she says: "I'll take the question seriously, and we can decide together. I notice it came up right after I told you about my time away. I wonder if part of you wants something from me to hold on to while I'm gone." The patient is quiet, then says the last time a doctor left, she "fell apart and nobody noticed." They agree to keep the dose, schedule a brief check-in call with the covering clinician, and spend the remaining sessions on the coming break. |
| Elsewhere |
| Developments worth knowing about |
| • | An October 2026 legal review tallies this summer's state laws on AI in mental health care: Illinois, Nevada and Maine now bar AI chatbots from delivering psychotherapy without a licensed clinician, and Colorado and Illinois require written client consent before AI records or transcribes a session. If you use an AI scribe in therapy, check your state's consent rules now. (source) |
| • | The FDA approved Teva's Weltruza, a once-monthly subcutaneous olanzapine long-acting injectable for adults with schizophrenia, announced October 9, 2026. Unlike olanzapine pamoate, it requires no loading dose, no oral supplementation and no 3-hour post-injection observation, which removes the main barrier to offering an olanzapine LAI in a busy clinic. (source) |
| *** |
| That's the five. Go see your first patient. |