Tuesday, November 3, 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 |
Bilateral Theta-Burst Stimulation of Dorsolateral Prefrontal Cortex Regions for Late-Life Depression: A Randomized, Sham-Controlled Clinical Trial
Valiengo LCL, Pinto BS, Luethi M, et al.; Forlenza OV, Brunoni AR. American Journal of Psychiatry. October 2026 (online March 2026).
This triple-blind trial in Brazil randomized 108 adults aged 60 and older (mean age 67) with moderate-to-severe major depression, none taking antidepressants, to active or sham bilateral theta-burst stimulation: intermittent TBS to the left DLPFC and continuous TBS to the right, 1,800 pulses per side. Patients received 20 daily weekday sessions, then single boosters at weeks 6, 8 and 12.
At the primary week-6 timepoint, active TBS did not separate from sham (HAM-D mean difference -1.65, 95% CI -3.38 to 0.08). By week 12 it did, with a mean difference of -1.89 points and response rates of 52% versus 33%. The benefit in older adults appears real but slow to emerge.
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In practice
When an older patient is three or four weeks into a TBS course with little to show, the evidence argues for finishing the course and the boosters rather than calling it a failure; set that expectation at consent, since many residents will see the TMS referral as a fast-acting option. |
Full text doi:10.1176/appi.ajp.20250537
| The Therapy Evidence |
| Research on what actually works in the room |
The working alliance predicts session-by-session change in problems and functioning in short-term psychodynamic psychotherapy
Østergård OK, Nilsson KK, Falkenström F. Journal of Counseling Psychology. July 2026 (online March 2026).
In a university training clinic, 152 clients in short-term psychodynamic therapy with novice therapists completed the CORE-10 before every session, and both clients and therapists rated the Working Alliance Inventory after every session. The authors used continuous-time structural equation modeling, which separates within-dyad change from stable between-person differences.
Improvement in the client-rated alliance predicted fewer problems at the next session, a small effect that grew to a large one by sessions 7-8. Symptom change also fed back into the alliance. The therapist-rated alliance predicted nothing. The alliance effect varied widely across dyads and was stronger in clients reporting more adverse childhood experiences.
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In practice
Your own sense that the alliance is going well is not a reliable outcome signal, especially early in training; asking the patient directly each session, for example with a brief alliance measure, is the information that predicts who gets better, and it matters most for patients with heavy early adversity. |
Full text doi:10.1037/cou0000867
| Past the Boards |
| One advanced clinical point, usually pharmacology |
In Duffy-null patients, a low ANC is a baseline, not a reason to skip clozapine
Most benign ethnic neutropenia (BEN) is explained by the Duffy-null phenotype, a common ACKR1 variant in people of African and Middle Eastern ancestry. Circulating ANC runs low because of how neutrophils are distributed, not because marrow reserve or host defense is impaired, so infection risk is not increased. The US clozapine label reflects this: in documented BEN, initiation is allowed at an ANC of at least 1000/µL (versus 1500/µL otherwise), after at least two baseline ANCs, with a separate BEN monitoring table thereafter.
This matters because a borderline ANC is a common reason clozapine is never started, or is stopped mid-response, in Black patients who are already underprescribed it. When a patient's baseline ANC sits between 1000 and 1500 with no infection history, order Duffy phenotyping (a routine blood-bank test) or ask hematology to document BEN before giving up on clozapine. It changes the thresholds, not the vigilance: a fall below the BEN cutoffs still means interrupting.
| In the Room |
| A psychotherapy technique, shown in a vignette |
In TFP, the contract exists so the breach can be read
Residents often hear the TFP treatment contract as a safety agreement to be enforced. Kernberg's group frames it differently. Negotiated before therapy starts, the contract names each party's responsibilities and the specific threats to this patient's treatment (self-harm, missed sessions, substance use, withholding). Its main job is to establish a frame against which a breach becomes legible as an enactment of an object relation rather than background noise.
The contract gives the therapist ground to stand on for confrontation: we agreed X, now Y is happening, what do you make of that? Without it the only reference point is the therapist's own irritation or alarm. In the TFP priority hierarchy a contract breach outranks transference themes, so it is addressed first. Addressing it means asking what role the breach casts the therapist in, typically the controlling jailer or the negligent parent, and declining both. That refusal is what neutrality means here.
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Vignette
A 24-year-old with borderline organization agreed in her contract to go to the ED, not call her therapist, during a suicidal crisis. Three weeks in she leaves a late-night voicemail: "I took some pills, not many. I just needed you to know." The resident hears it at 7 a.m., calls, and confirms she is medically safe. In session the pull is either to reassure warmly or to lecture. Instead the resident says: "We agreed that in a crisis you'd go to the ED. Last night you came to me, in a way that left me holding your life overnight with no way to act. I wonder if that was part of the point, that someone should feel as frightened and helpless as you did." The move is confrontation anchored in the contract, then a tentative interpretation of the role reversal. She is angry at first, then begins talking about her mother's unpredictability. |
| Elsewhere |
| Developments worth knowing about |
| • | The FDA's October 2026 approval of Teva's Weltruza, a once-monthly subcutaneous olanzapine LAI for schizophrenia (SOLARIS trial), comes with no loading dose, no oral overlap and no post-injection observation period. That removes the 3-hour monitoring burden that has kept olanzapine pamoate out of many clinics. (source) |
| • | AI in psychiatry: state laws passed this summer now govern mental-health chatbots and clinicians' AI use (per an October 2026 legal review). Rhode Island requires chatbots to route suicidal users to crisis services and clinicians to tell patients when AI records or transcribes sessions; Illinois and Nevada restrict AI-delivered therapy. Ask patients which chatbots they use, and check your scribe's consent step. (source) |
| *** |
| That's the five. Go see your first patient. |