Thursday, November 5, 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 |
Instrumental Support Calls vs. Caring Contacts Texts to Prevent Suicide in Adolescents and Adults: The SPARC Randomized Clinical Trial
Radin AK, Shaw J, Brown SP, et al.; Comtois KA. American Journal of Psychiatry. October 2026.
SPARC was a pragmatic comparative-effectiveness trial in Idaho. It enrolled 723 adolescents and 797 adults who screened at risk for suicide in nine emergency departments and 36 primary care clinics. On top of usual care, participants were randomized to instrumental support calls (crisis-line staff helping with practical needs and linkage to care) or two-way Caring Contacts texts. The outcome was the Columbia Suicide Severity Rating Scale ideation/behavior score at 6 and 12 months.
The best arm depended on age. Among adults, scores at 6 months were higher with Caring Contacts than with support calls, and the difference had faded by 12 months. Among adolescents, the arms were similar at 6 months, but by 12 months adolescents in the Caring Contacts arm scored lower. There was no usual-care-only arm, so the trial compares two active follow-up models rather than testing either against nothing.
|
In practice
After an ED or primary care visit where suicide risk is flagged, the follow-up may need to differ by age: hands-on help with logistics early for adults, and sustained low-burden connection over months for teenagers. When you write a discharge safety plan, ask what kind of contact will actually reach this patient. |
Full text doi:10.1176/appi.ajp.20260157
| The Therapy Evidence |
| Research on what actually works in the room |
Efficacy of measurement-based care (MBC) in routine child and youth behavioral therapy: A pragmatic randomized controlled trial
Hautmann C, Oswald F, Egemann J, et al.; OPTIE Study Group. Psychotherapy Research. October 2026.
In routine outpatient behavioral therapy in Cologne, 317 children (6 to 10) and adolescents (11 to 17) were randomized to therapy with or without a low-frequency measurement-based care system, in which caregivers, youth and therapists completed periodic symptom reports that were fed back to the therapist. Informants filled in the measures reliably (69% to 87% participation), but therapists discussed the feedback report with the family at least once in only 29% of cases.
On the primary outcome, ratings by masked assessors, measurement-based care had no effect (d = 0.00). Caregiver ratings, which were not blinded, showed small improvements in externalizing symptoms, and somewhat larger improvements in the per-protocol sample. The authors read the result as an implementation failure, and they note that the gap between caregiver and masked ratings shows how unblinded informants can inflate apparent treatment effects.
|
In practice
Collecting outcome measures doesn't help unless the measures enter the room. Feedback works when the therapist reviews the scores with the patient and changes course when they aren't improving, so if you use PHQ-9s or ROM scales, discuss the numbers in session. |
Full text doi:10.1080/10503307.2026.2721647
| Past the Boards |
| One advanced clinical point, usually pharmacology |
Valproate hyperammonemia can hide behind a normal level and normal LFTs
Valproate can cause hyperammonemic encephalopathy with a valproate level in the therapeutic range and completely normal liver tests. The mechanism is urea-cycle interference, not hepatotoxicity. Valproate metabolites, especially propionyl-CoA, reduce N-acetylglutamate, the required activator of carbamoyl phosphate synthetase I. Valproate also depletes carnitine, which pushes more of the drug through the toxic metabolic pathways.
Clinically, this looks like new lethargy, vomiting, confusion, or more frequent seizures in a patient who seems stable on paper. The label tells you to measure ammonia in exactly that situation rather than rely on the level or LFTs. Risk rises with topiramate co-prescription, which independently raises ammonia and carries its own label warning for the combination, and with unrecognized urea-cycle disorders. Asymptomatic elevations are common and warrant monitoring, not automatic discontinuation. Symptomatic encephalopathy means stopping valproate, and L-carnitine is widely used as supportive treatment.
| In the Room |
| A psychotherapy technique, shown in a vignette |
In DBT, when validation stalls, go irreverent - an off-beat response can unstick the session
DBT balances two communication styles. Reciprocal communication is warm, responsive and genuine. Irreverent communication is matter-of-fact, unexpected, sometimes deadpan or blunt. Irreverence is not sarcasm or impatience. It is a deliberate move to knock the patient off a rigid pattern, usually a catastrophizing or willful position that more validation would only reinforce. The cue to use it is a stuck session: you have validated, the patient escalates, and you notice yourself getting more careful and soothing. Linehan's idea is that the jolt grabs attention and interrupts the pattern long enough for a new response to happen. It works only on top of a solid relationship, and it should take the patient's point seriously while declining to take its catastrophic tone seriously. Return to warmth afterward.
|
Vignette
A 24-year-old in DBT skills training announces, for the third time this session, "If I don't get this job, my life is over, there's no point in any of this." The resident has validated the fear twice, and each time the patient escalated. Rather than validating a third time, she says in a level voice, "Okay. So we've got a week until the interview, and your plan is to be dead if it goes badly. That's a pretty short planning horizon. Want to work on a plan B that involves you still being here?" The patient laughs, startled, then says, "That sounds stupid when you say it." The resident softens: "It's not stupid that you want this badly. Let's do PLEASE and a cope-ahead for the interview." Because the irreverence came after real validation, the patient heard it as engagement, not dismissal. The resident still briefly checks for suicidal ideation before moving on. |
| *** |
| That's the five. Go see your first patient. |