Friday, July 31, 2026

Opparounds

🔬Psychiatric Research Article

Confirmatory Efficacy and Safety Trial of Magnetic Seizure Therapy versus Right Unilateral Ultra-Brief Electroconvulsive Therapy in Depression (CREST-MST): A Randomised, Double-Blind, Non-Inferiority Trial in Canada and the USA

Daniel M. Blumberger, Shawn M. McClintock, Kevin E. Thorpe, Carol A. Tamminga, Kate Foley, Mustafa M. Husain, et al. · The Lancet Psychiatry · May 2026

Across three academic centers in Toronto, Dallas, and San Diego, 239 adults with major depression were randomized to magnetic seizure therapy or right unilateral ultra-brief pulse ECT — the most cognitively sparing form of ECT in routine use — in a double-blind non-inferiority design. Remission on the 24-item Hamilton scale was 22.5 percent with MST versus 27.8 percent with RUL-UB ECT, a 5.3 percentage point difference that fell inside the prespecified 15 percent non-inferiority margin.

The separation was in cognition. Clinically meaningful worsening of autobiographical memory occurred in 17.3 percent of ECT patients versus 2.7 percent with MST. MST induces a seizure using a high-intensity magnetic field, which is more focal than an electrical stimulus and spares deeper temporal structures.

💡 Why it matters

MST is not more effective than ultra-brief right unilateral ECT and this trial does not claim it is — it is comparably effective with a markedly better autobiographical memory profile. That combination matters most for the patient who needs convulsive therapy and refuses ECT specifically because of memory, a conversation most of us have had more than once.

Read the paper → doi:10.1016/S2215-0366(26)00060-X

📖Psychotherapy Research Article

Embodied Movement Markers of Alliance Ruptures in Psychotherapy: A Machine Learning Study

Amit Tchizick, Aleksandr Laskorunskyi, Tohar Dolev-Amit, Galit Peysachov, Keren Deres-Cohen, Itai Dattner, Sigal Zilcha-Mano · Psychotherapy Research · June 2026

The investigators applied motion energy analysis and machine learning to 474 videotaped sessions from 86 patient-therapist dyads in a depression treatment trial, with ruptures independently coded using the Rupture Resolution Rating System. The question was whether nonverbal movement alone could flag a rupture in progress.

It could, but asymmetrically. Withdrawal ruptures were detectable at a mean AUC of .73, while confrontation ruptures performed near chance at .56. Therapist head movement was the single most robust marker across rupture types, and identifying withdrawal reliably required integrating movement from multiple body regions of both people, not just the patient.

💡 Why it matters

The clinically interesting result is which rupture the body gives away. Confrontation ruptures announce themselves — the patient tells you they are angry. Withdrawal ruptures are the ones we miss, and this study suggests they are nonetheless happening visibly, in the room, in a channel we are not attending to. It is an argument for watching tape in supervision rather than only reporting on sessions from memory.

Read the paper → doi:10.1080/10503307.2026.2689627

💊Psychiatric Fact

Your QTc is probably wrong, and the correction formula is why

Almost every automated ECG report uses Bazett's formula, which divides QT by the square root of the RR interval. Bazett was derived from 39 subjects in 1920 and it systematically overcorrects at high heart rates and undercorrects at low ones. In the agitated, tachycardic, often dehydrated patient in whom you are actually worried about the QT — the one who just got IV haloperidol, or who has been drinking and is now withdrawing — Bazett inflates the number, sometimes by 20 to 30 ms at a heart rate of 110. Fridericia's cube-root correction is far more stable across heart rates and is what most cardiology and regulatory guidance now prefers. When a Bazett QTc crosses a threshold in a tachycardic patient, recalculate with Fridericia before you stop the drug; you can do it at the bedside from the printed QT and RR.

The thresholds are worth holding precisely, because they are risk gradients and not cliffs. Absolute QTc above 500 ms, or an increase of more than 60 ms from the patient's own baseline, is where torsades risk becomes clinically meaningful — which is why a pretreatment ECG is worth far more than a post hoc one. Among the drugs, the ranking is not intuitive: IV haloperidol and intravenous administration generally carry the real signal, oral haloperidol much less so, and among the atypicals ziprasidone and iloperidone prolong most while aripiprazole, lurasidone, and olanzapine are close to neutral. Citalopram is dose-dependent and the reason for the 40 mg cap (20 mg over age 60 or with a 2C19 inhibitor), while escitalopram and sertraline are considerably safer choices. And before blaming the drug, correct the substrate: hypokalemia and hypomagnesemia do more to destabilize repolarization than most of what we prescribe.

🛋️Psychotherapy Teaching Pearl

Behavioral chain analysis is not a history — it is a search for the link you can actually change

Residents often run a chain analysis as an extended incident report: what happened, then what happened, then what happened. Linehan's point is narrower and more useful. The chain exists to find the earliest link that is both modifiable and reachable, because that is where a solution can be inserted next time. Vulnerability factors, prompting event, links (thoughts, feelings, sensations, actions), problem behavior, consequences — and then, crucially, the solution analysis, which is the half that gets skipped when the session runs short.

Two technical points separate a competent chain from a ritual one. First, the links must be granular to the point of tedium; 'I felt terrible and then I cut' is not a chain, it is a summary, and there is nothing in it to change. Second, the chain itself is an exposure — the patient is being asked to walk slowly back through an event they would rather round off — so the therapist's job is to keep it non-judgmental in a way that is almost conspicuous. If the patient experiences the chain as punishment, it becomes a therapy-interfering behavior of your own, and the next chain will be vaguer than this one.

🗒️ Vignette

A 24-year-old man in standard DBT has cut for the first time in eleven weeks. He arrives apologetic and wants to move on. The therapist declines to move on, and also declines to make it heavy: 'We are going to do this in slow motion, and I am going to be annoying about the details.'

The surface chain is: girlfriend texted that she needed space, he felt worthless, he cut. Useless. The therapist slows it down. Between the text and the cutting there were forty minutes. What happened in the forty minutes? He read the text, put the phone face down, and — here he pauses — went to the kitchen and stood there. Stood there doing what? Nothing. For how long? Maybe fifteen minutes. What was going through your mind in the kitchen? 'Nothing. It was blank.'

The blank is the link. The therapist stays on it: what was happening in your body while your mind was blank? Chest tight, hands cold, a sense of the room being far away. He is describing dissociation, and it turns out that in every previous chain the same fifteen minutes of blankness precedes the behavior. He had never reported it because it did not feel like anything.

The solution analysis now has a real target and a real window. Not 'use a skill when you feel worthless' — he does not feel worthless, he feels nothing — but a temperature-based TIP skill deployed the moment he notices he is standing still and the room has gone far away, a cue he can actually detect. They rehearse it in session, twice, including the walk to the sink. The point of the chain was never the girlfriend or the worthlessness. It was fifteen minutes in a kitchen that nobody had ever asked about.