Opparounds

Semaglutide and Effort-Based Decision-Making in Major Depressive Disorder: A Randomized Clinical Trial

Hartej Gill, Sebastian Badulescu, Hiya Shah, Ryan M. Brudner, Lee Phan, Joshua D. Di Vincenzo, Aniqa Tabassum, Sharmili Edwin Thanarajah, Cristian-Daniel Llach, Joshua D. Rosenblat, Roger S. McIntyre, Rodrigo B. Mansur · JAMA Psychiatry · July 2026

In this 16-week, double-blind, placebo-controlled trial, 72 adults with major depressive disorder and BMI ≥25 were randomized to adjunctive oral semaglutide (titrated to 14 mg) or placebo on top of standard treatment. The primary outcome was performance on the Effort-Expenditure for Rewards Task (EEfRT), a behavioral measure of motivation rather than a self-report scale. Semaglutide-treated participants showed a significantly greater willingness to exert effort for higher-value rewards (χ² = 12.024; P = .02), and computational modeling found this tracked with reduced effort discounting (β = −1.737; P = .03) rather than a general change in reward sensitivity — probability sensitivity to reward was unchanged.

The effect was specific to the cost side of the effort-reward calculation, not to how rewarding the outcomes felt.

Read the paper →  doi:10.1001/jamapsychiatry.2026.0594

Testing the Alliance Rupture Repair Model on Two Cases with Successful and Unsuccessful Rupture Repair: A Task Analytic Validation Study

Louise Ingvardsen Vemmelund, Anne-Sophie Spaanheden Moeslund, Stine Steen Høgenhaug, Ole Karkov Østergård · Psychotherapy Research · March 2026

Using task analysis — a method for building and testing fine-grained models of how change actually happens session to session — the authors compared one case where a therapeutic alliance rupture was successfully repaired against one where it was not, in short-term psychodynamic psychotherapy. Sessions were selected using the Working Alliance Inventory-Short and coded with the revised Rupture Resolution Rating System (3RS), which distinguishes withdrawal ruptures (client pulls away) from confrontation ruptures (client pushes back directly).

In the successful case, the therapist's acceptance, validation, curiosity, and engagement strategies (Pathway 1 of the rupture-repair model) predominated and preceded resolution; in the unsuccessful case, these strategies were comparatively rare, and the rupture never resolved within the sessions analyzed.

Read the paper →  doi:10.1080/10503307.2026.2642109

The loading dose determines whether you need oral overlap — and by how much

Long-acting injectables are not interchangeable in how fast they reach a therapeutic level, and the label tells you exactly what bridge you need. Paliperidone palmitate's once-monthly formulation is dosed with two loading injections — 234 mg on day 1, 156 mg on day 8, both deltoid — specifically so no oral overlap is required; the loading doses alone reach therapeutic concentrations within the second week. Aripiprazole lauroxil needs either 21 days of oral aripiprazole overlap or a single co-administered dose of Aristada Initio, because the depot alone doesn't reach steady state fast enough on its own.

Olanzapine pamoate sits in a different category entirely: it carries a boxed warning for post-injection delirium/sedation syndrome from accidental intravascular injection, which is why every dose requires 3 hours of monitoring at a certified facility — not because of slow onset. Missing which mechanism applies to which drug is how patients end up either unnecessarily bridged for a month, or unmonitored after a dose that didn't need an oral overlap but did need observation.

Your countertransference is either standing with the patient or standing in for someone else

Racker's classic distinction splits countertransference into two kinds, and confusing them leads to opposite clinical errors. Concordant countertransference is when the therapist's internal state mirrors the patient's own — feeling the patient's anxiety, sadness, or fear from the inside, empathic resonance rather than enactment. Complementary countertransference is different in kind: the therapist starts feeling like someone else in the patient's internal world — the critical parent, the abandoning partner, the persecutory boss — pulled into a role the patient is unconsciously assigning.

The clinical error runs in both directions. Mistake complementary feelings for concordant ones and you'll act out the assigned role — becoming genuinely irritable at a patient who is unconsciously casting you as the dismissive father. Mistake concordant feelings for complementary ones and you'll distance yourself from ordinary empathy as though it were contamination. The question worth asking mid-session: whose feeling is this, actually — the patient's, or someone else's the patient has placed onto you?