Opparounds

Risk of Presentation for Sexual Abuse After a First Emergency Department Presentation for Self-Harm in Childhood or Adolescence

Blundell M, Kurdyak P, Du Mont J, Gallagher L, Korczak DJ, Monga S, Vorstman JAS · American Journal of Psychiatry · July 2026

This population-based cohort study used linked health-administrative data from Ontario, Canada to follow more than 26,000 children and adolescents (ages 8-17) after a first emergency department presentation for self-harm between 2013 and 2022, comparing them against a matched general-population cohort for up to 10 years.

The 10-year cumulative incidence of a subsequent ED presentation specifically for sexual abuse was 9.06% in the self-harm cohort versus 1.26% in controls, and for sexual assault, 4.2% versus 0.48%. The elevated risk was concentrated among females, who were more than eight times as likely as males to later present for sexual abuse. Because the self-harm presentation preceded the sexual abuse presentation in this design, the authors argue self-harm functions as an early marker of vulnerability to abuse rather than only its downstream consequence.

Read the paper →  doi:10.1176/appi.ajp.20250691

The Effects of Antidepressants on Cardiometabolic and Other Physiological Parameters: A Systematic Review and Network Meta-Analysis

Pillinger T, et al. · The Lancet · October 2025

This systematic review and network meta-analysis pooled 151 randomized controlled trials (more than 58,000 participants, average treatment duration about eight weeks) to compare 30 antidepressants head-to-head on weight, lipids, glucose, blood pressure, heart rate, and QTc.

Weight gain was greatest with maprotiline, mirtazapine, and amitriptyline, while agomelatine, fluoxetine, and bupropion were weight-neutral or associated with modest weight loss. Duloxetine, venlafaxine, and paroxetine raised cholesterol and glucose despite modest weight loss, and amitriptyline, venlafaxine, fluoxetine, and duloxetine increased blood pressure relative to placebo; no drug produced a clinically meaningful QTc change. Critically, none of these physiological effects tracked with antidepressant efficacy -- cardiometabolic burden and expected benefit are separate axes to weigh, not a package deal.

Read the paper →  doi:10.1016/S0140-6736(25)01293-0

Benign ethnic neutropenia has its own clozapine threshold -- and it's genetic, not demographic

Roughly 20-50% of people of African ancestry -- plus many of Middle Eastern, Mediterranean, and Yemenite Jewish descent -- carry the Duffy-null phenotype, a promoter variant in ACKR1 that silences neutrophil Duffy antigen expression, and run a chronically lower absolute neutrophil count with no increase in infection risk. Left unaccounted for, this benign ethnic neutropenia (BEN) locks patients who stand to benefit most from clozapine out of it: a baseline ANC of 1200/uL looks disqualifying under the standard initiation threshold of >=1500/uL, but is normal physiology for a Duffy-null patient. The FDA's REMS algorithm builds this in explicitly -- a patient identified with BEN can start clozapine at a baseline ANC as low as 1000/uL, and treatment is interrupted only below 500/uL rather than the standard 1000/uL cutoff. The clinical error isn't ignoring a low count -- it's applying the wrong count's reference range and turning a normal variant into an unnecessary barrier to the one antipsychotic proven for treatment resistance.

Identification with the aggressor

A patient who suddenly turns harsh, controlling, or contemptuous toward you is not always projecting an internal object relation onto you -- sometimes they are occupying the aggressor's role directly. Anna Freud's identification with the aggressor describes a shift from passively enduring threat to actively becoming it: a patient with a history of humiliation or abuse converts helplessness into a felt sense of control by adopting the abuser's stance, often precisely when the treatment relationship starts to matter and the old fear of being hurt again resurfaces. The distinguishing clinical marker is direction of movement -- in projective identification, the therapist is pressured into feeling or enacting a disowned state; in identification with the aggressor, the patient has already installed themselves in it, and the countertransference pull is to feel like the original victim, not to search for a lost part of the patient.