Monday, September 7, 2026

Opparounds

🔬Psychiatric Research Article

Trends in the Prevalence and Severity of Alcohol and Cannabis Use Disorders Among US Adults

Beth Han, Wilson M. Compton, Jennifer A. Hobin, Nora D. Volkow · JAMA Psychiatry · August 2026

This cross-sectional analysis of 186,823 respondents to the 2021–2024 National Surveys on Drug Use and Health tracked past-year DSM-5 cannabis use disorder (CUD) and alcohol use disorder (AUD) using logistic regression. Overall CUD climbed from 7.3% to 9.3% in men and 4.5% to 5.6% in women over the study period, with moderate-to-severe CUD rising in both sexes — and a striking 7-fold jump (0.1% to 0.7%) in women 50 and older. Alcohol use disorder moved the opposite direction: stable in men and declining in women (9.7% to 8.2%). Among 18-to-20-year-olds in 2024, CUD outpaced AUD (about 14.5% vs 10.3%), and roughly half of young cannabis users met CUD criteria, most at the moderate-to-severe level.

💡 Why it matters

No FDA-approved medication exists for CUD, so this widening, age- and sex-specific gap between cannabis and alcohol problems is a screening and referral gap, not just an epidemiologic curiosity — ask about cannabis use with the same rigor you ask about drinking, especially in young adults and older women.

Read the paper → doi:10.1001/jamapsychiatry.2026.2497

📖Psychotherapy Research Article

Personalized and Optimal Treatment Estimated by a Value-Search Method in a Randomized Clinical Trial With Psychodynamic Versus Cognitive Behavioral Therapy for Depression

Ole Klungsøyr, Jon Røssberg, Christos Papageorgiou, Julie Horgen Evensen, et al. · Psychotherapy Research · July 2026

Using causal-inference-based value-search optimization, this reanalysis of a 100-patient RCT comparing short-term psychodynamic psychotherapy (STPP) and CBT for major depression estimated which treatment each patient should have received, rather than just comparing arms head-to-head. About 75% of patients were identified as optimally suited to CBT, and patients who got their model-predicted optimal treatment showed large effect-size gains (0.41 to 2.07) over those who got the mismatched therapy — more than a 30% improvement relative to standard randomized assignment. The single strongest predictor of who did better with CBT was higher baseline positive beliefs about rumination (the belief that dwelling on a problem produces insight or control).

💡 Why it matters

A quick pre-treatment probe of whether a depressed patient believes rumination is useful may be as clinically informative as diagnosis in choosing between STPP and CBT — though with only 100 patients this needs prospective replication before it drives real-world triage.

Read the paper → doi:10.1080/10503307.2026.2682995

💊Psychiatric Fact

Oral Ketamine Isn't a Weaker IV Dose — It's a Different Drug Exposure

Racemic ketamine's oral bioavailability is only about 17 to 25%, because a swallowed dose passes through the liver before reaching circulation. That first pass is dominated by CYP3A4 (with minor CYP2B6/2C9 contribution), and it doesn't just reduce ketamine levels — it converts most of the dose to norketamine, which circulates at roughly three times the concentration of the parent drug after oral dosing. Norketamine is not an inert byproduct: it has its own NMDA-antagonist and AMPA-potentiating activity and appears to contribute meaningfully to the antidepressant effect. That's why oral ketamine doesn't behave like a diluted IV infusion — it's a genuinely different pharmacokinetic and probably pharmacodynamic exposure, part of why effective oral doses (typically 1–3 mg/kg, given 2–3 times weekly) run several-fold higher than an IV dose divided by bioavailability would predict. Meta-analytic numbers for oral ketamine in depression run roughly NNT 5 for response and NNT 9 for remission — real, but more modest than IV or intranasal routes.

🛋️Psychotherapy Teaching Pearl

Introjective and Anaclitic Depression Aren't the Same Illness

Depression is not one core anxiety wearing different faces, and Blatt's distinction still organizes technique better than diagnosis alone. Introjective depression organizes around guilt, self-criticism, and failure against an internalized, punitive standard — the patient feels worthless, not unloved, and the pathology lives in a harsh superego. Anaclitic depression organizes around fear of abandonment and loss of the caregiving object — the patient feels unlovable, not inadequate, and the pathology lives in the relationship to the object itself. The two call for different technical emphasis. Introjective patients can tolerate, and need, exploratory interpretation of the harsh internal standard, including the aggression embedded in the self-attack. Anaclitic patients need more relational holding and a steadier, more actively engaged therapist before interpretation of anger at the object will be usable rather than experienced as further abandonment.

🗒️ Vignette

A PGY-3 resident's patient says, 'I don't deserve for things to go well — I sabotage everything.' The resident reflexively offers reassurance: 'You're being so hard on yourself; you deserve good things.' The patient grows more anxious, not less, and cancels the next session. In supervision, the case reformulates as introjective: the self-attack is the defense doing its job, not a wound reassurance can soothe — unearned warmth only proves the internal judge right that she's fooling everyone. The resident instead asks, 'What would happen if you let yourself have this and didn't punish yourself for it?' — turning toward the standard itself rather than arguing against it. She pauses, then names her mother's voice underneath her own for the first time.

📰In the News

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The FDA's August 2026 approval of centanafadine (Simtriyo) gives ADHD prescribing its first triple reuptake inhibitor — blocking norepinephrine, dopamine, and serotonin reuptake — as a non-stimulant-schedule option once the DEA assigns it a controlled-substance schedule. source →

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A joint IGSLi/ISBD expert panel's August 2026 lithium-kidney algorithm recommends keeping levels below 0.80 mmol/L — the 0.80–0.99 band carries a 4.3-fold higher CKD risk — and found no renal advantage to switching patients to valproate, aiming to counter under-prescribing driven by renal fear. source →