The AI Psych Brief

Incidence of clozapine-associated neutropenia in patients with schizophrenia: 20-year population-based study in Hong Kong

Zhou H, Luo H, Siskind D, Northwood K, Tang JY, Lui SSY, Lee EHM, Kan CK, Tsui CF, Poon LT, Leung SYJ, Wong YC, Wong JOY, Chan SKW · British Journal of Psychiatry · August 2026

Using Hong Kong's territory-wide electronic health records, the authors followed 4,868 people starting clozapine and 38,277 starting another second-generation antipsychotic between 2003 and 2019, with follow-up to 2023. Minor neutropenia was ANC 1.0–1.5 and serious neutropenia ANC below 1.0 × 10⁹/L.

Unadjusted, clozapine users had more of both (serious neutropenia 2.53% vs 1.45%), but the adjusted long-run rate of serious neutropenia was essentially identical: 0.37 vs 0.36 per 100 person-years. The excess was concentrated early — serious-neutropenia risk was about 3.5-fold higher in the first 18 weeks — and a change-point analysis showed it falling sharply after roughly 26–29 weeks and converging with other SGAs by about two years. Patients under 45 showed no significant early excess.

Read the paper →  doi:10.1192/bjp.2026.10726

Predicting patient outcomes from initial in-session interactions within cognitive behavioral therapy and person-centered experiential therapy for severe depression

Malins S, Saxon D, Figueredo G, Clos J, Trimble T, Fatehi K, Waldram D, Boycott N, Frost A, Sales C, Horton K, Hardy GE, Barkham M, Morriss R, Schröder T, Moghaddam N · Behaviour Research and Therapy · October 2026 (online September 2026)

Trained raters coded 103 first-session transcripts — 40 CBT and 63 person-centred experiential therapy (PCET) — from a pragmatic non-inferiority RCT for severe depression in England's NHS Talking Therapies, then used multilevel models to ask which kinds of first-session interaction predicted depression change over the whole course.

In both therapies, patients' active engagement in therapy-related action planning at session one predicted greater improvement. Conversely, the more of the first session spent on the administrative mechanics of completing measures — rather than discussing what the scores meant — the worse the outcome. Some predictors were model-specific: identifying protective factors helped in CBT, while spending more time exploring the patient's problems and context helped in PCET.

Read the paper →  doi:10.1016/j.brat.2026.105152

Trazodone's anxiogenic metabolite is cleared by the enzyme fluoxetine blocks

Trazodone is metabolized by CYP3A4 to m-chlorophenylpiperazine (m-CPP), and m-CPP is in turn cleared mainly by CYP2D6. That two-step pathway explains an interaction that is easy to misattribute. m-CPP is a 5-HT2C agonist — the compound used experimentally to provoke anxiety and panic — so when trazodone is added at bedtime to a patient on fluoxetine or paroxetine, both potent 2D6 inhibitors, m-CPP accumulates, and pharmacokinetic studies have shown rises in both trazodone and m-CPP levels. The clinical picture is new jitteriness, insomnia that paradoxically worsens, headache, or agitation that looks like 'the depression getting worse' or an activating SSRI.

The practical moves: start trazodone low (25–50 mg) on a 2D6 inhibitor, and treat new anxiety after it is added as a possible drug effect before escalating. The 3A4 step cuts the other way — ritonavir or ketoconazole raise trazodone itself, while carbamazepine lowers it.

The late arrival is a message about the frame, not a scheduling problem

The frame — fixed time, fee, length and place — is not administrative scaffolding around the therapy; it is one of the most reliable places the patient's conflicts show up, precisely because it is constant. A departure from a constant frame is a datum in a way that a shift in topic is not. The technical error residents make runs in two directions: treating frame deviations purely as logistics ('let's find a time that works better') forecloses their meaning, while confronting them as rule-breaking turns the therapist into a disciplinarian and invites compliance or defiance. The analytic move is to hold the frame steady and get curious about the deviation as communication — what it accomplishes, what affect it lets the patient avoid, and what it does to the therapist. The countertransference matters here: irritation, relief, or a wish to extend the session to compensate are all clues about the role the patient has assigned you.