Opparounds

Trauma-Focused Therapy Integrated With CBT for Psychosis in People With PTSD and Psychosis: The STAR Trial

Peters E, Swan S, Underwood R, et al. · The Lancet Psychiatry · July 2026

This multicentre UK trial randomized 305 adults with co-occurring psychosis and PTSD to trauma-focused CBT for psychosis (CBTp) plus treatment as usual, or to treatment as usual alone. The trauma-focused therapy integrated exposure-based trauma work directly into a psychosis-specific CBT framework over nine months, rather than treating the trauma and the psychosis in sequence.

At the nine-month primary endpoint, the therapy group showed a large reduction in PTSD severity (adjusted mean difference on the CAPS-5 of -8.67 points; Cohen's d -0.73), and PTSD remission was reached by 50% of the therapy group versus 22% of usual care (number needed to treat of 4). Delusions, hallucinations, paranoia, suicidal ideation, depression, and anxiety all improved alongside the PTSD symptoms, with no signal of destabilizing the psychosis, and 94% of assigned patients engaged with therapy.

Read the paper →  doi:10.1016/S2215-0366(26)00090-8

Antipsychotic Exposure and Pharmacologically Treated Type 2 Diabetes in Dutch Youths

Gangapersad RN, García-Gómez P, Koch BCP, Moghani V, Dierckx B. · JAMA Network Open · July 2026

Using 17 years of Dutch national registry data on nearly 90,000 youths who started an antipsychotic, this within-person cohort study tracked pharmacologically treated type 2 diabetes before and after treatment initiation, using each youth as their own control to remove confounding by baseline illness severity.

Diabetes-treatment prevalence was flat in the years before antipsychotic initiation, then rose steadily afterward, from roughly 2.5 excess cases per 10,000 users in year one to about 9 per 10,000 by year five. The risk was substantially higher in adolescents than in children aged 7-12, and higher in girls than boys. Even youths who used an antipsychotic only briefly, in the initiation year alone, still carried elevated diabetes risk years later.

Read the paper →  doi:10.1001/jamanetworkopen.2026.25377

Grapefruit Doesn't Just Interact With Statins — It Can Double Your Patient's Quetiapine Level

Quetiapine undergoes extensive first-pass metabolism through CYP3A4, both in the gut wall and the liver, so its oral bioavailability is normally kept low by that first pass. Grapefruit's furanocoumarins irreversibly inhibit intestinal CYP3A4 for 24 to 72 hours after ingestion — long enough that spacing the fruit and the dose apart doesn't help.

With intestinal first-pass metabolism knocked out, quetiapine's AUC can rise roughly two- to threefold, and the effect is dose-independent: a patient on 400 mg for bipolar depression sees the same proportional jump as one on 25 mg for insomnia augmentation. Clinically this shows up as exaggerated orthostatic hypotension, sedation, or QTc prolongation that seems out of proportion to the prescribed dose — and because the interaction is intestinal rather than hepatic, it won't show up on a typical interaction checker that only flags hepatic CYP3A4 substrates. Ask about grapefruit and Seville oranges specifically when a previously stable quetiapine dose suddenly looks too strong, especially in older patients already prone to falls.

The Negative Therapeutic Reaction: When Getting Better Feels Like a Threat

Freud named the negative therapeutic reaction to describe a patient who worsens, not despite good interpretive work, but because of it — symptoms flare, sessions get missed, or a crisis erupts right as treatment seems to be taking hold. The reflexive reading is resistance, but the more useful frame is unconscious guilt: improvement threatens an internal equilibrium organized around suffering, whether that means loyalty to a depressed parent, punishment for a forbidden wish, or the loss of an identity built around being the sick one.

A less common but important variant is a bid to defeat the therapist — unconsciously proving that no one, including this clinician, can actually help. The technical trap is escalating effort: pushing harder for insight only confirms, for the patient, that getting better is dangerous.