The edition · Psychiatry
Depot antipsychotics earn their place in bipolar disorder
A twenty-year Hong Kong record linkage halves manic relapse on long-acting injectables; prescribable depression apps deliver a real but narrow effect; and a Danish registry shows how much of what we call heritability comes from who people partner with.
The edition in brief
Today's psychiatry edition opens with prescription-eligible digital applications for depression and generalised anxiety disorder. Across 19 randomised trials and 4,078 participants, digital tools reduced depressive symptom severity with a standardised mean difference of −0.49 immediately after treatment and −0.35 at follow-up, but the evidence is dominated by a single application and the anxiety evidence rests on two studies. A meta-analysis of 11 studies and 5,568 participants links sleep paralysis to higher anxiety scores with a standardised mean difference of 0.35 and no heterogeneity at all, though the prevalence comparison was not robust. From a Danish registry of 4.24 million residents, parental correlation for any psychiatric disorder was 0.28, rising to 0.38 for schizophrenia, and simulation suggests this non-random partnering inflates family-based heritability estimates by 12.5% — a reminder that a strong family history reflects two parents, not one gene. A cross-sectional Johns Hopkins study found angiotensin-converting enzyme protein levels lower in cerebrospinal fluid and serum in early-stage psychosis, and lower again in treatment-resistant cases, without a matching change in enzymatic activity; this is biomarker research, not a test to order. The practice-changer is a self-controlled case series in 2,086 people with bipolar disorder who received both long-acting injectable and oral antipsychotics over twenty years. Injectable periods carried lower rates of psychiatric hospitalisation (adjusted incidence rate ratio 0.67), manic-episode admission (0.51) and mixed-episode admission (0.31), with no signal for depressive episodes and no excess non-psychiatric or cardiovascular admission. Extrapyramidal symptoms rose nearly threefold in the first 90 days and then settled. The edition closes with a bedside note on separating akathisia from anxiety.
Prescribable depression apps work, but the evidence is one app deep
A prescribable digital programme for depression is worth offering as an adjunct, but ask which product and check that the specific one has been trialled — the pooled effect comes from a handful of applications, not the category.
Sleep paralysis belongs in the anxiety history
Add one question about sleep paralysis to the sleep history in anxious patients — it flags higher symptom burden and the explanation alone often helps.
Family history is two parents, and they are not independent
When you find psychiatric illness in one parent, ask about the other — partner similarity is substantial and cross-diagnostic, and family risk concentrates rather than dilutes.
An enzyme that goes down in early psychosis
Interesting biology, no clinical action: ACE levels are lower in early psychosis and lower again in treatment-resistant cases, but this is not a test to order.
The anxious patient who cannot sit still may not be anxious
In a restless patient on an antipsychotic, ask where the restlessness sits and whether moving relieves it, then watch them seated for a minute before calling it anxiety.
Long-acting injectables halve manic relapse in bipolar disorder
In bipolar disorder with recurrent manic or mixed relapse, a long-acting injectable is a reasonable choice — with structured extrapyramidal review through the first 90 days.
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