A diffuse reduction of 5-HTT binding in the PFC of individuals with major depression may reflect a widespread impairment of serotonergic function consistent with the range of psychopathologic features in major depression. The localized reduction in 5-HTT binding in the ventral PFC of suicides may reflect reduced serotonin input to that brain region, underlying the predisposition to act on suicidal thoughts. The 5-HTTLPR genotype was not related to the level of 5-HTT binding and does not explain why 5-HTT binding is lower in major depression or suicide. Arch Gen Psychiatry. 2000;57:729-738

Comorbidity of borderline personality disorder with major depressive episode increases the number and seriousness of suicide attempts. Hopelessness and impulsive aggression independently increase the risk of suicidal behavior in patients with borderline personality disorder and in patients with major depressive episode.

Psychological autopsies are an important research tool in establishing risk factors associated with suicide. We report the results of a validity study comparing psychological autopsy-generated DSM-III-R diagnoses in suicides and non-suicides with chart diagnoses generated by clinicians who had treated the subjects prior to death. The Structured Clinical Interview for DSM-III-R Disorders (SCID-P) and the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) were used to make independent post-mortem diagnoses. Comparison of research diagnoses with clinician ante-mortem diagnoses generated kappa coefficients of 0.85 for Axis I diagnoses and 0.65 for Axis II conditions. These kappa coefficients compare favourably with direct patient interview reliability studies. This provides evidence for the validity of the psychological autopsy as a method of determining psychiatric diagnosis.

Objective To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence based process that enhances treatment effectiveness in comorbid patients. Method Articles were extracted from Pubmed using the search terms “dual diagnosis,” “comorbidity” and “co-occurring” and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity. Results Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second-generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions. Conclusions Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.

The relationship of self-mutilation to suicidal behavior was studied in 108 borderline inpatients (defined by the Diagnostic Interview for Borderline Patients). Patients with histories of selfmutilation were compared to those with no self-mutilation on diagnostic comorbidity, symptom patterns, prior suicidal be haviors, and attempt characteristics, including number of at tempts, seriousness of intent, and medical lethality.Self-mutilation was found in 63% of patients, suicidal attempts in 75.7%. Patients with self-mutilation were significantly younger and more symptomatic than controls, and had more serious suicidal ideation and recent suicide attempts. On the DIB they had significantly more manipulative suicide threat or effort, depersonalization and drug-free hallucinations or delu sions. They tended toward more depression and schizotypal symptoms but less anger and assaultiveness compared to nonmutilating patients. Histories of manipulative suicide attempts were characteristic of self mutilating patients; however, self mutilation was not associated with increased seriousness of in tent or lethality of suicide attempts.Self-mutilation is a common clinical phenomenon, with a reported inci dence of 3.4-7.7% among general psychiatric admissions (Ballinger, 1971;Pao, 1969). Etiology is often described as "multifactorial," with psychologi cal, behavioral, and biologic determinants, though generally related to the disorder in which the symptom arises. The most bizarre and destructive acts arise from the thought disorder of the psychotic patient, including autocastration, enucleation, and amputations. The least severe acts, de scribed as syndromes of "wrist slashing," "delicate cutting," or "parasuicide," are generally attributed to personality-disordered patients, especially those with borderline personality disorder (BPD) (Grunebaum &