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Up to 45% of patients with debilitating and potentially lethal depressive illness do not achieve remission with initial drug treatment. Using combinations of antidepressants as an early option for treatment-resistant depression has become increasingly common. Before trying combination therapy, it is essential first to ensure diagnosis is correct, and then to optimise antidepressant monotherapy, using an effective dose for an adequate period. Subsequently, augmentation of antidepressants with lithium and triiodothyronine should be considered, as these strategies are strongly supported by numerous clinical trials. Electroconvulsive therapy is the most effective treatment for severe depression. There is little evidence to support use of antidepressant combinations. Risk of toxicity and drug interactions mandate that combinations be used as a last resort, and only in specialist settings.

Objective: To determine the trends in youth suicide in Victoria and Australia as a whole, and their relation to youth unemployment., Design: We used Australian Bureau of Statistics data to analyse suicide trends between 1907 and 1990 in young people aged 15-24 years and made an in-depth study of youth suicides between 1980 and 1990, for which computerised data are available., Results: There has been a steady increase in youth suicide both in Victoria and Australia as a whole since 1960 in males but not females. There were significant differences in age, sex and area of residence in both the rate and the method of suicide. The increase in youth suicide was not associated with the rise in unemployment. Male (not female) suicide rates were higher in non-metropolitan areas and areas of high youth unemployment. The reasons for the increase in youth suicide remain obscure., Conclusions: There is a need for a prospective in-depth study to determine factors in the aetiology of youth suicide, with particular reference to possible areas for prevention.

A self-reported survey of 878 medical students in Monash University (excluding students sponsored by overseas governments) showed that 21.4% had a fluent command of a language other than English, and 62.2% had a basic usable knowledge of another language. Only 28.5% of the students reported having neither a fluent nor a usable command of another language. These results suggest a rich resource of skills in community languages other than English among people who will be entering the medical workforce. Positive recommendations are made to develop and use this resource effectively.

Anxiolytic drugs are adjuncts to non-pharmacological treatments for anxiety. Alcohol and tobacco remain the major psychoactive agents that are used in our community. Benzodiazepine drugs are the agents of choice if an acute reduction in anxiety or intermittent therapy is needed and are helpful for long-term use in a few patients. For panic disorders, alprazolam is effective for short- and long-term treatment, although it needs a slow reduction in dosage and carries a risk of withdrawal reactions in about 30% of sufferers. Clonazepam also may help panic attacks and possibly other benzodiazepine agents would show similar effects at equivalent doses. Antidepressant drugs, including monoamine-oxidase inhibitor agents, although more toxic and sometimes less tolerated than is alprazolam, have antipanic effects in high doses and are of use for prolonged therapy for panic disorders. Neuroleptic agents' general usefulness as anxiolytic drugs is restricted because of their acute and long-term toxicity. There is no place for the use of antidepressant or neuroleptic drugs as treatments of first choice in uncomplicated generalized anxiety. beta-blocking agents have limited adjunctive use for performance anxiety and social phobias. Buspirone heralds a new class of anxiolytic agents. Buspirone has advantages in patients who can tolerate its slow onset of action, with reduced psychomotor effects, lower interactive effects with cortical depressant substances and a seeming lack of dependency or any withdrawal syndrome.

One hundred and ninety-one consecutive psychiatric referrals from the medical and surgical wards of a children's hospital were studied. The referral rate approximated 2% of admission rate, and patients who were referred stayed in hospital longer than three times the average stay for all inpatients. The hospital's medical units supplied 69% of referrals and the rest came from the surgical units. The male to female ratio of admissions to hospital was 3:2, but that of referrals was 1:1 (a significant difference (P less than 0.02). Main diagnostic categories for patients under one year of age were congenital and metabolic disorders (35%), and psychosocial problems which included maltreatment and children at risk (58%). The records for patients between one and 14 years of age imply that over 50% of them had family social problems or behaviour disorder. Of patients over 14 years of age, 93% had affective disorder.