Suicide among young Australians, 1964-1993: an interstate comparison of metropolitan and rural trends.

OBJECTIVES: (i) To compare suicide rates in 15-24 year old men and women; and (ii) for 15-24 year old men, to investigate differences in suicide rates between metropolitan and rural area, and changes in method-specific suicide rates and, in particular, firearm and hanging suicide rates in rural and metropolitan areas. DESIGN: Retrospective analysis of Australian Bureau of Statistics (ABS) suicide data (1964-1993). SETTING: All Australian States. SUBJECTS: Young women and men aged 15-24 years who died by suicide. RESULTS: Male youth suicide rates rose substantially over the 30 years in all Australian States, whereas female rates did not increase. Increases in suicide rates in young men in small rural towns consistently exceeded those in metropolitan areas in all Australian States. Metropolitan rates in 1964 were higher than those in small rural towns, but by 1993 the position was reversed. Medium-sized cities were the only areas where there was no consistent interstate trend. Differences were noted in suicide base rates in different States. High car exhaust suicide rates were noted in Western Australia, and high firearm suicide rates in Tasmania and Queensland. The ratio of firearm suicide rates in small rural areas to those in metropolitan areas rose in all mainland States, but the same ratio for hanging suicide rates changed little. CONCLUSIONS: All Australian States reflect national suicide trend in relation to sex and residential area. In some States, particular suicide methods predominate. A decreasing trend in overall firearm suicide rates in young men in all States from 1984 to 1993 conceals substantial increases in firearm suicide rates in small rural areas in all mainland States over the 30-year period. This, together with the marked rate ratio difference in firearm suicides between metropolitan and small rural areas, suggests that particular risk factors for suicide are operating in small rural areas. The fact that hanging rate ratios changed little suggests that more general factors in male youth suicide are also operating in all areas. A better understanding of similarities and differences in health risks faced by metropolitan and rural youth is required.

Providing dental treatment for patients with cardiovascular disease.

The appropriate management of dental patients with cardiovascular disease is contingent on appropriate assessment and evaluation. Baseline vital signs, a good medical history and medical evaluation are all essential for the safe delivery of care. All patients with cardiovascular disease can be managed using the following guidelines: 1. Properly assess the patient. This should include an assessment by the dentist and also a medical consultation if required. 2. Establish what medications the patient is taking along with the dose and timing and note any potential drug interactions and side effects. 3. Use short appointments (less than one hour), preferably in the morning. 4. Premedication should be considered to alleviate anxiety. The intraoperative use of nitrous oxide and oxygen is also a reasonable strategy for patients with cardiovascular disease, particularly those with ischemic heart disease. 5. Effective local anesthesia is important in order to avoid undue stress during the appointment as long as the guidelines for the administration of epinephrine are followed. The use of epinephrine impregnated gingival displacement cord should be strictly avoided in patients with cardiovascular disease. 6. For patients with angina pectoris, a fresh supply of nitroglycerin should be available at the time of the appointment. Prophylactic nitroglycerin has been shown to be effective in the prevention of both hypertension and angina pectoris during dental treatment. The appointment should be terminated early if the patient becomes overly anxious. In the event of cardiovascular symptoms during dental treatment, all work should be stopped. Emergency measures should be instituted if necessary. Preparations for emergencies should be undertaken by all dentists. The treatment of patients with cardiovascular disease is relatively simple if the proper steps are taken. The use of blood pressure measurements on all patients will help to screen for undiagnosed hypertension and all patients who are potentially hypertensive should be referred for medical evaluation. A preventive approach to the treatment of these patients will serve to prevent untoward outcomes and provide safe and simple delivery of dental care for cardiovascular patients.

Psychosocial management of chronic fatigue syndrome in adolescence.

The state of chronic fatigue syndrome (CFS) as abnormal illness behaviour or as biologically determined disease is undecided. The ensuing, often public, debate has confused the community and has led to sharp differences in the therapeutic approach to individual patients. These challenges are compounded when the patient is an adolescent and intergenerational issues enter the picture. Two adolescent cases with different outcomes are presented and the principles of a rehabilitation approach to treatment are outlined which attempt to avoid being drawn into unproductive debates about aetiology.

Psychopharmacology of the psychiatric disorders of childhood and adolescence.

The literature on the psychopharmacology of child and adolescent psychiatric disorders is reviewed. The scanty epidemiological data suggest that psychotherapeutic drugs are utilized more widely than research findings would warrant, especially in preschool-age children. With the exception of hyperactivity, the disorders of childhood and adolescence for which the use of psychopharmacological agents is well-established are rare. This highlights the need for careful prescribing, in which the child's rights, problems with compliance and developmental and behavioural adverse effects are important considerations.

Neuropsychological sequelae of central nervous system prophylaxis in survivors of childhood acute lymphoblastic leukemia.

We assessed neuropsychologically 106 children with acute lymphoblastic leukemia (ALL) who had all received cranial irradiation for the prevention of central nervous system (CNS) leukemia 1-13 years previously. Children were assessed for adverse late effects of their therapy, using age-appropriate Wechsler measures of overall intellectual ability and supplementary tests. Forty-five siblings near in age to the patients were tested as controls. The patients who had had the most intensive central nervous system (CNS) prophylaxis were found to have a WISC-R Full Scale IQ 17 points lower than the sibling control group. Performance IQ was more affected than verbal IQ. The patients were more easily distracted and less able to concentrate. The severity of the aftereffects was related to younger age at the time of CNS prophylaxis and to a higher dose of cranial irradiation but not to time since CNS prophylaxis. CNS prophylaxis using a combination of cranial irradiation and intrathecal methotrexate has lowered the incidence of CNS relapse in childhood ALL but is associated with considerable long-term morbidity in survivors.

The psychosocial consequences of childhood infection with human immunodeficiency virus.

This article reviews the available medical literature on the psychosocial and neuropsychiatric implications of childhood infection by the human immunodeficiency virus. This information is supplemented by discussion of cases from our clinical experience. It is clear that different psychosocial issues are confronted by children of different ages (infants, young children or adolescents) and their families. The differences are due partly to the social correlates of different modes of transmission of the acquired immunodeficiency syndrome (AIDS), the psychosocial risk factors that are associated with certain family life-styles, whether other family members are infected, and the developmental stage and awareness of the child. Psychiatric assessments of these children and their families are recommended as a routine as they will identify potential ethical dilemmas, and will allow for the detection and management of the psychosocial and neuropsychiatric consequences of AIDS.

Cholinesterases in primary affective disorders.

Cholinesterase activities were measured in plasma (ChE) and in intact erythrocytes (AChE) in patients suffering from manic-depressive illness, their first degree relatives who were well, and unrelated normal volunteers. All the subjects were in a normal mood state at the time of testing. Plasma cholinesterase activity was found to be significantly lower than normal in bipolar (BP), unipolar (UP), other affective disorder (OA) and well subjects belonging to manic-depressive families. Intact erythrocyte cholinesterase (true cholinesterase) activity was also found to be significantly lower than normal in all the above mentioned patients and their relatives. Half of the BP subjects were on lithium treatment and their cholinesterase activities were similar to those patients not on lithium treatment. The data suggest a significant role of cholinergic mechanisms in the etiology of manic-depressive illness.

Erythrocyte membrane sodium-potassium and magnesium ATPase in primary affective disorder.

Erythrocyte membrane Mg2+ ATPase and Na+-K+ ATPase were measured in patients with affective disorder, their well relatives, and normal controls during euthymic moods. On the average, the Mg2+ ATPase activity was high in subjects belonging to affective disorder families. However, the difference between normal and affective disordered individuals was not statistically significant. Only the well individuals from affective disorder pedigrees as a group had significantly higher than normal Mg2+ ATPase activity (p less than 0.05). The Na+-K+ ATPase activity was similar for all the groups, including normal, bipolar manic-depressive (with or without lithium), unipolar depressive, and well individuals. Lithium treatment did not seem to have any effect on Mg2+ ATPase. Even though the values of Na+-K+ ATPase in the lithium-treated group were high, it is not certain that this was due to lithium per se.

Depression in pre-pubertal, children.

Pre-pubertal depression has attracted a great deal of interest recently. The literature is reviewed with a particular focus on the better designed studies. While isolated symptoms of depression are relatively common, definite depressive disorder is much less prevalent. The majority of studies have focused on the most severely depressed subgroup of children. While effective treatment regimes are being developed for this small group of children, there is no evidence that such regimes should be applied to every depressed child. Major gaps exist in our knowledge of the range of depressive symptomatology in pre-pubertal children, the relationship of developmental factors to depressive symptoms, the reliability and validity of existing diagnostic tools, and the effectiveness of traditional child psychiatric treatment modalities for depression.

Lithium and carbamazepine interaction: possible neurotoxicity.

A case is described of a 22-year-old woman with bipolar affective disorder who developed severe neurotoxic symptoms when treated with a combined regimen of lithium carbonate and carbamazepine in therapeutic doses. An open A-B-C-B trial of the two medications separately and concurrently implicated a synergistic interaction between the two.

The use of the MMPI for the differentiation of suicidal and non-suicidal depressions.

The MMPI profiles of forty suicidal and forty non-suicidal male and female depressed patients, matched for age, were compared. Significant differences between MMPI scale T scores which showed some sex specificity were found between the suicidal and non-suicidal depressives. These results replicate previous findings. However neither individual scale T scores, derived discriminant functions, nor actuarial or cluster analysis-derived MMPI profiles could completely discriminate between suicidal and non-suicidal depressed inpatients of either sex. The relevance and implications of these findings to the ascertainment of suicidal risk are discussed.