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Ruth Armstrong
Med J Aust 2007; 186 (6): 274.
Published online: 19 March 2007

A first episode and delusional beliefs predict homicide during psychosis

People who commit homicide during a psychotic illness are more likely than not to be having their first psychotic episode and often have delusional beliefs that their victim is a threat. So say Nielssen et al, after reviewing the cases of 88 people charged with 93 homicides in NSW between 1993 and 2002 (→ Homicide during psychotic illness in New South Wales between 1993 and 2002). Selection was on the basis that the offenders were believed by a psychiatrist at the time of Supreme Court proceedings to have the defence of mental illness available to them. Fifty-four of the subjects were having their first psychotic episode at the time of the murder, and 61 had been mentally ill for less than a year. Over half of the subjects had auditory hallucinations, and a similar proportion had delusional beliefs that they were in danger from the victim. Forty of the subjects had had contact with mental health services in the 2 weeks before the murder, suggesting an avenue for early identification of risky symptoms.

Focus on colorectal cancer

The first phase of the National Bowel Cancer Screening Program has begun and, while it is universally welcomed, the program has already raised some challenging issues for delivering timely and equitable diagnosis and treatment, including the capacity of the public health system to deal with the extra load.

To provide some background information, Lynch et al interviewed nearly 2000 patients diagnosed with bowel cancer in Queensland in 2003 and 2004, before the program’s introduction (→ Modes of presentation and pathways to diagnosis of colorectal cancer in Queensland). Only 2% were diagnosed after a screening faecal occult blood test; 90% were symptomatic at diagnosis. Patients with abdominal pain presented to a doctor within the shortest time after the onset of symptoms, and were the most rapidly diagnosed. Patients without private health insurance were relatively delayed in both their initial presentation and the final diagnosis.

Even more suggestive of a public/private divide are the findings of Morris et al (→ Comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals). Correlating the pathology reports of all patients diagnosed with colorectal cancer in Western Australia between 1993 and 2003 with death records, they found that, independently of more predictable risk factors such as age, sex and cancer stage, patients treated in public hospitals had significantly poorer 5-year survival rates than those treated in the private system (48.6% v 59.4%).

Foreshadowing the problem of long waiting times for colonoscopies in the public system once the colorectal screening program is fully operational, Viiala et al analysed data from all colonoscopies performed over 12 months at a tertiary public hospital in WA (→ Waiting times for colonoscopy and colorectal cancer diagnosis). All Category 1 patients (those nominated by the referring doctor as needing a colonoscopy within 30 days) received timely colonoscopy, but the median waiting times for those in Categories 2 and 3 (deemed able to wait 90 or 180 days) exceeded these recommendations. Despite this, Category 2 and 3 patients had low numbers of cancers detected (2.4% and 0.6%, respectively) and waiting time was not associated with an increase in the proportion of late-stage tumours diagnosed.

Once it has been diagnosed, how well are we treating colorectal cancer? Young et al prospectively audited the care of all new patients reported to the NSW Central Cancer Registry over 12 months in 2000-2001 (→ Concordance with national guidelines for colorectal cancer care in New South Wales: a population-based patterns of care study). On average, 78% of relevant guidelines were followed for individual patients, but there were important differences according to age, surgeon and treatment location.

Overall, says Macrae, there will be ways of stretching our finite resources to meet the increased demands of the new program, which offers our best chance of having a significant impact on our second biggest cancer killer (→ Providing colonoscopy services for the National Bowel Cancer Screening Program).

School-based mental health programs are worthwhile

As the federal government continues its plan to roll out funding for school-based mental health programs, such as “MindMatters Plus”, a review of the evidence for such interventions in Australia reveals that, according to the limited information available, the results are generally positive. Neil and Christensen conducted a systematic review of studies evaluating school-based interventions for anxiety and depression (→ Australian school-based prevention and early intervention programs for anxiety and depression: a systematic review). They identified 28 trials pertaining to 13 programs. Although study quality was not ideal, and meta-analysis was not possible, most of the studies indicated short-term benefits. The authors called for further (and better) studies.

Another time . . . another place

Bubo is an apostem breeding within the anus in the rectum with great hardness but little aching. This I say, before it ulcerates, is nothing else than a hidden cancer . . . it is called bubo, for as a bubo, ie, an owl, is always dwelling in hiding . . . after passage of time it ulcerates and, eroding the anus, comes out.

John of Arderne, 1306-1390?

 

  • Ruth Armstrong


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