From Cognitive-Behavior Therapy to Psychotherapy Integration by Marvin R. Goldfried. New York: Springer Publishing Co., 1995. Reviewed by Jeremy D. Safran,New School for Social Research

Psychotherapy research in managed health-care settings is discussed. Investigations of the relationships between amount of therapy and subsequent outcome adjusted by such patient characteristics as diagnosis, indicators of illness chronicity and severity, and social support markers are well suited to these settings. In addition, research on the effectiveness of treatment guidelines, treatment manuals, alternative therapies, and alternatives to therapy, is likely to be conducted in these companies resulting in potentially important applied results. Finally, investigations dealing with the selection and training of therapists and care managers would seem to be particularly relevant in managed care. Problems associated with the conduct of research in these settings are presented including lack of experimental control, demand characteristics, and the effects of business decisions on the collection and dissemination of data. On balance we conclude that managed healthcare organizations will be an important future source of naturalistic studies on the effects of psychotherapy.In dieser Arbeit wird die Psychotherapieforschung im Kontext von «Managed Care» im Gesundheitswesen diskutiert. Untersuchungen zur Beziehung zwischen dem therapeutischen Aufwand und dem Therapieergebnis, relativiert durch Patientenmerkmale wie Diagnosen, Hinweise auf die Chronizität und Schwere der Erkrankung sowie die soziale Unterstüzung, sind für diesen Kontext sehr gut geeignet. Dazu kommt, dass Effektivitätsforschung bezogen auf Behandlungsrichtlinien, Manuale, alternative Behandlungen bzw. Alternativen zur Behandlung durch die entsprechenden Gesellschaften mit grosser Wahrscheinlichkeit künftig durchgeführt werden und möglicherweise Ergebnisse erbringen, die im Hinblick auf die praktische Anwendung wichtig sind. Als weiteres Feld dürften Unterscuhungen, die sich auf die Auswahl und die Weiterbildung von Therapeuten und Managern beziehen, im Zusammenhang mit «Managed Care» besonders relevant sein. Einer Darstellung dieser Möglichkeiten werden Probleme gegenübergestellt, die mit der Durchführung von Forschung in diesem Kontext verbunden sind. Dazu gehört das häufige Fehlen experimenteller Kontrollgruppen, Anforderungscharakteristika und die Auswirkungen von wirtschaflichen Entscheidungen auf das Sammeln und die Analyse von Daten. Zusammengefasst kommen wir zu dem Schluss, dass Organisatioen, die für «Managed Care» im Gesundheitswesen zuständig sind, in Zukunft eine wichtige Quelle für naturalistische Studien zum Effekt von Psychotherapie sein werden.La recherche en psychothrapie dans le contexte de «managed health care» est discutée. Des investigations sur les relations entre la quantité de thérapie et le résultat, modelées par les caractéristiques du patient telles que le diagnostic, les indications à la chronicité et sévérité de la maladie ainsi que les marqueurs de support social, sont bien appropriés à ce cadre. De plus, des recherches sur l'efficacité des directives de traitement, des thérapies alternatives et des alternatives à la thérapie, sont probablement conduites dans ces compagnies, ce qui améne à des résultats appliqués potentiellement importants. Enfin, des investigations portant sur la sélection et l'entraînement des thérapeutes et des managers des prises en charge semblent être particuliérement mises en évidence dans le «managed care», Les problémes associés à la conduite des recherches dans ces situations sont présentés incluant le manque de groupes de contrôle, les charatéristiques de la demande et les effets de décisions commerciales dans le recueil et la dissémination des données. De façon générale, nous conclurons que les organisations de type «managed care» seront une future source importante d'études naturalistes sur les effets de la psychothérapie.     

Emmetropisation in normal and strabismic children and the associated changes of anisometropia

The purpose of this study was to measure whether emmetropisation failed in children who had strabismus irrespective of their refraction in infancy, and to record simultaneous changes in anisometropia. We also report how often hypermetropia increased before these children presented with esotropia. A total of 2920 infants had a cycloplegic retinoscopy at age 5-7 months and again at 42 months or when defective vision was identified. Changes of refraction in 210 children with strabismus are compared with the remaining 2710 who did not. When the spherical equivalent of the fixing eyes was > +2.75 D in infancy, hypermetropia decreased less in both eyes of those who had microtropia (p <. 001) and heterotropia (p <. 001) than in normal children. When it was < +2.75 D, the spherical and/or cylindrical refraction more often remained outside the ‘normal’ range in both eyes of those who had microtropia and heterotropia (p <. 05). Emmetropisation was deficient in both eyes of at least 80% of these strabismic children irrespective of their refraction in infancy. Furthermore, in the strabismic children, the mean change of refraction was less (p <. 05) in their fellow eyes than in their fixing eyes, the difference between the two eyes being on average three times greater than that in those who had normal vision. Thus, anisometropia increased in 53% of those who had strabismus but remained within normal limits (< ca. 0.75 D spherical equivalent) in 94 % of those who did not.‘Abormal’ anisometropia in infancy did not, per se, permanently affect vision because 72% of all those who had it did not have strabismus. Finally, the spherical hypermetropia of fixing eyes increased in only 35% of the children with esotropia – similar to the incidence in those who had a microtropia (p =. 36). This does not obviously support the concept that increasing hypermetropia causes accommodation to increase before convergence.     

Giant basal cell carcinoma with metastases and myelophthisic anemia

We report a 59-year-old, dark-complexioned black man with a giant basal cell carcinoma infiltrating virtually the entire scalp. Widespread metastatic bone marrow involvement produced a myelophthisic anemia. Basal cell carcinoma is rare in blacks, is rarely this large, and very rarely produces myelophthisic anemia from bone marrow metastases.     

Androgenic anabolic steroid use in matric pupils. A survey of prevalence of use in the western Cape.

A survey was undertaken to determine the prevalence of use of androgenic anabolic steroids (AAS) by matric pupils in the western Cape. A cluster sample, stratified by language and a subjective assessment of sporting status, of 13 schools in the area was selected, and 1,361 pupils completed a questionnaire containing questions about sports participation and the use of AAS. The prevalence of use of AAS in the sample was 5.9/1,000 and prevalences in subgroups were 11.7/1,000 for males, 12.5/1,000 for male sports participants and 25.4/1,000 for Afrikaans-speaking male sports participants. A significant amount of under-reporting (AAS users denying their status as such) occurred. General knowledge about AAS was poor, particularly among females and non-sports participants. AAS users experienced more pressure to perform well at sport than did non-users; the drugs were obtained mostly from peers and no user indicated that they were legally obtained. Because there is much evidence regarding the detrimental effects of AAS on health, it is clear that a strategy must be adopted to decrease the prevalence of their use in the schoolgoing population.