Effectiveness and cost-effectiveness of cognitive behavior therapy-enhanced compared with treatment-as-usual for anorexia nervosa in an inpatient and outpatient routine setting: a consecutive cohort study

Abstract Background For anorexia nervosa, firm evidence of the superiority of specialized psychological treatments is limited and economic evaluations of such treatments in real world settings are scarce. This consecutive cohort study examined differential (cost-)effectiveness for adult inpatients and outpatients with anorexia nervosa, after implementing cognitive behavioral therapy-enhanced (CBT-E) throughout a routine setting. Methods Differences in remission, weight regain and direct eating disorder treatment costs were examined between one cohort (N = 75) receiving treatment-as-usual (TAU) between 2012–2014, and the other (N = 88) CBT-E between 2015–2017. The economic evaluation was performed from a health care perspective with a one-year time horizon, using EDE global score < 2.77, the absence of eating disorder behaviors combined with a BMI ≥ 18.5, as effect measure. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were displayed to assess the probability that CBT-E is cost effective compared to TAU. Results Using direct eating disorder treatment costs in the cost-effectiveness analysis, the cost-effectiveness plane of the base case scenario for all patients indicated a 84% likelihood of CBT-E generating better health gain at additional costs. The median ICER is €51,081, indicating a probable preference for CBT-E (> 50% probability of cost-effectiveness) assuming a WTP of €51,081 or more for each additional remission, On remission, no difference was found with 9.3% remission during TAU and 14.6% during CBT-E (p = .304). Weight regain was higher during CBT-E (EMD = 1.33 kg/m2, SE = .29, 95% CI [0.76–1.9], p < .001). Conclusions In this mixed inpatient and outpatient cohort study, findings indicate a probability of CBT-Ebeing more effective at higher costs. These findings may contribute to the knowledge of effectiveness and cost-effectiveness of specialized psychological treatments. Plain English Summary In this study, the effectiveness and treatment costs of a specialized psychological treatment for adult clients with anorexia nervosa were compared with a regular, non-specialist treatment. One group of inpatients and outpatients did receive non-specialist treatment, the next group of inpatients and outpatients received CBT-E, a specialized treatment, later on. CBT-E is recommended for clients with bulimia and with binge eating disorder, for clients with anorexia nervosa it is less clear which specialized psychological treatment should be recommended. Results indicate that at end-of-treatment, CBT-E was not superior on remission. When looking at weight regain, CBT-E seemed superior than the treatment offered earlier. Economic evaluation suggests that CBT-E generates better health gain, but at additional costs. This study contributes to the knowledge on the effectiveness and treatment costs of psychological treatments, as they are offered in routine practice, to adults with anorexia nervosa.

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Children in Need—Diagnostics, Epidemiology, Treatment and Outcome of Early Onset Anorexia Nervosa

Nutrients ◽

10.3390/nu11081932 ◽

2019 ◽

Vol 11 (8) ◽

pp. 1932 ◽

Cited By ~ 6

Author(s):

Herpertz-Dahlmann ◽

Dahmen

Keyword(s):

Anorexia Nervosa ◽

Eating Disorder ◽

Psychological Assessment ◽

Psychiatric Comorbidity ◽

State Of The Art ◽

Psychological Treatment ◽

Young Patients ◽

Treatment Strategies ◽

Specific Treatment ◽

Restrictive Eating

Knowledge of anorexia nervosa (AN) in childhood is scarce. This review gives a state-of-the-art overview on the definition, classification, epidemiology and etiology of this serious disorder. The typical features of childhood AN in comparison to adolescent AN and avoidant restrictive eating disorder (ARFID) are described. Other important issues discussed in this article are somatic and psychiatric comorbidity, differential diagnoses and medical and psychological assessment of young patients with AN. Special problems in the medical and psychological treatment of AN in children are listed, although very few studies have investigated age-specific treatment strategies. The physical and mental outcomes of childhood AN appear to be worse than those of adolescent AN, although the causes for these outcomes are unclear. There is an urgent need for ongoing intensive research to reduce the consequences of this debilitating disorder of childhood and to help patients recover.

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A systematic review of cost-effectiveness studies of prevention and treatment for eating disorders

Australian & New Zealand Journal of Psychiatry ◽

10.1177/0004867417739690 ◽

2017 ◽

Vol 52 (4) ◽

pp. 328-338 ◽

Cited By ~ 11

Author(s):

Long Khanh-Dao Le ◽

Phillipa Hay ◽

Cathrine Mihalopoulos

Keyword(s):

Systematic Review ◽

Eating Disorders ◽

Anorexia Nervosa ◽

Eating Disorder ◽

Cost Effectiveness ◽

Bulimia Nervosa ◽

Binge Eating Disorder ◽

Cost Effective ◽

Prevention And Treatment ◽

Effectiveness Studies

Background: Eating disorders are serious mental disorders and are associated with substantial economic and social burden. The aim of this study is to undertake a systematic review of the cost-effectiveness studies of both preventive and treatment interventions for eating disorder. Method: Electronic databases (including the Cochrane Controlled Trial Register, MEDLINE, PsycINFO, Academic Search Complete, Global Health, CINAHL complete, Health Business Elite, Econlit, Health Policy Reference Center and ERIC) were searched for published cost-effectiveness studies of eating disorder prevention and treatment including papers published up to January 2017. The quality of studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results: In all, 13 studies met the review inclusion criteria as full cost-effectiveness studies and 8 were published since 2011. The studies included three modelled and one trial-based study focused on prevention, two trial-based and one modelled study for anorexia nervosa treatment and three trial-based studies for bulimia nervosa treatment. The remaining studies targeted binge-eating disorder or non-specific eating disorder treatment. The average percent of CHEERS checklist items reported was 71% (standard deviation 21%). Eating disorder interventions were mainly cost-saving or more effective and more costly compared to comparators; however, some results did not reach statistical significance. In the two studies that achieved 100% CHEERS checklist, one study reported that a cognitive dissonance intervention might be cost-effective for prevention of anorexia nervosa and bulimia nervosa with a 90% participation rate and the second study supported lisdexamfetamine to be cost-effective in the treatment of binge-eating disorder. Insufficient evidence for long-term cost-effectiveness (e.g. over 2 years) was found. Conclusion: Cost-effectiveness studies in eating disorder appear to be increasing in number over the last 6 years. Findings were inconsistent and no firm conclusion can be drawn with regard to comparative value-for-money conclusions. However, some promising interventions were identified. Further research with improved methodology is required.

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Excess mortality associated with eating disorders: population-based cohort study

The British Journal of Psychiatry ◽

10.1192/bjp.2020.197 ◽

2020 ◽

pp. 1-7

Author(s):

Tomisin Iwajomo ◽

Susan J. Bondy ◽

Claire de Oliveira ◽

Patricia Colton ◽

Kathryn Trottier ◽

...

Keyword(s):

Eating Disorders ◽

Anorexia Nervosa ◽

Cohort Study ◽

Eating Disorder ◽

Mortality Risk ◽

Excess Mortality ◽

Population Based ◽

Cox Proportional Hazards ◽

Years Of Life Lost ◽

All Cause Mortality

Background Individuals with eating disorders have a high mortality risk. Few population-based studies have estimated this risk in eating disorders other than anorexia nervosa. Aims To investigate all-cause mortality in a population-based cohort of individuals who received hospital-based care for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in Ontario, Canada. Method We conducted a retrospective cohort study of 19 041 individuals with an eating disorder from 1 January 1990 to 31 December 2013 using administrative healthcare data. The outcome of interest was death. Excess mortality was assessed using standardised mortality ratios (SMRs) and potential years of life lost (PYLL). Cox proportional hazards regression models were used to examine sociodemographic and medical comorbidities associated with greater mortality risk. Results The cohort had 17 108 females (89.9%) and 1933 males (10.1%). The all-cause mortality for the entire cohort was five times higher than expected compared with the Ontario population (SMR = 5.06; 95% CI 4.82–5.30). SMRs were higher for males (SMR = 7.24; 95% CI 6.58–7.96) relative to females (SMR = 4.59; 95% CI 4.34–4.85) overall, and in all age groups in the cohort. For both genders, the cohort PYLL was more than six times higher than the expected PYLL in the Ontario population. Conclusions Patients with eating disorders diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population. There is an urgent need to understand the mortality risk factors to improve health outcomes among individuals with eating disorders.

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A randomised clinical trial to evaluate the acceptability and efficacy of an early phase, online, guided augmentation of outpatient care for adults with anorexia nervosa

Psychological Medicine ◽

10.1017/s0033291719002824 ◽

2019 ◽

Vol 50 (15) ◽

pp. 2610-2621 ◽

Cited By ~ 7

Author(s):

Valentina Cardi ◽

Gaia Albano ◽

Suman Ambwani ◽

Li Cao ◽

Ross D. Crosby ◽

...

Keyword(s):

Anorexia Nervosa ◽

Eating Disorder ◽

Social Adjustment ◽

Outpatient Service ◽

Group Differences ◽

Control Group ◽

Outpatient Services ◽

Motivation To Change ◽

Significant Group ◽

Treatment As Usual

AbstractBackgroundOutpatient interventions for adult anorexia nervosa typically have a modest impact on weight and eating disorder symptomatology. This study examined whether adding a brief online intervention focused on enhancing motivation to change and the development of a recovery identity (RecoveryMANTRA) would improve outcomes in adults with anorexia nervosa.MethodsParticipants with anorexia nervosa (n = 187) were recruited from 22 eating disorder outpatient services throughout the UK. They were randomised to receiving RecoveryMANTRA in addition to treatment as usual (TAU) (n = 99; experimental group) or TAU only (n = 88; control group). Outcomes were measured at end-of-intervention (6 weeks), 6 and 12 months.ResultsAdherence rates to RecoveryMANTRA were 83% for the online guidance sessions and 77% for the use of self-help materials (workbook and/or short video clips). Group differences in body mass index at 6 weeks (primary outcome) were not significant. Group differences in eating disorder symptoms, psychological wellbeing and work and social adjustment (at 6 weeks and at follow-up) were not significant, except for a trend-level greater reduction in anxiety at 6 weeks in the RecoveryMANTRA group (p = 0.06). However, the RecoveryMANTRA group had significantly higher levels of confidence in own ability to change (p = 0.02) and alliance with the therapist at the outpatient service (p = 0.005) compared to the control group at 6 weeks.ConclusionsAugmenting outpatient treatment for adult anorexia nervosa with a focus on recovery and motivation produced short-term reductions in anxiety and increased confidence to change and therapeutic alliance.

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Can temporary cessation of CBT really be therapeutic? A case study

The Cognitive Behaviour Therapist ◽

10.1017/s1754470x17000101 ◽

2017 ◽

Vol 10 ◽

Cited By ~ 1

Author(s):

Paul E. Jenkins

Keyword(s):

Eating Disorders ◽

Anorexia Nervosa ◽

Eating Disorder ◽

Psychiatric Illness ◽

Psychological Treatment ◽

Evidence Base ◽

Psychological Theories ◽

Symptom Measures

AbstractAnorexia nervosa (AN) is a notoriously costly and challenging psychiatric illness to treat. Despite an accumulating evidence base, psychological treatment fails to achieve symptom abstinence in many patients with eating disorders, a shortcoming that is likely to be further pronounced in AN. The case study reported here describes how a mutually agreed break in a course of psychotherapy following an initial lack of progress might have influenced outcome for a client with a severe eating disorder. The patient received 26 sessions of CBT and results, consistent with those of larger studies, showed significant improvement on primary symptom measures. These results are discussed in the context of relevant psychological theories and an exploration of the client's motivation. Consideration is also given to other factors that may have influenced outcome.

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A randomised controlled trial of three psychological treatments for anorexia nervosa

Psychological Medicine ◽

10.1017/s0033291717001349 ◽

2017 ◽

Vol 47 (16) ◽

pp. 2823-2833 ◽

Cited By ~ 46

Author(s):

S. Byrne ◽

T. Wade ◽

P. Hay ◽

S. Touyz ◽

C. G. Fairburn ◽

...

Keyword(s):

Anorexia Nervosa ◽

Eating Disorder ◽

Randomised Controlled Trial ◽

Controlled Trial ◽

Healthy Weight ◽

Psychological Treatments ◽

Psychosocial Impairment ◽

Eating Disorder Psychopathology ◽

Randomised Controlled

BackgroundThere is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy.MethodA multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25–40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment.ResultsTreatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up.ConclusionThe findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/

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Does a Skills Intervention for Parents Have a Positive Impact on Adolescents‘ Anorexia Nervosa Outcome? Answers from a Quasi-Randomised Feasibility Trial of SUCCEAT

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18094656 ◽

2021 ◽

Vol 18 (9) ◽

pp. 4656

Author(s):

Julia Philipp ◽

Claudia Franta ◽

Michael Zeiler ◽

Stefanie Truttmann ◽

Tanja Wittek ◽

...

Keyword(s):

Eating Disorders ◽

Anorexia Nervosa ◽

Eating Disorder ◽

Stages Of Change ◽

Positive Impact ◽

Skills Training ◽

Self Report ◽

Feasibility Trial ◽

Motivation To Change ◽

Treatment As Usual

Skills trainings for caregivers of patients with anorexia nervosa (AN) have been proven to be effective in improving caregiver skills and reducing caregivers’ psychopathology. The effects on patients, especially adolescents, are largely unknown. The aim of this study was to evaluate the effectiveness of a caregivers’ skills training program (Supporting Carers of Children and Adoles-cents with Eating Disorders in Austria, SUCCEAT, workshop or online version) on adolescents with AN delivered as workshops (WS) or online (ONL). Outcomes are Body-Mass-Index (BMI) percen-tile, eating psychopathology (Eating Disorder Examination, EDE), attitudinal and behavioural dimensions of eating disorders (Eating Disorder Inventory-2), motivation to change (AN Stages of Change Questionnaire), emotional and behavioural problems (Youth Self-Report) and quality of life (KINDL). All outcome variables significantly improved across both SUCCEAT groups (WS and ONL) and were sustained at 12-month follow-up. The online and workshop delivery of SUCCEAT were equally effective. Most effect sizes were in the medium-to-high range. Full or partial remission was observed in 72% (WS) and 87% (ONL) of patients. Caregiver skills trainings, either delivered as workshops or online modules, are highly recommended to complement treatment as usual.

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Comparing the clinical effectiveness, acceptability and cost-effectiveness of a ‘stepping into day treatment’ approach versus inpatient treatment as usual for anorexia nervosa

http://isrctn.com/ ◽

10.1186/isrctn10166784 ◽

2020 ◽

Author(s):

Bethan Dalton ◽

Ulrike Schmidt ◽

Madeleine Irish

Keyword(s):

Anorexia Nervosa ◽

Cost Effectiveness ◽

Inpatient Treatment ◽

Treatment Approach ◽

Day Treatment ◽

Clinical Effectiveness ◽

Treatment As Usual

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Risk, demand and capacity in adult specialist eating disorder services in the South of England – before and since Covid-19.

10.31234/osf.io/z76qj ◽

2020 ◽

Author(s):

Agnes Ayton ◽

David.Viljoen ◽

Sharon Ryan ◽

Ali Ibrahim ◽

Duncan Ford

Keyword(s):

Eating Disorders ◽

Anorexia Nervosa ◽

Cohort Study ◽

Eating Disorder ◽

Inpatient Treatment ◽

Waiting Times ◽

Emergency Admissions ◽

Acute Hospitals ◽

The Impact ◽

Demand And Capacity

Aims and Method: This is a longitudinal cohort study describing the demand and capacity for specialist inpatient treatment of patients with severe eating disorders covering a population of 3.5 million. We compared and the impact of the pandemic and the outcomes between different inpatient services.Results: Between July 2018 and 1 November 2020 there were 293 referrals. 97% were female. 93% had a diagnosis of anorexia nervosa. 19.5% of referrals were below BMI 13, and a further 40% had extreme malnutrition. Referrals and emergency admissions to acute hospitals have increased by 20% since the pandemic. Waiting times have doubled from 33 to 67 days.A novel integrated CBTE model has shown better outcomes and shorter length of stay compared to traditional eclectic treatment.Clinical Implications.The pandemic has worsened the mismatch of demand and capacity, causing increasing serious risks and this needs to be addressed as a matter of urgency.

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