Cost-effectiveness of internet-based cognitive-behavioral treatment for bulimia nervosa: Results of a randomized controlled trial

Hunna J. Watson, Nicole McLagan, Stephanie C. Zerwas, Ross D. Crosby, Michele D. Levine, Cristin D. Runfola, Christine M. Peat, Markus Moessner, Benjamin Zimmer, Sara M. Hofmeier, Robert M. Hamer, Marsha D. Marcus, Cynthia M. Bulik, Scott J. Crow

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Objective: To evaluate the cost-effectiveness of Internet-based cognitive-behavioral therapy for bulimia nervosa (CBT-BN) compared to face-to-face delivery of CBT-BN. Methods: This study is a planned secondary analysis of data from a randomized clinical trial. Participants were 179 adults (98% female, mean age = 28 years) meeting DSM-IV criteria for bulimia nervosa who were randomized to group face-to-face or group Internet-based CBTBN for 16 sessions during 20 weeks. The cost-effectiveness analysis was conducted from a third-party payor perspective, and a partial societal perspective analysis was conducted to investigate cost-utility (ie, cost per gain in quality-adjusted life-years) and patient outof-pocket travel-related costs. Net health care costs were calculated from protocol and nonprotocol health care services using third-party payor cost estimates. The primary outcome measure in the clinical trial was abstinence from binge eating and purging, and the trial start and end dates were 2008 and 2016. Results: The mean cost per abstinent patient at posttreatment was $7,757 (95% confidence limit [CL], $4,515, $13,361) for face-to-face and $11,870 (95% CL, $6,486, $22,188) for Internet-based CBT-BN, and at 1-year follow-up was $16,777 (95% CL, $10,298, $27,042) for face-to-face and $14,561 (95% CL, $10,165, $21,028) for Internet-based CBT-BN. There were no statistically significant differences between treatment arms in cost-effectiveness or costutility at posttreatment or 1-year follow-up. Out-of-pocket patient costs were significantly higher for face-to-face (mean [95% CL] = $178 [$127, $140]) than Internet-based ($50 [$50, $50]) therapy. Conclusions: Third-party payor cost-effectiveness of Internet-based CBT-BN is comparable with that of an accepted standard. Internet-based dissemination of CBT-BN may be a viable alternative for patients geographically distant from specialist eating disorder services who have an unmet need for treatment.

Original languageEnglish (US)
Article number16m11314
JournalJournal of Clinical Psychiatry
Issue number1
StatePublished - Jan 1 2018

Bibliographical note

Funding Information:
Consulting.DrWatsonis supported by a research Shire and has consulted for Sunovion and L.E.K 1. Hudson JI, Hiripi E, Pope HG Jr, et al. The internet-assisted cognitive behavioural grant from Shire awarded to The University of prevalence and correlates of eating disorders therapy.Behav Res Ther. 2007;45(4):649–661.PubMeddoi:10.1016/j.brat.2006.06.010 North Carolina at Chapel Hill. DrZerwashas in the National Comorbidity Survey Sánchez-Ortiz VC, Munro C, Stahl D, et al. A consulted for L.E.K Consulting. DrCrosbyis Replication. Biol Psychiatry. randomized controlled trial of internet-based a statistical consultant for Health Outcomes 2007;61(3):348–358.PubMed doi:10.1016/j.biopsych.2006.03.040 cognitive-behavioural therapy for bulimia Solutions.MssMcLaganand Hofmeierand Drs 2. Arcelus J, Mitchell AJ, Wales J, et al. Mortality nervosa or related disorders in a student Levine, Runfola, Moessner, Zimmer, Hamer, and rates in patients with anorexia nervosa and population.PsycholMed.2011;41(2):407–417.PubMeddoi:10.1017/S0033291710000711 Crowhave no conflicts of interest to declare. other eating disorders: a meta-analysis of 36 Zerwas SC, Watson HJ, Hofmeier SM, et al. studies. Arch Gen Psychiatry. CBT4BN: a randomized controlled trial of Funding/support:This research was supported 2011;68(7):724–731.PubMed doi:10.1001/archgenpsychiatry.2011.74 online chat and face-to-face group therapy by a National Institutes of Health grant 3. Deloitte Economic Access. Paying the Price: The for bulimia nervosa. Psychother Psychosom. (R01MH080065), the Alexander von Humboldt Economic and Social Impact of Eating Disorders 2017;86(1):47–53.PubMed doi:10.1159/000449025 Stiftung (PIs: Hans Kordy, PhD, and Dr Bulik), and a in Australia. Sydney, Australia: The Butterfly Hepworth N, Paxton SJ. Pathways to help-Clinical Translational Science Award (UL1TR000083). Foundation; 2012. seeking in bulimia nervosa and binge eating Dr Zerwas is supported by a National Institute 4. Erskine HE, Whiteford HA, Pike KM. The global problems: a concept mapping approach. Int J of Mental Health (NIMH) career development burden of eating disorders. Curr Opin Eat Disord. 2007;40(6):493–504.PubMed doi:10.1002/eat.20402 grant (K01MH100435). Drs Peat and Runfola were Psychiatry. 2016;29(6):346–353.PubMed doi:10.1097/YCO.0000000000000276 American Psychiatric Association. Diagnostic supported by a NIMH post-doctoral training grant 5. Keski-Rahkonen A, Hoek HW, Linna MS, et al. and Statistical Manual for Mental Disorders. (T32MH076694). Dr Runfola was supported by Incidence and outcomes of bulimia nervosa: a Fourth Edition. Washington, DC: American the Global Foundation for Eating Disorders (PI: Dr nationwide population-based study. Psychol Psychiatric Press; 1994. Bulik; Dr Zimmer was supported Med. 2009;39(5):823–831.PubMed doi:10.1017/S0033291708003942 Bulik CM, Marcus MD, Zerwas S, et al. CBT4BN by a Fellowship for Postdoctoral Researchers from 6. Mond JM, Hay PJ, Rodgers B, et al. Health versus CBTF2F: comparison of online versus the German Academic Exchange Service (DAAD). service utilization for eating disorders: face-to-face treatment for bulimia nervosa. Dr Bulik acknowledges funding from the Swedish findings from a community-based study. Int J Contemp Clin Trials.2012;33(5):1056–1064.PubMeddoi:10.1016/j.cct.2012.05.008 Research Council (VR Dnr: 538-2013-8864).Eat Disord. 2007;40(5):399–408.PubMeddoi:10.1002/eat.20382 Fairburn CG, Cooper Z. The Eating Disorder Roleofthesponsor:The supporters had no role in 7. Shapiro JR, Berkman ND, Brownley KA, et al. Examination. In: Fairburn CG, Wilson GT, eds. the design, analysis, interpretation, or publication Bulimia nervosa treatment: a systematic Binge Eating: Nature, Assessment, and ofthisstudy. review of randomized controlled trials. Int J Treatment. 12th ed. New York, NY: Guilford Acknowledgments: The authors would like to Eat Disord. 2007;40(4):321–336.PubMed doi:10.1002/eat.20372 Press; 1993:317–360. acknowledge Hans Kordy, PhD, of the University of 8. Crow S. The economics of eating disorder 17. Brazier J, Usherwood T, Harper R, et al.

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