Page 70 - The efficacy and effectiveness of psychological treatments for eating disorders - Elske van den Berg

70 Chapter 3
Discussion
The study aim was to examine effectiveness and cost-effectiveness following implementation of an EST in a routine treatment center. Two sizeable cohorts of patients were therefore compared, one receiving TAU between 2012-2014, the other receiving CBT-E between 2015-2017. There are two main findings. First, with regard to effectiveness, no significant differences were found between the two cohorts; in both cohorts, eating disorder and general psychopathology, measured with self- reports, decreased significantly. With regard to responders’ remission rates, findings are mixed: with regard to RCI, a significant difference was found in favor of CBT-E. When applying a robust definition of remission, a significant difference was found in favor of the 2012-2014 cohort. Imputed ITT analyses, however, did not show any significant differences between both samples. Comparing completers remission rates (global EDE-Q score < one SD above community mean) of the Byrne and the Knott studies (Byrne et al, 2011; Knott et al, 2015) to the 2015-2017 responders, outcomes are in line, although the Knott rate stands out (66.7% Byrne study; 78.3% Knott study; 62.1% 2015-2017 sample UK norms). When comparing the 2015-2017 robust defined remission rate to the Turner rate (Turner et al., 2015), outcomes appear in line (31% Turner study; 26.1% in 2015-2017), although the Turner study included patients with lower BMIs. Comparing ITT robust remission rates, the 2015-2017 rate seems some- what better (19% Turner study; 31.9% in 2015-2017).
Compared to the 2012-2014 sample, treatment duration and the duration of the inpatient stay reduced in 2015-2017. In addition, by stopping offering outpatient daycare, those contacts reduced significantly as well.
Second, CBT-E is potentially cost effective when limiting the cost analysis to eating disorder treatment costs. Based on the distribution of the cost-effectiveness plane, there is a 71% likelihood that CBT-E is more cost effective and a 29% likelihood that CBT-E leads to less remissions at lower costs. The likelihood that TAU leads to lower costs is 0%.
The finding that, on clinical outcome, no significant differences were found between a specialized psychological treatment, like CBT-E, and TAU is in line with the literature (Hay, Claudino, Touyz, & Abd Elbaky, 2015; Van den Berg et al., 2019), both anorexia reviews stated that difficulties in establishing differences may be due to the nature of an optimized TAU consisting of recommended, multimodal interventions, such as engaging the patient, nutritional & physical rehabilitation and establishing a regular eating pattern. As effectiveness was examined shortly after CBT-E being implemented, as staff gets more experienced, outcomes may enhance over time. The finding that CBT-E for adult patients with all types of eating disorders and a BMI > 17.5 is superior to TAU from a cost-effectiveness perspective is, to our knowledge,