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Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive–behavioural therapy in out-patients with anorexia nervosa

  • N. Egger (a1), B. Wild (a2), S. Zipfel (a3), F. Junne (a3), A. Konnopka (a1), U. Schmidt (a4), M. de Zwaan (a5), S. Herpertz (a6), A. Zeeck (a7), B. Löwe (a8), J. von Wietersheim (a9), S. Tagay (a10), M. Burgmer (a11), A. Dinkel (a12), W. Herzog (a2) and H.-H. König (a1)...

Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive–behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.


The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost–utility and assumptions underlying the base case were investigated in exploratory analyses.


Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends.


Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Corresponding author
*Address for correspondence: N. Egger, Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. (Email:
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Abbate-Daga, G, Amianto, F, Delsedime, N, De-Bacco, C, Fassino, S (2013). Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview. BMC Psychiatry 13, 294.
Abbate-Daga, G, Facchini, F, Marzola, E, Delsedime, N, Giovannone, C, Amianto, F, Fassino, S (2014). Health-related quality of life in adult inpatients affected by anorexia nervosa. European Eating Disorders Review 22, 285291.
Ackard, DM, Richter, S, Egan, A, Engel, S, Cronemeyer, CL (2014). The meaning of (quality of) life in patients with eating disorders: a comparison of generic and disease-specific measures across diagnosis and outcome. International Journal of Eating Disorders 47, 259267.
Azur, MJ, Stuart, EA, Frangakis, C, Leaf, PJ (2011). Multiple imputation by chained equations: what is it and how does it work? International Journal of Methods in Psychiatric Research 20, 4049.
Brooks, A, Hagen, SE, Sathyanarayanan, S, Schultz, AB, Edington, DW (2010). Presenteeism: critical issues. Journal of Occupational and Environmental Medicine 52, 10551067.
Byford, S, Barrett, B, Roberts, C, Clark, A, Edwards, V, Smethurst, N, Gowers, SG (2007). Economic evaluation of a randomised controlled trial for anorexia nervosa in adolescents. British Journal of Psychiatry 191, 436440.
Chisholm, D, Knapp, MR, Knudsen, HC, Amaddeo, F, Gaite, L, van Wijngaarden, B (2000). Client Socio-Demographic and Service Receipt Inventory – European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs. British Journal of Psychiatry 39, s28s33.
Crow, S (2014). The economics of eating disorder treatment. Current Psychiatry Reports 16, 454.
de Jong, P, Heller, GZ (2008). Generalized Linear Models for Insurance Data. Cambridge University Press: Cambridge, UK.
Dejong, H, Broadbent, H, Schmidt, U (2012). A systematic review of dropout from treatment in outpatients with anorexia nervosa. International Journal of Eating Disorders 45, 635647.
Deutsche Krankenhausgesellschaft (2009). Bestandsaufnahme zur Krankenhausplanung und Investitionsfinanzierung in den Bundesländern. Deutsche Krankenhausgesellschaft: Berlin.
Dolan, P (1997). Modeling valuations for EuroQol health states. Medical Care 35, 10951108.
Fairburn, CG (2008). Cognitive Behavior Therapy and Eating Disorders. The Guilford Press: New York and London.
Fenwick, E, O'Brien, BJ, Briggs, A (2004). Cost-effectiveness acceptability curves – facts, fallacies and frequently asked questions. Health Economics 13, 405415.
Fichter, M, Quadflieg, N (2001). The Structured Interview for Anorexic and Bulimic Disorders for DSM-IV and ICD-10 (SIAB-EX): reliability and validity. European Psychiatry 16, 3848.
Friederich, HC, Herzog, W, Wild, B, Zipfel, S, Schauenburg, H (2014). Anorexia Nervosa. Fokale psychodynamische Psychotherapie. Hogrefe: Göttingen.
Graham, JW, Olchowski, AE, Gilreath, TD (2007). How many imputations are really needed? Some practical clarifications of multiple imputation theory. Prevention Science 8, 206213.
Gray, AM (2011). Applied Methods of Cost-Effectiveness Analysis in Health Care. Oxford University Press: Oxford.
Hoch, JS, Briggs, AH, Willan, AR (2002). Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis. Health Economics 11, 415430.
Hoch, JS, Rockx, MA, Krahn, AD (2006). Using the net benefit regression framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of “community acquired” syncope. BMC Health Services Research 6, 68.
Kessler, RC, Ames, M, Hymel, PA, Loeppke, R, McKenas, DK, Richling, DE, Stang, PE, Ustun, TB (2004). Using the World Health Organization Health and Work Performance Questionnaire (HPQ) to evaluate the indirect workplace costs of illness. Journal of Occupational and Environmental Medicine 46, S23S37.
Krauth, C, Hessel, F, Hansmeier, T, Wasem, J, Seitz, R, Schweikert, B (2005). Empirical standard costs for health economic evaluation in Germany – a proposal by the working group methods in health economic evaluation. Gesundheitswesen 67, 736746.
Legenbauer, T, Vocks, S (2005). Manual der kognitiven Verhaltenstherapie bei Anorexie und Bulimie. Springer: Berlin.
Nan, L, Johnson, JA, Shaw, JW, Coons, SJ (2007). A comparison of EQ-5D index scores derived from the US and UK population-based scoring functions. Medical Decision Making 27, 321326.
National Collaborating Centre for Mental Health (2004). National Institute for Health and Clinical Excellence: guidance. In Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders, pp. 6465. British Psychological Society: UK, The British Psychological Society & The Royal College of Psychiatrists: Leicester.
Raghunathan, TE, Lepkowski, JM, Van Hoewyk, J, Solenberger, P (2001). A multivariate technique for multiply imputing missing values using a sequence of regression models. Survey Methodology 27, 8595.
Rote Liste Service GmbH (2008). Rote Liste 2008. Arzneimittelverzeichnis für Deutschland. Rote Liste Service GmbH: Frankfurt am Main.
Statistisches Bundesamt (2008). Pflegestatistik 2007. Statistisches Bundsamt: Wiesbaden.
Statistisches Bundesamt (2009 a). Kostennachweis der Krankenhäuser 2008. Statistisches Bundesamt: Wiesbaden.
Statistisches Bundesamt (2009 b). Grunddaten der Krankenhäuser 2008. Statistisches Bundesamt: Wiesbaden.
Statistisches Bundesamt (2009 c). Verdienste und Arbeitskosten. Statistisches Bundesamt: Wiesbaden.
Statistisches Bundesamt (2010). Volkswirtschaftliche Gesamtrechnungen 2009. Statistisches Bundesamt: Wiesbaden.
Stuhldreher, N, Konnopka, A, Wild, B, Herzog, W, Zipfel, S, Lowe, B, Konig, HH (2012). Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review. International Journal of Eating Disorders 45, 476491.
van Buuren, S, Groothuis-Oudshoorn, K (2011). mice: Multiple imputation by chained equations in R. Journal of Statistical Software 45, 167.
Wild, B, Friederich, HC, Gross, G, Teufel, M, Herzog, W, Giel, KE, de Zwaan, M, Schauenburg, H, Schade-Brittinger, C, Schafer, H, Zipfel, S (2009). The ANTOP study: focal psychodynamic psychotherapy, cognitive–behavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa – a randomized controlled trial. Trials 10, 23.
Wu, M, Brazier, JE, Kearns, B, Relton, C, Smith, C, Cooper, CL (2015). Examining the impact of 11 long-standing health conditions on health-related quality of life using the EQ-5D in a general population sample. European Journal of Health Economics 16, 141151.
Zerwas, S, Larsen, JT, Petersen, L, Thornton, LM, Mortensen, PB, Bulik, CM (2015). The incidence of eating disorders in a Danish register study: associations with suicide risk and mortality. Journal of Psychiatric Research 65, 1622.
Zethraeus, N, Johannesson, M, Jonsson, B, Lothgren, M, Tambour, M (2003). Advantages of using the net-benefit approach for analysing uncertainty in economic evaluation studies. Pharmacoeconomics 21, 3948.
Zipfel, S, Giel, KE, Bulik, CM, Hay, P, Schmidt, U (2015). Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry 2, 10991111.
Zipfel, S, Wild, B, Gross, G, Friederich, HC, Teufel, M, Schellberg, D, Giel, KE, de Zwaan, M, Dinkel, A, Herpertz, S, Burgmer, M, Löwe, B, Tagay, S, von Wietersheim, J, Zeeck, A, Schade-Brittinger, C, Schauenburg, H, Herzog, W; ANTOP study group (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Lancet 383, 127137.
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Psychological Medicine
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