Cost-effectiveness of Intervention Implementation Support for Reducing Eating Disorder Symptoms Among College Students.

Implementation support for prevention interventions is receiving increased attention, as many organizations receive training in evidence-based practices but do not deliver the interventions optimally. The Body Project, a four-session program, significantly reduces eating disorder symptoms and future disorder onset among group participants when delivered by peer educators at colleges/universities. Costs and cost-effectiveness of the program were examined using data from a randomized trial that compared three levels of implementation support at 63 colleges: (1) a train-the-trainer (TTT) workshop alone, (2) TTT plus a technical assistance (TA) workshop, or (3) TTT plus TA plus monthly quality assurance (QA) consultations. Effectiveness was measured by the production of reliable change in eating disorder symptoms from pretest to posttest. Costs and cost-effectiveness of two levels of implementation support are reported, comparing TTT-only with TTT + TA + QA (effectiveness of the TTT + TA condition did not differ from TTT-only) and using results from an earlier study as a proxy for a no-treatment control. Two perspectives are considered: a sponsoring organization providing the training at multiple sites and a college delivering the intervention to its eligible students. From the perspective of a sponsoring organization, adding both the TA training and QA support improves the cost-effectiveness per eligible student receiving the intervention. From the perspective of costs for a college to deliver the intervention, receiving TA training and QA support is also more cost-effective than the training workshop alone, whether the peer educators are paid or unpaid and whether costs of group supervision are included or excluded. Results converge with previous research showing that more intensive implementation support can be more cost-effective.

Cost-Effectiveness Comparison of Delivery Modalities for a Dissonance-Based Eating Disorder Prevention Program over 4-Year Follow-Up.

The cost-effectiveness of delivery methods for an eating disorder prevention program is reported. In an effectiveness trial (enrollment 2013-2015) comparing three formats (clinician-led, peer-led, and Internet-delivered) for delivering the Body Project eating disorder prevention program to college women versus an educational video control, the peer-led method was more effective than the three alternatives at preventing onset of eating disorders over 4-year follow-up. Eating disorder incidence was 19.3% for clinician-led groups, 8.1% for peer-led groups, 15.5% for Internet-based eBody Project participants, and 17.6% for educational video controls. Delivery costs per person are reported for the Body Project, including participant time, and the cost-effectiveness is calculated for peer-led groups versus the video control. Data analyses were conducted in 2019-2021. Delivery costs per person for the Body Project, including participant time, were approximately $96 for clinician-led groups, $80 for peer-led groups, and $22 for the eBody Project, compared with $9 for the educational video control. For each additional case of eating disorder onset that was prevented by the peer-led groups, compared with the video control, the cost was about $740. There were no differences in health care utilization across condition. Eating disorder prevention costs via the Body Project compare very favorably with the costs for treating an eating disorder, which previously have been estimated to range from approximately $20,300 for cognitive-behavioral therapy for bulimia nervosa to approximately $119,200 for adequate care treatment of anorexia nervosa. These analyses demonstrate the economic value of the Body Project for preventing eating disorders among college-age women when delivered in peer-facilitated groups. ClinicalTrials.gov Identifier: NCT01949649.

Cost-effectiveness of achieving clinical improvement with a dissonance-based eating disorder prevention program.

Using data from an effectiveness trial delivered by college clinicians, we examined the cost-effectiveness of the dissonance-based Body Project program for reducing eating disorder symptoms in women with body dissatisfaction. The outcome of interest was individual-level change; 14.9% of Body Project participants attained clinically meaningful improvement vs. 6.7% of controls. Delivering the intervention costs approximately $70 (2012 U.S. dollars) per person. Incremental cost-effectiveness was $838 for each additional at-risk person reducing eating disorder symptomology to a clinically meaningful degree. These analyses demonstrate the economic value of the Body Project for college-age women with symptoms below the eating disorder diagnosis threshold.

Assessing program sustainability in an eating disorder prevention effectiveness trial delivered by college clinicians.

Sustainability of the Body Project, a dissonance-based selective eating disorder prevention program supported by efficacy and effectiveness trials, has not previously been examined. This mixed-methods study collected qualitative and quantitative data on training, supervision, and the intervention from 27 mental health clinicians from eight US universities who participated in an effectiveness trial and quantitative data on 2-year sustainability of program delivery. Clinicians, who were primarily masters-level mental health providers, had limited experience delivering manualized interventions. They rated the training and manual favorably, noting that they particularly liked the role-plays of session activities and intervention rationale, but requested more discussion of processes and group management issues. Clinicians were satisfied receiving emailed supervision based on videotape review. They reported enjoying delivering the Body Project but reported some challenges with the manualized format and time constraints. Most clinicians anticipated running more groups after the study ended but only four universities (50%) reported providing additional Body Project groups at the 1-year follow-up assessment and sustained delivery of the groups decreased substantially two years after study completion, with only one university (12%) continuing to deliver groups. The most commonly reported barriers for conducting additional groups were limited time and high staff turnover.

Obesity, depression, and health services costs among middle-aged women.

BACKGROUND: Both obesity and depression have been associated with significant increases in health care costs. Previous research has not examined whether cost increases associated with obesity could be explained by confounding effects of depression. OBJECTIVE: Examine whether the association between obesity and health care costs is explained by co-occurring depression. DESIGN: Cross-sectional study including telephone survey and linkage to health plan records. PARTICIPANTS: 4462 women aged 40 to 65 enrolled in prepaid health plan in the Pacific Northwest. MAIN MEASURES: The telephone survey included self-report of height and weight and measurement of depression by the Patient Health Questionnaire (PHQ9). Survey data were linked to health plan cost accounting records. KEY RESULTS: Compared to women with BMI less than 25, proportional increases in health care costs were 65% (95% CI 41% to 93%) for women with BMI 30 to 35 and 157% (95% CI 91% to 246%) for women with BMI of 35 or more. Adjustment for co-occurring symptoms of depression reduced these proportional differences to 40% (95% CI 18% to 66%) and 87% (95% CI 42% to 147%), respectively. Cost increases associated with obesity were spread across all major categories of health services (primary care visits, outpatient prescriptions, inpatient medical services, and specialty mental health care). CONCLUSIONS: Among middle-aged women, both obesity and depression are independently associated with substantially higher health care costs. These cost increases are spread across the full range of outpatient and inpatient health services. Given the high prevalence of obesity, cost increases of this magnitude have major policy and public health importance.

Major and minor depression in female adolescents: onset, course, symptom presentation, and demographic associations.

We examined the epidemiology and phenomenology of major depressive disorder (MDD) and minor depression among a community sample of 496 female adolescents. Diagnostic interviews were conducted annually for 7 years, allowing us to examine onset, course, and symptom presentation among participants 12 through 20 years old. Approximately 1 of 6 girls experienced MDD. MDD episodes had a mean duration of 5.3 months (SD=4.2). One-year prevalence for MDD peaked at age 16 (5.3%). White racial status and younger age were associated with greater worthlessness and suicidality during an MDD episode. One of 5 girls met criteria for minor depression. Adolescents from racial/ethnic minority groups were at especially high risk for minor depression. Adolescence is a high-risk period for depression in young women, although its prevalence and phenomenology vary as a function of age and race/ethnicity.

Assessment of safety and long-term outcomes of initial treatment with placebo in TADS.

OBJECTIVE: The authors examined whether initial assignment to receive placebo for 12 weeks followed by open active treatment as clinically indicated was associated with different levels of benefit and risk of harm across 36 weeks as compared with initial assignment to receive active treatments. METHOD: Adolescents with major depressive disorder (N=439) were randomly assigned to receive an initial 12 weeks of treatment with fluoxetine, cognitive-behavioral therapy (CBT), combination treatment with fluoxetine and CBT, or clinical management with placebo; those assigned to placebo received open active treatment as clinically indicated after 12 weeks of placebo. Assessments were conducted every 6 weeks for 36 weeks. The primary outcome measures were response and remission based on scores on the Children's Depression Rating Scale-Revised and the Clinical Global Impression improvement subscale. RESULTS: At week 36, the response rate was 82% in the placebo/open group and 83% in the active treatment groups. The remission rate was 48% in the placebo/open group and 59% in the active treatment groups, a difference that approached statistical significance. Patients who responded to placebo generally retained their response. Those who did not respond to placebo subsequently responded to active treatment at the same rate as those initially assigned to active treatments. There were no differences between groups in rates of suicidal events, study retention, or symptom worsening. CONCLUSIONS: Remission rates at 9 months were lower in patients treated initially with placebo, but 3 months of placebo treatment was not associated with any harm or diminished response to subsequent treatment.

Comparability of self-report checklist and interview data in the assessment of stressful life events in young adults.

The purpose of this study was to evaluate the incremental value of conducting an interview to assess stressful life events over the self-report questionnaire approach, first by examining the degree to which life events reported on a questionnaire met inclusion criteria in a detailed stress interview, and second, by comparing the magnitude of prospective associations with depression symptoms for the two different assessment procedures. Data from the Oregon Adolescent Depression Project were examined, in which 191 community-residing young adults (55% female; M age=23.6, SD=0.6) completed a mailed questionnaire assessing the frequency with which 33 life events had occurred to them or to other important people in their lives prior to the diagnostic and stress interviews. An average of 67.5% of events occurring to self met criteria for classification as a life event on the stress interview, as did 19.7% of the events occurring to others. Events having a large effect on the participant had a greater likelihood of meeting inclusion criteria on the stress interview. Contrary to expectation, stress scores from the interview assessment did not result in stronger associations with depression. Recommendations for assessment of stressful life events are offered.