Evolving evidence and continuing uncertainties for eating disorders

In reply: The commitment of Russell and Abraham to their own program has distracted them from accurate reporting and sound epidemiological principles. They say that the majority of patients that we studied received no treatment. Not so. We clearly stated that only 34 of the 220 patients studied received no treatment.1 They then draw a range of inferences from the fact that "3/95 (3.2%)" patients with anorexia nervosa died. In fact, only 2 of 95 patients with anorexia nervosa died as a consequence of that disorder during the five years of our study. At 2.1%, this is similar to the crude death rate of 1/61 (1.6%) that they describe in their own study.

However, it is only acceptable to use a rare outcome as a measure of the efficacy of a treatment program if the clinical characteristics that put patients at risk for such an outcome are known and accounted for. We do not know the specific factors that put people at particular risk of dying from anorexia nervosa. Without such knowledge, small differences in crude death rates can not of themselves inform us whether treatment programs diminish or accentuate such risks. Unfortunately, there are no other studies against which to compare the outcomes of the patients with "eating disorders not otherwise specified" in our study. We have dealt with issues such as the representative nature of our study elsewhere.2 I stand by our work and the conclusions we draw from it.