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To the Editor: We applaud Hans-Christoph Steinhausen, M.D., Ph.D. (1), for his latest update summarizing the literature on the outcome of anorexia nervosa. This was a particularly daunting task given the tremendous heterogeneity across studies. Although several key design issues and limitations were highlighted, the issue of study groups was not as thoroughly addressed. Generalizability is always an important factor in interpreting clinical research. As matter of practice, the majority of the anorexia nervosa outcome studies were conducted by academic centers and specialty research centers (2, 3). It is well known that such groups tend to be more severely ill and have more comorbidity than patients treated in the community setting, factors that are likely to negatively affect outcome (1, 3).
While additional studies of the natural history and outcome of anorexia nervosa in community and ambulatory practices are essential, our clinical experience conservatively indicates that 50% of patients remit within 1–3 years and never require an inpatient level of care. Of the remaining 50% who require inpatient care, the review by Dr. Steinhausen (1) estimated that an additional 50%–70% will recover, depending on the duration of follow-up. Combining these observations suggests that for the overall spectrum of patients with anorexia nervosa, approximately 75%–85% will completely recover. If patients who experience significant improvement are included, the rate of positive outcome rises to over 90%. Thus, a 75%–90% rate of recovery is a more accurate estimate and does not represent as poor a prognosis as the review by Dr. Steinhausen conveys. This perspective regarding the magnitude of the rate of recovery across the full spectrum of the illness has important implications for patients, families, clinicians, payers, and policy makers for the general view of anorexia nervosa as a chronic versus remitting illness.
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