In Reference to Haliburn: Australian and New Zealand Clinical Practice Guidelines for the Treatment of Anorexia Nervosa

Phillipa Hay , School of Medicine, Townsville, Queensland, Australia

I am writing on behalf of the Guidelines Team for Anorexia Nervosa. The team welcomes debate on the guidelines and we would be pleased to see this letter joining a chorus of calls for support for more controlled trials in anorexia nervosa treatment research. In this regard, since publication of the guidelines, the Christchurch controlled trial has been published [1]. The unexpected result of this trial, namely that a control therapy, non-specific supportive management, was favoured over the two specific therapies (cognitive behaviour therapy and interpersonal psychotherapy) highlights the complexity and challenges in evaluating therapies for people with anorexia nervosa. More research is urgently needed.

The team is pleased to reiterate issues from the Guidelines [2] raised by Haliburn [1]. It is necessary to treat comorbidities, and psychological therapies should be part of every therapeutic regimen (see p.662, para 2–5, p.664, para 3). Indicators for good and bad outcomes are important (and the reader can find a summary of these in Table 3, p.661). The team also agree that major depression should be treated as appropriate with antidepressants (see p.662, para 10 and also the specific guideline on p.666: ‘Evidence for antidepressant and antipsychotic efficacy is insufficient. However, the consensus is that antidepressants have a role in patients with marked depressive symptoms…’). In the section entitled ‘Current evidence on treatment’ interested readers will also find (where it was evaluated) reports on the efficacy of specific psychological and pharmacological approaches for depressive, as well as other, symptoms. We are puzzled that Haliburn has read in the guidelines an argument that depression in anorexia nervosa is a consequence of poor nutritional state. Nevertheless, important and well-described psychological effects of starvation, such as mood changes and cognitive impairment should not be underestimated in treatment (see Garner [3] for a full discussion of this).

That anorexia nervosa as a monosymptomatic psychosis is an interesting point of view. More recently much publicity has also gone to Bergh and Södersten's views that the biological nature of anorexia nervosa has been neglected [4]. The Practice Guidelines reflect a consensus understanding of the nature and characteristics of the disorder, but the team welcomes further debate.

Finally, Haliburn is incorrect in the statement that the ‘expert team has only told us what does not work’. This is a regrettable, but all too common misconception. Indeed, we stated ‘In addition, “insufficient evidence” and “no evidence” are not synonymous with “evidence of ineffectiveness” and, in the absence of evidence, clinical consensus is legitimate’ ([2], p.662, para 1, emphasis added here). It is imperative that people with anorexia nervosa are treated, that they are not left to languish in a starvation state, that, as best as it is currently understood, psychological approaches are part of treatment and that research is undertaken to evaluate which approaches are likely to be most helpful.