There have been comprehensive appraisals of follow-up studies in anorexia nervosa (108) which have put forward criteria for the near-perfect follow-up study, which in practice are seldom fully met. Among the easier criteria are precision in the diagnostic features, the use of standardized interviews, 100 per cent success in tracing the patients, and a sufficiently long follow-up to determine eventual outcome. An arbitrary interval of at least 4 years was previously set (24) and most recent studies have adhered to this recommendation. Several groups of investigators have adopted the same measures of outcome based on the Morgan-Russell scales. fy0.9.) Their use gives rise to three possible categories of general outcome based on body weight and menstrual function: 'good', 'medium', and 'poor'.
In a review comparing three British studies and one Swedish study, (110) each with a mean follow-up of 5 to 6 years, it was found that the patients treated in Bristol had a better outcome than those treated at the Maudsley Hospital in London. The explanation is one of selection bias already mentioned: the Maudsley patients had all required inpatient treatment, whereas in the Bristol series the majority were outpatients. The third British study, from St George's Hospital, London, showed a quality of outcome intermediate between the other two.
The Swedish study was extended by two later follow-ups at 15 and 33 years, and showed a trend in two directions. On the one hand, the percentage of good outcomes gradually increased, while the percentage of poor outcomes diminished. On the other hand, the death rates increased with time; after 33 years the total mortality from anorexia nervosa or suicide was 18 per cent. Slow recovery was the rule: only 29 per cent of patients recovered in less than 3 years of illness, another 35 per cent within 3 to 6 years, and the remainder took much longer with recovery after 12 years being rare. (H0) The Maudsley series of patients was also extended to a mean follow-up of 20 years. There was a reduction in the percentage of patients with a poor outcome, but an increase in the mortality rate close to that of the Swedish study.(111)
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