Refeeding is not a treatment for the underlying symptoms of anorexia nervosa

We have recently proposed that research in anorexia nervosa (AN) requires greater focus on the biopsychosocial model of the illness as a whole, and that biologically inspired treatments for the condition are lacking (Phillipou et al., 2019). Russell (2019) disagrees with this proposal and suggests that we have an ‘effective biological treatment’ for AN – refeeding and nutritional rehabilitation. The author goes on to propose that ‘this can bring about complete resolution of physical, endocrine and psychological symptoms’ and that food is a ‘miracle cure’ for AN. Refeeding is not a treatment for AN itself – it is a treatment for restoring the resultant weight loss driven by the psychological symptoms of AN. Restoring one’s physical state is indeed a critical component of AN treatment, but it does not address the underlying mental illness that has led to weight loss in the first place. It is not responsible to suggest that the primary purpose of refeeding is much more than restoring a patient’s physical state. The effects of starvation can, and are likely to, exacerbate psychological symptoms including depression and anxiety (Kezelman et al., 2015), but these symptoms do not completely resolve with weight restoration (Phillipou et al., 2018). Psychological symptoms of AN are present before weight loss, may be exacerbated in the acute state, and frequently continue at high rates into weight restoration and recovery. We are not suggesting that refeeding and nutritional rehabilitation are not critical components to AN treatment. They are essential for medical stabilisation of patients to restore physical health and to improve some aspects of mental health affected by starvation. Refeeding is an important component of treatment but is not a biological treatment for AN in itself. AN is a psychiatric illness that requires psychiatric treatment through psychosocial and/or biological interventions. There is no evidence-based biological treatment currently available to treat AN specifically. Psychiatric medications and neurostimulation are routinely available for other mental illnesses, and there is strong evidence that these interventions remediate important psychiatric symptoms in these conditions. Although these biologically based treatments are not available for AN specifically, some medications can be used with some success to reduce co-morbid symptoms in AN such as increased arousal during the early stages of refeeding. There are no ‘cures’ for mental illnesses. Our treatments do not improve all symptoms associated with an illness. Antipsychotics, for example, have significant success in reducing positive symptoms in individuals with psychosis, but do not improve cognition or other aspects of functioning. However, antipsychotics are an effective evidence-based treatment for reducing some of the most distressing symptoms of psychosis itself. Simply, we do not have a treatment of similar efficacy to reduce some of the most distressing symptoms of AN. In fact, refeeding itself is considered a very distressing experience by many AN patients (Levinson et al., 2019). Food may be a ‘miracle cure’ for starvation; it is most certainly not a cure for AN. Our psychosocial interventions show limited efficacy and biological treatments simply do not exist for AN itself. Clinicians are doing the best they can with the treatments we have available. However, as a community of researchers and clinicians, we need to acknowledge that there is significant room for improvement in AN treatment. We need to give hope to our patients who have not responded to treatment, that we are trying to do better. Recognising that we need to improve our therapeutic interventions for AN is the first step. Gaining a better understanding of the illness so we can develop treatments that are more effective is the next step. Only by gaining a clear picture of the wide-ranging biological, psychological and sociocultural mechanisms involved in AN will we be able to progress our Commentaries 924474 ANP ANZJP CorrespondenceANZJP Correspondence