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Hi! Jim Phelps here for the Psychopharmacology Institute. Before we look at borderline personality disorder and electroconvulsive therapy, I have to explain a personal problem with our nomenclature. Telling patients that you have a personality disorder is usually not good for the therapeutic alliance, which is why I suspect most of us would not offer this official diagnostic label to a patient, at least initially. We duck and call it depression NOS or something. For this and other reasons, I cringe every time I hear the phrase “borderline.” Lately, I’ve been using dimensional language instead, which is borderlinity. I’ll use that approach throughout this Quick Take, and you can back-translate to DSM lingo if you wish.
This paper by Dr. Agustin Yip and colleagues begins by explaining that borderlinity is generally thought not to respond well to ECT. This prevailing view is codified in the 2010 treatment guidelines of the American Psychiatric Association, which states that major depression with a concomitant personality disorder is associated with “less favorable outcomes.”
That prevailing view is based on small case series or studies with nonstandard outcome measures, leaving some room for conflict in the interpretation of results. So, the authors offer a comparison of outcomes for patients receiving ECT at McLean Hospital with or without borderlinity.
Based on 6 recent years of records, 1057 patients received ECT. Of these, 800 completed the McLean’s screening instrument for borderlinity, and about 500 had follow-up assessment. The idea was to compare outcomes for patients with and without borderlinity in addition to their depression. The problem was that patients with borderlinity differed from those without in important ways. In addition to having been less likely to complete college and less likely to become married, they were less likely to be in permanent accommodation, more likely to have been recently hospitalized, and more likely to have substance misuse. Nevertheless, depression scale score improvement after a course of ECT was parallel. The borderlinity group started out significantly worse than patients without borderlinity, but they lowered their score on the depression scale, the QIDS-SR, by just as many points.
After comparing previous similar studies, the authors conclude that their results offer a rationale for proceeding with ECT among depressed patients, notwithstanding borderlinity. There’s a hitch, though. At the third followup visit, patients without borderlinity maintained their improvement, while the depression scores for those with borderlinity went back up about a third of the way toward where they started. By the third assessment, the sample size had gone from 554 patients to 287 patients. The authors explained that this could have been part of the natural affective lability of borderlinity or the lack of durability of the ECT response, and they suggested further study.
In summary, the retrospective data suggest that ECT can be considered in patients with depression and concomitant borderlinity, even borderlinity sufficient to warrant the DSM label. Long-term results may not be as good for patients compared to those without borderlinity, but that warrants further study. For more on this, there are other relevant studies of the issue which are cited in the paper’s introduction and discussion.
Abstract
Treatment Outcomes of Electroconvulsive Therapy for Depressed Patients With and Without Borderline Personality Disorder: A Retrospective Cohort Study
Agustin G Yip, Kerry J Ressler, Fernando Rodriguez-Villa, Shan H Siddiqi, Steven J Seiner
Background: Electroconvulsive therapy (ECT) is the gold-standard treatment for refractory depression. Borderline personality disorder (BPD) is generally considered a poor predictor of treatment response. We sought to assess symptom-severity outcomes among depressed patients with (BPD+) and without (BPD-) comorbid BPD undergoing acute phase ECT.
Methods: The study sample consisted of at least moderately depressed patients who received an acute course of ECT from January 2011 to December 2016 at an academic, freestanding psychiatric hospital. Participants completed a DSM-IV-validated BPD screening instrument at baseline. Measures of DSM-IV depressive symptom severity from the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) were taken serially on 4 occasions. Outcomes of interest comprised total QIDS-SR score trajectory, QIDS-SR suicidality subscore, and symptom cluster subscores posited to differentiate response among antidepressant treatments.
Results: Of the 693 individuals who met study inclusion criteria, 145 (20.9%) screened positive for BPD. Overall, ECT was associated with significant improvement of depressive symptoms (χ²₁ = 504.8, P < .0001). Despite differing from BPD- individuals on key baseline features, BPD+ individuals responded to ECT with similar improvement in overall depression severity (χ²₁ = 0.22, P = .64), suicidality (χ²₁ = 1.63, P = .20), and core emotional (χ²₁ = 0.63, P = .43), sleep (χ²₁ = 0.20, P = .65), and atypical (χ²₁ = 1.30, P = .25) symptoms after 15 treatments. Post hoc analysis indicated a slightly less robust overall response among the BPD+ group by the 15th treatment.
Conclusions: Acute course ECT benefits depressed patients with or without comorbid BPD, although patients with BPD may exhibit less pronounced improvement over time.
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Reference
Yip, A. G., Ressler, K. J., Rodriguez-Villa, F., Siddiqi, S. H., & Seiner, S. J. (2021). Treatment outcomes of electroconvulsive therapy for depressed patients with and without borderline personality disorder. The Journal of Clinical Psychiatry, 82(2).
