Neuromodulation May Help Depressed Patients With Borderline Personality Disorder

Many, but not all, patients with treatment-resistant depression benefit from electroconvulsive therapy (ECT). For years researchers have believed that depressed individuals with comorbid borderline personality disorder were less likely to benefit from ECT than those without this comorbidity. A recent study in the Journal of Affective Disorders may help change this view, while also pointing to transcranial magnetic stimulation (TMS) as another viable option for treating depression in these patients.

The hesitation toward treating patients with borderline personality disorder with ECT stems in part from a 2004 clinical trial involving 139 patients with treatment-resistant depression. That prospective study found that patients with treatment-resistant depression and comorbid borderline personality disorder were significantly less likely to achieve depression remission after eight to 12 ECT sessions than patients without borderline personality disorder or those with another personality disorder.

Tom Kates

Stephen Seiner, M.D., the medical director of the ECT Service at Harvard-affiliated McLean Hospital, noted that at the time, researchers were not surprised by these findings; people with borderline personality disorder tend to have more severe depression and often don’t respond to antidepressants or psychotherapy. However, in the years since, other studies have suggested that some patients with borderline personality disorder may respond to ECT.

One limitation of the 2004 trial was that the researchers used remission of depression as the outcome, Seiner explained. Given that individuals with both depression and borderline personality disorder typically have more severe symptoms, they could improve significantly with ECT but still fail to achieve full remission. Borderline personality disorder is itself associated with mood swings and dysphoria, he added.

“The goal of ECT with depressed borderline patients is not to eliminate their depression, but to get it to a manageable point where established personality disorder therapies have a greater chance of success,” he said.

Seiner and colleagues analyzed data from over 1,400 patients who received ECT between 2011 and 2018. They compared the overall symptom improvement of the patients, as assessed with the Quick Inventory of Depression Symptomatology Self-Report (QIDS-SR).

As anticipated, the patients with comorbid borderline personality disorder had higher QIDS-SR scores than those without throughout ECT treatment, but both groups showed a similar response over time. QIDS-SR scores for patients with or without borderline personality disorder dropped by about eight points after the first five ECT sessions, followed by a period of stability over the next 10 to 15 sessions.

Seiner and his team also assessed the outcomes of 356 patients with treatment-resistant depression who received TMS therapy. While TMS was approved for treatment-resistant depression in 2008, the impact of borderline personality disorder on responsiveness to TMS had yet to be examined. As with ECT, Seiner’s analysis found that patients with depression and borderline personality disorder had similar responses to TMS as did patients who did not have borderline personality disorder.

TMS appeared to be slightly more effective at reducing depression than ECT for patients with comorbid borderline personality disorder (QIDS-SR scores dropped by about 10 points in those in the TMS group compared with eight points in the ECT group). One difference between the response of patients who received TMS versus ECT was that QIDS-SR scores dropped gradually but continually declined across all treatment sessions rather than dropping rapidly and plateauing.

“This was a really exciting finding,” Seiner noted. “Now clinicians can feel confident that they have a choice when evaluating patients with depression and borderline symptoms. If a patient has severe bipolar depression or psychotic depression, then ECT would be preferred; but if not, they can try TMS and avoid some of the side effects of ECT.”

Seiner told Psychiatric News that people with borderline personality disorder can be more sensitive to the cognitive side effects of ECT, such as transient memory loss, which is another factor for physicians to take into account when considering treatment options for these patients. The study was funded by the Sidney R. Baer Jr. Foundation. ■