Source: Lee, J. H., Kung, S., Rasmussen, K. G., & Palmer, B. A. (2019). Effectiveness of Electroconvulsive Therapy in Patients With Major Depressive Disorder and Comorbid Borderline Personality Disorder. The journal of ECT, 35(1), 44–47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6584612/

The article begins by explaining that personality disorders, such as borderline personality disorder, commonly coexist with mood disorders like major depressive disorder (MDD). The coexistence of these two conditions can greater complicate treatment for patients, and many patients can end up resistant to treatments. Furthermore, previous research suggests that while electroconvulsive therapy is effective in treating severe depression, it is significantly less effective when the patient has comorbid borderline personality disorder. The goal of this study was therefore to assess the effectiveness of electroconvulsive therapy (ECT) in relieving depressive symptoms in patients with Major Depressive Disorder and comorbid Borderline Personality Disorder.

The article used a retrospective cohort study that looked at adult inpatients (18-65 years old) who were treated for severe depression using ECT at the Mayo Clinic from December 2013 through January 2017. These patients were routinely evaluated using the Patient Health Questionnaire-9 (PHQ-9) before treatment and after the final ECT treatment, as well as the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) during the first hospital stay. A total of 137 patients who received ECT were included in the study, and of those 29 had an MSI-BPD score of 7 or greater. Those 29 patients made up the comorbid BPD group. The remaining 108 patients made up the control group who did not have a diagnosis of BPD. The results of the study showed that both the patients with BPD and the patients without BPD who received ECT demonstrated a significant improvement in depression. Additionally the difference in treatment response between the two groups was insignificant when evaluated in the acute hospital setting and at the 1-month outpatient follow up. Therefore, contrary to previous research, this study suggests that major depressive disorder patients with and those without BPD respond equally well to ECT in both the short-term and 1-month following treatment, and thus BPD does not seem to reduce the efficacy of ECT in treating depression.

While these results are compelling, there were some limitations to this study and therefore more research should be done before concluding that ECT is effective for patients with MDD and comorbid BPD. First of all, the use of the MSI-BPD scoring system to differentiate patients with BPD from those without comorbid BPD is not totally accurate, as this is simply a screening tool and should not be used to make a definitive diagnosis. The article explains that the MSI-BPD has only a moderate validity with moderate sensitivity and specificity compared to diagnostic interviews. Since this was the primary tool used in this study, we cannot refute previous studies that show BPD reduces the efficacy of ECT.  Additionally, the use of the PHQ-9 scoring system also reduces the validity of this study. That is because the PHQ-9 is a simplified assessment for measuring depressive symptoms, especially when compared to the Hamilton Depression Rating Scale, which is a much more comprehensive instrument that has been used by other researchers who assessed depression with comorbid BPD.

This study was relevant to my patient, F.W. This patient has a diagnosed history of Borderline Personality Disorder and presented to the Comprehensive Psychiatric Emergency Program due to suicidal ideation in the context of medication noncompliance (Escitalopram 10 mg daily). The patient has a reported history of one prior suicide attempt 3 months ago, which is when she began taking Escitalopram for her depressive symptoms. Although the suicidal ideation she presents with today is likely due to going off her medication, the patient could also possibly be suffering from comorbid Major Depressive Disorder, especially considering her history of depression. This article teaches that Major Depressive Disorder with comorbid Borderline Personality Disorder is difficult to treat according to previous research. While the Escitalopram was working for the patient, the article provides a case in support of ECT for depression in patients with Borderline Personality Disorder. While this article alone is not sufficient enough to argue that the patient should get ECT, it does suggest that ECT might be helpful for her in the same way that it is effective in treating severe forms of Major Depressive Disorder.