Electroconvulsive therapy effective for depressed patients with, without comorbid BPD

Acute course electroconvulsive therapy benefited patients with depression with or without comorbid borderline personality disorder, according to results of a retrospective cohort study published in Journal of Clinical Psychiatry.

However, those with borderline personality disorder (BPD) appeared to exhibit less pronounced improvement over time, researchers noted.

“Notably, most of the clinical and empirical studies that describe experience with ECT in patients with comorbid personality disorders do not report results specifically for BPD, are small case series, or, with few exceptions, use non-standardized outcome measures,” Agustin G. Yip, MD, PhD, of McLean Hospital at Harvard Medical School, and colleagues wrote. “A systematic review presented conflicting results concerning the treatment modifying effect of BPD on ECT for depression but concluded that depressed patients with BPD can be effectively treated with ECT. There is clearly a need to expand the limited evidence base to help clinicians and patients weigh the harms and benefits of ECT.”

The investigators aimed to evaluate symptom-severity outcomes among patients with depression who either did or did not have comorbid BPD and who were undergoing acute phase ECT. Participants included at least moderately depressed individuals who received an acute course of ECT between January 2011 and December 2016 at a single psychiatric hospital. They completed a DSM-IV-validated BPD screening instrument at baseline and provided responses to DSM-IV depressive symptom severity measures per the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) on four occasions. Main outcomes included total QIDS-SR score trajectory, QIDS-SR suicidality subscore and symptom cluster subscores posited for differentiation of antidepressant treatment responses.

Results were available for 693 individuals who met study inclusion criteria. Of these, 145 (20.9%) screened positive for BPD. Results showed an overall association between ECT and significant depressive symptom improvement. Although they differed from individuals without BPD on key baseline features, those with BPD had similar improvement related to ECT in overall depression severity, suicidality and core emotional, sleep and atypical symptoms after 15 treatments. The researchers observed a slightly less robust overall response among the group with BPD by the 15th treatment according to post hoc analysis.

“Depression and BPD exhibit phenotypic divergence and yet are highly comorbid, suggesting overlapping underlying liabilities and longitudinal course,” Yip and colleagues wrote. “Our findings add to the evidence base that provides the clinician with a rationale for proceeding with ECT among depressed patients, notwithstanding comorbid BPD. While these data suggest that [patients with BPD] show improvement in depression symptoms from ECT, they do not speak to whether there is similar improvement in the BPD core symptoms that led patients and their doctors to turn to ECT in the first place.”