Major Depressive Disorder with Borderline Personality Disorder and ECT

One of the senior medical students, Rachel Maurer, rotating on our Medical-Psychiatry Unit volunteered to search the medical literature for reviews and studies that would guide psychiatrists about how to apply electroconvulsive therapy (ECT) in the treatment of Major Depressive Disorder (MDD) in patients who are also diagnosed with Borderline Personality Disorder (BPD). See web link for more information about BPD. Also don’t miss STEPPS for BPD. [Note: This post has updated links–J.A.]

Rachel did an efficient search of the literature and her outline summarizes basic major points:

  • There is double the risk of a poor outcome for patients diagnosed with depression with comorbid personality disorder compared to those without personality disorder. This uses depression as defined by criteria used in the Hamilton Depression rating scale and the relevant paper is by Newton-Howes and colleagues (see references below).
  • Persons with personality disorder generally had higher scores on depression rating scales at the beginning of treatment (Newton-Howes and colleagues review)
  • 30-70% pf depressed patients have a concurrent Axis II (personality) disorder (DeBattista and Mueller review)
  • Borderline Personality Disorder tends to be more prevalent in inpatient samples
  • Comorbid personality disorder diagnoses are associated with poorer outcomes in response to all treatments including ECT
  • Patients with Borderline Personality Disorder tend to endorse a variety of depressive symptoms at baseline (DeBattista and Mueller)
  • Patients with a concurrent personality disorder may be more treatment resistant and appear to have response rates comparable to other medication-resistant depressed patients (DeBattista and Mueller)

The relevant factors in tabular format tending to support or weigh against a trial of ECT:

It’s important to know that in four of the more recently published prospective studies, 40-75% of MDD + BPD patients had at least a 50% reduction in standardized depression rating scale scores at the completion of ECT.


Although there is limited data upon which to base clinical decisions on the implementation of any one treatment modality to help patients with both Major Depressive Disorder and Borderline Personality achieve symptomatic relief and to move forward in their lives, there are in fact several evidence-based, effective approaches available in addition to ECT. These include mentalization, dialectical behavior therapy, Systems Training in Emotional Predictability and Problem Solving (STEPPS). Treatment responses tend to be unique to each individual. While the range of responses can be no response to significant improvement, there are undoubtedly sound reasons to have hope. It isn’t just either ECT or not ECT–it’s both/and approaches that win the day with the strength of the therapeutic alliance (meaning trust) the glue that binds them together.


Bales, D., N. van Beek, et al. (2012). “Treatment Outcome of 18-Month, Day Hospital Mentalization-Based Treatment (MBT) in Patients With Severe Borderline Personality Disorder in the Netherlands.” J Pers Disord.

Psychoanalytically oriented day hospital therapy, later manualized and named mentalization-based treatment (MBT), has proven to be a (cost-) effective treatment for patients with severe borderline personality disorder and a high degree of psychiatric comorbidity (BPD) in the United Kingdom (UK). As to yet it has not been shown whether manualized day hospital MBT would yield similar results when conducted by an independent institute outside the UK. We investigated the applicability and treatment outcome of 18-month, manualized day hospital MBT in the Netherlands by means of a prospective cohort study with 45 Dutch patients with severe BPD and a high degree of comorbid Axis I and Axis II disorders. Outcomes were assessed each six months. Symptom distress, social and interpersonal functioning, and personality pathology and functioning all improved significantly, with effect sizes between 0.7 and 1.7. Suicide attempts, acts of self-harm, and care consumption were also significantly reduced. The results indicate that MBT can effectively be implemented in an independent treatment institute outside the UK. This study also supports the clinical effectiveness of manualized day hospital MBT in patients with severe BPD and a high degree of psychiatric comorbidity.

Barnicot, K., C. Katsakou, et al. (2012). “Factors predicting the outcome of psychotherapy for borderline personality disorder: a systematic review.” Clin Psychol Rev 32(5): 400-412.

BACKGROUND: There is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified. METHOD: A systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included. RESULTS: Two consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome. CONCLUSION: More severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.

Black, D. W., J. Allen, et al. (2009). “Predictors of response to Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder: an exploratory study.” Acta Psychiatr Scand 120(1): 53-61.

OBJECTIVE: Few predictors of treatment outcome or early discontinuation have been identified in persons with borderline personality disorder (BPD). AIM: The aim of the study was to examine the relationship between baseline clinical variables and treatment response and early discontinuation in a randomized controlled trial of System Training for Emotional Predictability and Problem Solving, a new cognitive group treatment. METHOD: Improvement was rated using the Zanarini Rating Scale for BPD, the Clinical Global Impression Scale, the Global Assessment Scale and the Beck Depression Inventory. Subjects were assessed during the 20 week trial and a 1-year follow-up. RESULTS: Higher baseline severity was associated with greater improvement in global functioning and BPD-related symptoms. Higher impulsivity was predictive of early discontinuation. Optimal improvement was associated with attending > or = 15 sessions. CONCLUSION: Subjects likely to improve have the more severe BPD symptoms at baseline, while high levels of impulsivity are associated with early discontinuation.

Bloom, J. M., E. N. Woodward, et al. (2012). “Use of Dialectical Behavior Therapy in Inpatient Treatment of Borderline Personality Disorder: A Systematic Review.” Psychiatr Serv.

OBJECTIVE: Dialectical behavior therapy (DBT) is an empirically supported treatment for outpatients with borderline personality disorder. However, the utility of DBT strategies for inpatients with the disorder is unclear. This review summarizes and synthesizes findings from trials of DBT in inpatient settings. METHODS: Multiple research databases were searched for articles published through June 2011 that reported on any implementation of DBT in an inpatient setting to address symptoms related to borderline personality disorder, including suicidal and self-injurious behavior. RESULTS: Eleven studies that reported pre- and post-treatment symptoms related to borderline personality disorder were evaluated. Studies indicated that many variations of standard DBT have been used in inpatient settings, including approaches that do not include phone consultation, that include group therapy only, and that vary in treatment duration (from two weeks to three months). Most studies reported reductions in suicidal ideation, self-injurious behaviors, and symptoms of depression and anxiety, whereas results for reducing anger and violent behaviors were mixed. Follow-up data indicated that symptom reduction was often maintained between one and 21 months post-treatment. On the basis of the evidence, the authors identify essential components of an inpatient DBT package and discuss its potential function as an “intensive orientation” to outpatient DBT services. CONCLUSIONS: There is considerable variation in the configuration and duration of DBT implementation for inpatients with borderline personality disorder. However, findings suggest that DBT may be effective in reducing symptoms related to borderline personality disorder in inpatient settings. Future research should standardize and systematically test inpatient DBT. (Psychiatric Services in Advance, July 1, 2012; doi: 10.1176/

Blum, N., B. Pfohl, et al. (2002). “STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder–a preliminary report.” Compr Psychiatry 43(4): 301-310.

We describe a new cognitive-behavioral systems-based group treatment for persons with borderline personality disorder (BPD). The program is called STEPPS, an acronym for Systems Training for Emotional Predictability and Problem Solving. Briefly, the program combines cognitive-behavioral techniques and skills training with a systems component. The latter involves patients with BPD and persons in their system (e.g., family members, significant others, health care professionals). The program involves 20 two-hour weekly group meetings with two facilitators, is manual-based, and has specific goals to accomplish each week. Here, we review the background and development of the program, and present preliminary efficacy data from a subset of patients which suggest that patients experience improvement in BPD and mood-related symptoms. Survey results suggest moderate to high levels of satisfaction for the treatment from patients and therapists. A new scale, the Borderline Evaluation of Severity Over Time (BEST), developed to measure severity and change in persons with BPD, is described. We propose to conduct additional research to further validate the efficacy of STEPPS.

Blum, N., D. St John, et al. (2008). “Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up.” Am J Psychiatry 165(4): 468-478.

OBJECTIVE: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. METHOD: Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. RESULTS: Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. CONCLUSIONS: STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

DeBattista, C. and K. Mueller (2001). “Is electroconvulsive therapy effective for the depressed patient with comorbid borderline personality disorder?” J ECT 17(2): 91-98.

Among the more common current indications for electroconvulsive therapy (ECT) is treatment-resistant depression. Treatment resistance is correlated with a number of factors, including the presence of comorbid personality disorders, such as borderline personality disorder (BPD). A detailed review of the literature was undertaken and very few reports or studies have dealt specifically with ECT in borderline patients. Thirteen original reports on ECT outcome in personality disordered patients were identified. Depressed patients with a personality disorder, particularly BPD, may have a poorer outcome on some measures. However, the available data suggests that depression in these patients can be effectively treated with ECT. The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not. Unfortunately, the literature is limited by lack of rigorous randomized treatment studies, lack of long-term follow-up, and other methodological weaknesses. Clinical guidelines are suggested.

Feske, U., B. H. Mulsant, et al. (2004). “Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder.” Am J Psychiatry 161(11): 2073-2080.

OBJECTIVE: Previous research suggests that the comorbidity of major depression with a personality disorder, especially borderline personality disorder, is associated with a poorer response to ECT. The authors compared the acute outcome of ECT in depressed patients with borderline personality disorder, with personality disorders other than borderline personality disorder, and with no personality disorder. METHOD: The study subjects were 139 patients with a primary diagnosis of unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale. Patients were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner and were assessed with the Hamilton depression scale within 3 days and 4-8 days after completing ECT. RESULTS: Compared to patients with personality disorders other than borderline personality disorder (N=42) and those with no personality disorder (N=77), patients with borderline personality disorder (N=20) had less symptomatic improvement assessed up to 8 days after ECT. Patients with personality disorders other than borderline personality disorder responded as well to ECT as those with no personality disorder. Borderline personality disorder patients were more likely to be female and to have medication-resistant depression than the patients in the two comparison groups; they were also younger. However, none of these differences accounted for the borderline personality disorder patients’ poorer response to ECT. CONCLUSIONS: Patients with borderline personality disorder have a poorer acute response to ECT, but explanations for this finding remain elusive.

McMain, S. F., T. Guimond, et al. (2012). “Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up.” Am J Psychiatry 169(6): 650-661.

OBJECTIVE: The authors conducted a 2-year prospective naturalistic follow-up study to evaluate posttreatment clinical outcomes in outpatients who were randomly selected to receive 1 year of either dialectical behavior therapy or general psychiatric management for borderline personality disorder. METHOD: Patients were assessed by blind raters 6, 12, 18, and 24 months after treatment. The clinical effectiveness of treatment was assessed on measures of suicidal and nonsuicidal self-injurious behaviors, health care utilization, general symptom distress, depression, anger, quality of life, social adjustment, borderline psychopathology, and diagnostic status. The authors conducted between-group comparisons using generalized estimating equation, mixed-effects models, or chi-square statistics, depending on the distribution and nature of the data. RESULTS: Both treatment groups showed similar and statistically significant improvements on the majority of outcomes 2 years after discharge. The original effects of treatment did not diminish for any outcome domain, including suicidal and nonsuicidal self-injurious behaviors. Further improvements were seen on measures of depression, interpersonal functioning, and anger. However, even though two-thirds of the participants achieved diagnostic remission and significant increases in quality of life, 53% were neither employed nor in school, and 39% were receiving psychiatric disability support after 36 months. CONCLUSIONS: One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.

Newton-Howes, G., P. Tyrer, et al. (2006). “Personality disorder and the outcome of depression: meta-analysis of published studies.” Br J Psychiatry 188: 13-20.

BACKGROUND: There is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. AIMS: Meta-analysis of studies in which a categorical assessment of personality disorder or no personality disorder was made in people with depressive disorders, and categorical outcome (recovered/not recovered) also determined. METHOD: Systematic electronic search of the literature for relevant publications. Hand searches of Journal of Affective Disorders and recent reviews, with subsequent meta-analysis of selected studies. RESULTS: Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder (random effects model OR=2.18, 95% CI 1.70-2.80), a robust finding maintained with only Hamilton-type depression criteria at outcome (OR=2.20, 95% CI 1.61-3.01). All treatments apart from electroconvulsive therapy (ECT) showed this poor outcome, and the ECT group was small. CONCLUSIONS: Combined depression and personality disorder is associated with a poorer outcome than depression alone.

Shanks, C., B. Pfohl, et al. (2011). “Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop.” J Pers Disord 25(6): 806-812.

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians’ attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.

Zanarini, M. C., F. R. Frankenburg, et al. (2012). “Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study.” Am J Psychiatry 169(5): 476-483.

OBJECTIVE: The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes. METHOD: A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R. RESULTS: Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%-99%; range for axis II comparison subjects: 97%-99%) but not recovery (40%-60% compared with 75%-85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%-36% compared with 4%-7%; loss of recovery: 20%-44% compared with 9%-28%). CONCLUSIONS: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

Bateman, A. and P. Fonagy (2008). “8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual.” Am J Psychiatry 165(5): 631-638.

OBJECTIVE: This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete. METHOD: Interviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data. RESULTS: Five years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of medication (0.02 versus 1.90 years taking three or more medications), global function above 60 (45% versus 10%), and vocational status (employed or in education 3.2 years versus 1.2 years). CONCLUSIONS: Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.

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