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Borderline personality disorder traits are not associated with a differential change in global cognitive function during acute course ECT

Open AccessPublished:April 14, 2022DOI:https://doi.org/10.1016/j.brs.2022.04.006

      Abbreviations:

      BPD (borderline personality disorder), ECT (electroconvulsive therapy), QIDS (quick inventory of depressive symptomatology), MoCA (Montreal cognitive assessment), MSI-BPD (McLean Screening Instrument for BPD)

      1. Introduction

      Borderline personality disorder (BPD) is characterized by persistent impairments in emotional regulation and interpersonal relationships [
      • Gunderson J.G.
      Clinical practice. Borderline personality disorder.
      ]. It is highly comorbid with mood, anxiety, and substance use disorders, and when comorbid with major depressive disorder is associated with reduced remission rate for depressive symptoms [
      • Gunderson J.G.
      • Morey L.C.
      • Stout R.L.
      • et al.
      Major depressive disorder and borderline personality disorder revisited: longitudinal interactions.
      ]. Recent evidence has shown that electroconvulsive therapy (ECT) results in equivalent short-term improvement in depressive symptoms among patients who screen positive or negative for BPD traits [
      • Yip A.G.
      • Ressler K.J.
      • Rodriguez-Villa F.
      • Siddiqi S.H.
      • Seiner S.J.
      Treatment outcomes of electroconvulsive therapy for depressed patients with and without borderline personality disorder: a retrospective cohort study.
      ]. Less is known, however, about whether the presence of BPD traits mediates the potential cognitive side effects of ECT. In order to characterize the risks and benefits of ECT treatments in patients with BPD traits, this study assesses changes in global cognitive function during acute course ECT among patients who screen positive or negative for BPD traits.

      2. Methods

      This is a retrospective cohort study of patients aged 16+ receiving ECT at a single center between April 2015 and May 2020. Patients were treated using a Mecta Spectrum 5000Q (Tualatin, OR) with methohexital as the default anesthetic agent (although etomidate, propofol, or ketamine could also be used) and succinylcholine muscle relaxant. Individualized seizure threshold was determined at the time of first treatment [
      • Luccarelli J.
      • McCoy T.H.
      • Seiner S.J.
      • Henry M.E.
      Charge required to induce a seizure during initial dose titration using right unilateral brief pulse electroconvulsive therapy.
      ,
      • Luccarelli J.
      • McCoy T.H.J.
      • Seiner S.J.
      • Henry M.E.
      Total charge required to induce a seizure in a retrospective cohort of patients undergoing dose titration of right unilateral ultrabrief pulse electroconvulsive therapy.
      ], and subsequent treatments were given a default schedule of three times weekly [
      • Luccarelli J.
      • McCoy T.H.
      • Shannon A.P.
      • Forester B.P.
      • Seiner S.J.
      • Henry M.E.
      Rate of continuing acute course treatment using right unilateral ultrabrief pulse electroconvulsive therapy at a large academic medical center.
      ]. As part of routine care, patients were screened using multiple self-reported measures including the Quick Inventory of Depressive Symptomatology Self Report 16 item scale (QIDS; a scale of depression severity), the Montreal Cognitive Assessment (MoCA; a screening measure for global cognitive function) [
      • Nasreddine Z.S.
      • Phillips N.A.
      • Bédirian V.
      • et al.
      The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment.
      ], and the McLean Screening Instrument for BPD (MSI-BPD; a 10-item screening instrument for BPD traits) [
      • Zanarini M.C.
      • Vujanovic A.A.
      • Parachini E.A.
      • Boulanger J.L.
      • Frankenburg F.R.
      • Hennen J.
      A screening measure for BPD: the McLean screening instrument for borderline personality disorder (MSI-BPD).
      ].
      For this study, all patients who completed the baseline screening scales and remained in ECT for at least 10 ± 1 treatments were reassessed using the MoCA, with an alternative version used to reduce practice effects. Patients were divided into two groups, with those answering “yes” to ≥7 MSI-BPI items defined as screening positive for BPD traits (BPD+); patients with MSI-BPD scores <7 were defined as screening negative for BPD traits (BPD-). In prior studies, a score of ≥7 on the MSI-BPD was associated with a sensitivity of 0.81 and a specificity of 0.85 for defining BPD vs. a structured clinical interview [
      • Zanarini M.C.
      • Vujanovic A.A.
      • Parachini E.A.
      • Boulanger J.L.
      • Frankenburg F.R.
      • Hennen J.
      A screening measure for BPD: the McLean screening instrument for borderline personality disorder (MSI-BPD).
      ].
      Baseline differences between treatment groups were analyzed using χ2 tests for categorical variables and two-sided t tests for continuous variables. For the primary statistical analysis, the MoCA score at treatment #10 was analyzed using linear regression, with age, sex, diagnosis (major depressive disorder, bipolar affective disorder, other), initial treatment location (inpatient vs. outpatient), initial QIDS score, initial MoCA, and screening positive or negative for BPD as covariates. In a secondary analysis, we explored factors associated with decline in MoCA of ≥2 points during ECT, representing a clinically-relevant decline on that scale [
      • Wu C.Y.
      • Hung S.J.
      • Lin K.
      • chung
      • Chen K.H.
      • Chen P.
      • Tsay P.K.
      Responsiveness, minimal clinically important difference, and validity of the MoCA in stroke rehabilitation.
      ]. The binary outcome of ≥2 point decline in MoCA vs. < 2 point decline in MoCA (including patients with unchanged or improved scores) was analyzed using logistic regression, with age, sex, diagnosis (major depressive disorder, bipolar affective disorder, other), initial treatment location (inpatient vs. outpatient), initial QIDS score, initial MoCA, and screening positive or negative for BPD as covariates. Analyses were completed using GraphPad Prism (v 9, San Diego, California, USA).

      3. Results

      A total of 915 patients had MoCA data available at baseline and at treatment #10 ± 1. Of these, 154 (16.8%) were BPD + while 761 (83.2%) were BPD- (Table S1). These groups differed in baseline characteristics, with BPD + patients being younger (mean age 34.7 ± 12.4 for BPD + vs. 47.7 ± 17.1 for BPD-) and more likely to begin treatment as inpatients (68.8% for BPD + vs. 58.3% for BPD-). Baseline depression severity was higher for BPD + patients (QIDS 19.4 ± 4.1 for BPD + vs. 16.5 ± 4.8 for BPD-), but the two groups did not differ significantly in baseline global cognitive function (MoCA 26.3 ± 2.9 for BPD + vs. 25.8 ± 3.0 for BPD-), ECT parameters, or other demographics.
      In a linear model of MoCA score at treatment #10, BPD traits were not associated with a differential change in MoCA (estimate −0.347, 95% CI -0.836 to 0.141; P = 0.163). Likewise, sex, age, diagnosis, and initial treatment location were not significantly associated with final MoCA (Table 1). In contrast, initial QIDS and baseline MoCA scores were both positively associated with the final MoCA score.
      Table 1Linear model of MoCA at treatment 10 ± 1, with age, sex, diagnosis (major depressive disorder, bipolar affective disorder, other), initial treatment location (inpatient vs. outpatient), initial QIDS score, initial MoCA, and screening positive or negative for BPD traits as covariates. Bolded values are significant at the level of p < 0.05.
      EstimateCIp
      BPD+−0.347−0.836 to 0.1410.163
      Sex (male)−0.194−0.548 to 0.1600.283
      Age0.00257−0.00830 to 0.01340.643
      Diagnosis
      MDD0.359−0.505 to 1.220.415
      BPAD0.457−0.454 to 1.370.325
      Location (outpatient)0.167−0.187 to 0.5220.354
      Baseline QIDS0.04150.00420 to 0.07890.0292
      Baseline MoCA0.4430.383 to 0.502<0.0001
      In order to specifically examine those patients who demonstrate a clinically-significant worsening in MoCA score with ECT treatment, we conducted a logistic regression on the binary outcome of a ≥2 point decline in MoCA vs. no such decline. In total, 319 patients demonstrated a decline in MoCA of ≥2 points (Fig. 1). In this logistic model, only a higher baseline MoCA score was associated with a higher odds of MoCA decline of ≥2 points (aOR 1.34, 95% CI 1.26 to 1.43; P < 0.0001). BPD traits were not significantly associated with the odds of having a MoCA decline ≥2 points (Table S2).
      Fig. 1
      Fig. 1Histogram of change in MoCA over the course of 10 ECT treatments, stratified by BPD+ (purple) and BPD- (blue). Negative numbers represent reduction in MoCA over the course of ECT treatment, and positive numbers represent improvement in MoCA over the course of treatment. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

      4. Discussion

      Among 915 patients presenting for ECT and then completing a 10 treatment course, screening positive for BPD traits was not associated with a differential change in global cognitive function, as measured by the MoCA. Patients in this sample had a mean reduction in MoCA of 0.5 over 10 treatments, a magnitude of change that is lower than the minimal clinically important difference of 1.22–2.15 that has been determined among stroke patients [
      • Wu C.Y.
      • Hung S.J.
      • Lin K.
      • chung
      • Chen K.H.
      • Chen P.
      • Tsay P.K.
      Responsiveness, minimal clinically important difference, and validity of the MoCA in stroke rehabilitation.
      ]. In our model only baseline cognition and depression severity were associated with final MoCA, with demographic parameters and treatment location not showing a significant association. Screening positive for BPD traits was likewise not associated with a differential change in MoCA, and so these results do not support the idea that BPD + patients are more likely to demonstrate a differential change in global cognitive function. Moreover, BPD traits were not associated with a higher odds of experiencing a clinically significant decline in MoCA score with ECT treatment.
      Strengths of this study include large sample size, consistent assessment of subjects, and consistent treatment methods over the study period. The chief limitation is the use of a single screening tool, the MoCA, as the assessment of global cognitive function. This tool has not been specifically designed for ECT, and it may not optimally track changes in relevant cognitive parameters with treatment. In particular, it does not assess autobiographical memory loss following ECT that is among the most distressing complications noted from treatments [
      • Sackeim H.A.
      Autobiographical memory and ECT: don't throw out the baby.
      ]. Whether these side effects differ in BPD+ and BPD-patients requires further study. Additionally, the MoCA has not previously detected changes in global cognitive function on a group level among patients receiving ECT [
      • Hebbrecht K.
      • Giltay E.J.
      • Birkenhäger T.K.
      • et al.
      Cognitive change after electroconvulsive therapy in mood disorders measured with the Montreal Cognitive Assessment.
      ]. Moreover we are unable to assess the cognitive changes in patients who discontinue treatment before the follow-up MoCA at treatment #10 and thus the estimation of MoCA change is subject to survivorship bias. Some patients may have discontinued treatment because of adverse cognitive effects, and the calculated change in MoCA will not reflect those cognitive changes among those patients without follow-up MoCA. As rates of continuation in ECT differ based on BPD + or BPD-status [

      Luccarelli J, McCoy THJ, Yip AG, Seiner SJ, Henry ME. The duration in treatment with electroconvulsive therapy among patients screening positive or negative for borderline personality disorder traits: a retrospective cohort study. J ECT. doi:10.1097/YCT.0000000000000847.

      ], this introduces an additional cofounding effect. Furthermore, assignment to BPD+ and BPD-groups is based on a screening instrument and not a structured clinical diagnosis of borderline personality disorder. As a result, some of those BPD + patients may not meet full criteria for borderline personality disorder, and so these results may not generalize to patients with formal personality disorder diagnoses. Finally, as we only assess cognitive outcomes following treatment #10, we are unable to assess the long-term cognitive or depressive outcomes in patients, and how these may be modulated by BPD status. Existing data suggests that even 8 days out from treatment the response to ECT is lower in BPD patients [
      • Feske U.
      • Mulsant B.H.
      • Pilkonis P.A.
      • et al.
      Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder.
      ], and it is unknown whether groups diverge more significantly during longer follow-up.

      5. Conclusion

      Among 915 patients receiving 10 acute course ECT treatments, screening positive for BPD traits was not associated with a differential change in global cognitive function, as measured by the MoCA, nor were BPD traits associated with a higher odds of experiencing a clinically significant MoCA decline.

      Funding

      This work was supported by the National Institute of Mental Health ( R25MH094612 , JL; R01MH120991 , THM; 5R01MH112737-03 , MEH) The sponsors had no role in study design, writing of the report, or data collection, analysis, or interpretation.

      Declaration of competing interest

      THM receives research funding from the Stanley Center at the Broad Institute , the Brain and Behavior Research Foundation , National Institute of Mental Health , National Human Genome Research Institute Home, and Telefonica Alfa . The remaining authors have no disclosures to report.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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