by Eric M. Plakun, M.D., DLFAPA, FACPsych  
In the January 17, 2014 issue of Psychiatric News (Volume 49, Number 2), John Gunderson, M.D, outlines the crucial role of borderline personality (BPD) disorder in making patients with major depression into patients with "treatment resistant depression." He also writes of the importance of developing an alliance with patients diagnosed with BPD, and of examining their “psychosocial adaptations” as a path toward improvement in both disorders--BPD and depression.
Gunderson’s piece is spot on and most welcome. For many years the conventional wisdom has been that if one treats the depression, an accompanying personality disorder, like BPD, would also improve. Over time we have learned this is not the case. Studies like the multi site Collaborative Longitudinal Personality Disorder Study (CLPS), led by Andy Skodol, suggest that when depression is combined with a personality disorder, there is persistent functional impairment, extensive treatment utilization and significant suicide risk. Further, personality disorders, especially borderline personality disorder “robustly predicted persistence” of major depressive disorder (Skodol et al., 2011). While Skodol argues convincingly that assessment of personality disorders is essential in patients with major depressive disorder, the sad reality is that for many psychiatrists the most frequent personality diagnosis made is “deferred,” meaning that they defer thinking about whether there is a personality disorder and focus first on treating the depression alone—usually with medications.
According to the American Psychiatric Association Practice Guideline on Borderline Personality Disorder, the most effective treatment modality is not medication, but psychotherapy.
Unfortunately, being blind to personality disorders contributes to the depression becoming what has come to be known as “treatment resistant” depression. The treatment of these depressed patients has been shown by Crowne and colleagues to cost 19 times as much in total medical expenditures as that of depressed patients with more treatment responsive depression. It often turns out that what looks like treatment resistant depression actually reflects resistance on the part of treaters—not patients--to noticing the complicating role of other factors, like personality disorders, in a depressed patient’s failure to respond to treatment. Nearly 80% of the people we treat at Riggs are these so-called “treatment resistant” depressed patients who struggle with both depression and personality disorders. According to the American Psychiatric Association Practice Guideline on BPD, the most effective treatment modality for BPD is not medication, but psychotherapy. We agree. This is why we make intensive individual psychodynamic psychotherapy a foundation of every treatment at Riggs.
Thanks, John, for shedding light on this important issue, which is dear to our hearts. For more about this issue in depth, see the book I edited a few years ago entitled Treatment Resistance and Patient Authority: The Austen Riggs Reader . You can also read Dr. Gunderson’s full article here: Reorienting a Depressed Patient to Address Underlying BPD .