Dr. Feske and Colleagues Reply

To the Editor: We agree with Dr. Ness that a course of ECT for patients with major depressive disorder and comorbid borderline personality disorder may be worthwhile for a fraction of such patients when other treatments have proved inadequate. Our major point still stands, however: with this group of patients, the prognosis of ECT was poor in the aggregate, and we had no valid basis for predicting which individual patient would benefit. In addition, previous studies have documented relapse rates as high as 84% 6 months after ECT without continuation therapy (1). Thus, even the longer-term prognosis of the patients who do respond with an acute remission of depressive symptoms remains guarded in the absence of an effective follow-up intervention. Adequately powered, randomized clinical trials with long-term follow-up evaluations (i.e., of at least 6-months’ duration) and a comprehensive assessment of symptoms other than depression (i.e., anger, impulsivity, anxiety, substance use, and interpersonal adjustment) are needed to more fully evaluate the advantages and disadvantages of ECT for this subgroup of patients. In the absence of such trials, the expectations about the benefits of ECT for the treatment of depression in patients with borderline personality disorder have to be realistic: ECT alone is unlikely to be a “magic bullet,” and additional interventions, including psychotherapy (e.g., dialectical behavior therapy [2]) and pharmacological treatments, are likely needed to achieve clinically meaningful and sustained improvement for the complex symptoms faced by this population.