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A feasibility trial of conjoint magnetic seizure therapy and dialectical behavior therapy for suicidal patients with borderline personality disorder and treatment-resistant depression

Nature Mental Health volume 1, pages 45–54 (2023)Cite this article

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Abstract

Non-invasive brain stimulation interventions for treating suicidal ideation in individuals with treatment-resistant depression offer the potential for new therapeutic options for patients with borderline personality disorder (BPD), a condition that responds poorly to antidepressant medications. Here we present a study to explore the application of magnetic seizure therapy (MST) in an open-label pilot trial of moderately to severely suicidal individuals with comorbid BPD and treatment-resistant depression conducted at the Centre for Addiction and Mental Health (Toronto, Canada). Using a non-randomized, case-control design, we investigated the feasibility and initial clinical effects of 5 weeks of conjoint MST and dialectical behaviour therapy (MST + DBT) compared with 5 weeks of DBT alone. Changes in primary symptom outcomes of suicidal ideation on the Modified Scale for Suicide Ideation and clinician-rated depression severity on the Hamilton Rating Scale for Depression – 24 were investigated using multilevel models. Additional outcomes included self-reported depression, BPD symptom severity and cognitive functioning. Out of 62 screened participants, n = 21 were enrolled, and N = 19 completed the intervention (n = 9 MST + DBT and n = 10 DBT only). The intervention was feasible to implement. Conjoint MST + DBT, but not DBT alone, led to a rapid, significant and clinically meaningful reduction in suicidal ideation at 5 weeks that was sustained at four-month follow-up. Conjoint MST + DBT was also associated with significant reductions in clinician-rated depression and BPD interpersonal symptom severity, but neither effect was sustained at four-month follow-up. There were no treatment-related effects on cognition. There were no treatment-related serious adverse events. These findings provide initial evidence to suggest that MST + DBT is a feasible intervention to reduce acute suicide risk in individuals with BPD and warrant further exploration in a sham-controlled randomized clinical trial.

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Fig. 1: CONSORT flow diagram.
Fig. 2: Multilevel-modelling post hoc tests of primary outcomes of suicide ideation and clinician-assessed depression severity and additional outcomes of BPD symptom severity and self-reported depression.
Fig. 3: Individual symptom trajectories of suicidal ideation, clinician-assessed depression severity, total BPD symptom severity and self-reported depression.

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Data availability

Study participants did not consent to have their data shared publicly. Deidentified participant data from all study timepoints, along with data dictionaries and the study protocol, can be made available, beginning 12 months and ending 3 years after publication of this paper, to researchers who provide a methodologically sound proposal that includes a protocol and a statistical analysis plan and is not in conflict with the investigators’ research plans. Proposals should be directed to the corresponding author and will need to be reviewed by the study’s principal investigators. To gain access, data requestors will need to sign a data access agreement.

Code availability

Data were analysed using custom scripts created in freely-available R Programming (v.4.1.2). All custom code used to analyse the data in this manuscript are available on Open Science Framework (OSF): https://osf.io/2hwcg/.

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Acknowledgements

First and foremost, we thank the participants in this study for their time and meaningful contribution to scientific research. This research was supported by a 2014 NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation (BBRF) awarded to A.C.R. and Z.D. (ID: 22376). J.M.T. was supported by a Canadian Institutes of Health Research (CIHR) Fellowship Award (2019–2021). Z.D.’s work has been supported by the CIHR, the National Institutes of Mental Health (NIMH), Brain Canada and the Temerty Family and Grant Family through the Centre for Addiction and Mental Health (CAMH) Foundation and the Campbell Institute. A.C.R. is a BBRF ‘Families for Borderline Personality Disorder Investigator’ and University of Toronto Scarborough Research Excellence Faculty Scholar and reports research grants from the Social Sciences and Humanities Research Council of Canada, American Foundation for Suicide Prevention, CAMH Foundation and the Ministry of Research & Innovation, Province of Ontario. S.F.M. has received research funding from the CIHR. D.M.B. has received research support from the CIHR, NIH, Brain Canada and the Temerty Family through the CAMH Foundation.

Author information

Author notes

  1. These authors contributed equally: Jenna M. Traynor, Anthony C. Ruocco.

Authors and Affiliations

  1. Borderline Personality Disorder Clinic, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

    Jenna M. Traynor, Shelley F. McMain, Nicola Hermanto & Robert Cardish

  2. Department of Psychology, University of Toronto Scarborough, Toronto, Ontario, Canada

    Jenna M. Traynor, Anthony C. Ruocco & Nicola Hermanto

  3. Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada

    Anthony C. Ruocco

  4. Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada

    Anthony C. Ruocco, Shelley F. McMain, Daniel M. Blumberger & Robert Cardish

  5. Clinical Research—General Adult Psychiatry and Health Systems, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

    Anthony C. Ruocco

  6. Temerty Centre for Therapeutic Brain Intervention and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

    Anthony C. Ruocco & Daniel M. Blumberger

  7. Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA

    Zafiris Daskalakis

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Contributions

A.C.R., S.F.M., D.M.B. and Z.D. designed the study and supervised the work. J.M.T., A.C.R., N.H., D.M.B. and Z.D. were involved in preparation and submission of regulatory approvals. J.M.T., S.F.M., N.H., R.C., D.M.B. and Z.D. were involved in data collection. J.M.T. analysed the data and drafted the manuscript. All co-authors discussed the results and commented on the manuscript.

Corresponding author

Correspondence to Anthony C. Ruocco.

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Competing interests

The authors declare the following competing interests: Z.D. has received research and equipment in-kind support for an investigator-initiated study through Brainsway Inc and Magventure Inc. He is also on the scientific advisory board for Brainsway Inc. D.M.B. received research support and in-kind equipment support for an investigator-initiated study from Brainsway Ltd, and he has been the site principal investigator for sponsor-initiated studies for Brainsway Ltd. He also receives in-kind equipment support from Magventure for investigator-initiated studies. He received medication supplies for an investigator-initiated trial from Indivior. He has participated in advisory boards for Welcony Inc and for Janssen. None of these organizations played a role in the conceptualization, design, data collection, analysis, decision to publish or preparation of this manuscript.

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Nature Mental Health thanks Jacopo Lisoni and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Supplementary Tables 1 and 2, Inclusion and Exclusion Criteria, MST Protocol and Anaesthesia, and references.

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Traynor, J.M., Ruocco, A.C., McMain, S.F. et al. A feasibility trial of conjoint magnetic seizure therapy and dialectical behavior therapy for suicidal patients with borderline personality disorder and treatment-resistant depression. Nat. Mental Health 1, 45–54 (2023). https://doi.org/10.1038/s44220-022-00003-x

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