Can Epidemiology Translate Into Understanding Major Depression With Borderline Personality Disorder?
Authors: Myrna M. Weissman
Journal: American Journal of Psychiatry (2011)

Epidemiologic surveys have mapped the terrain of psychiatric disorders.Personality disorders have bedeviled the clinician's practice.Rarely have these two been rearranged in a meaningful clinical dialogue.Using the largest psychiatric epidemiologic survey ever, the National Epidemiologic Survey on Alcoholism and Related Conditions, and among the few to venture into axis II disorders, Skodol et al. (1), in this issue of the Journal, give a community-based national view of a common clinical question: What is the effect of specific personality disorder comorbidity on the course of major depression?The original sample included over 40,000 adults, and 2,422 met criteria for DSM-IV current major depressive disorder.Three years later, 1,996 of the original currently depressed subjects were available for reinterviewing, which makes both a respectable sample size and response rate for generalizability.However, some caution is needed, since the sample was over-represented with Caucasian, college-educated, and married respondents.Fifteen percent of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence over the follow-up period.These figures are within the range of longitudinal studies of patients with major depressive disorder (2).While the presence of any personality disorder elevated the risk for persistence of major depressive disorder, when all axis I and II disorders, age of onset of major depressive disorder, number of previous episodes, family history, treatment, and duration of illness were controlled, borderline personality disorder remained the most robust predictor of major depressive disorder persistence.Neither personality disorders nor other clinical variables predicted recurrence of major depressive disorder.Thus, an epidemiologic survey yielded a practical jewel.The finding, undoubtedly, does not surprise the clinician but is now confirmed nationally.As the authors conclude, borderline personality disorder should be assessed in all depressed patients and considered in prognosis and addressed in treatment.One can raise a number of methodologic issues about this study, including the use of lay interviewers or the instrument for assessing axis II disorders.The diagnostic interview, the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (3), was developed for this survey.The personality disorders included were adapted from items in the Structured Clinical Interview for DSM-IV Personality Disorders.The test-retest and internal consistency results reported for all personality disorders are fair to good, not great.However, the agreement with clinician interviews for borderline personality disorder (kappa=0.71) is about as good as it gets (4).The only other national survey to venture into assessing all axis II disorders was the National Comorbidity Survey Replication (5), which used the International Personality Disorder Examination.The investigators carried out a clinical reappraisal in a sample of 214 subjects using clinically trained interviewers to follow up screened, positive subjects and reported excellent predictions of classification.They also noted that the International Personality Disorder Examination is commonly regarded as