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A shocking number of people with borderline personality disorder will also develop major depressive disorder at some point in their lives. This combo presents some diagnostic challenges, but treatment is available.

Plenty of physical and mental health issues increase the risk of depression — from multiple sclerosis to ADHD, and from cancer, HIV, and heart disease to anxiety. When it comes to borderline personality disorder, however, that increased risk is rather extreme. A large study concluded that 83 percent of people diagnosed with BPD will suffer from major depression at some point in their lives. 

Unfortunately, both the diagnostic process and approach to treatment present some challenges. What can you do if you — or someone you love — are facing depression with a diagnosis of borderline personality disorder?

Borderline personality disorder and depression: Diagnostic challenges

A person diagnosed with borderline personality disorder would already clinically be expected to present with several symptoms that are very much reminiscent of some of the diagnostic criteria for major depressive disorder.

Let's take a look at the possible symptoms of depression, as included in the DSM-5:

  • A "depressed mood", which can mean feeling sad, tearful, empty, or low. 
  • Reduced or lost interest in activities that were meaningful before. 
  • A decreased appetite with weight loss, or increased appetite with weight gain. 
  • Psychomotor agitation or retardation, which means a physical speeding up or slowing down that others can see — you can't just subjectively "feel" it. 
  • Insomnia or oversleeping.
  • Fatigue and low energy. 
  • Feelings of excessive or inappropriate guilt or worthlessness. 
  • Being unable to concentrate or make decisions. 
  • Being plagued by thoughts about death or suicide. 

Some of these symptoms overlap with certain diagnostic criteria for borderline personality disorder, for instance:

  • "Frantic efforts to avoid real or imagined abandonment" can conceivably come off as a depressed mood. 
  • A "markedly and persistently unstable self-image" is one of the things clinicians will look for when diagnosing BPD, and inappropriate guilt and worthlessness are part of a negative self-image. 
  • Suicidal behaviors, too, are part of the clinical picture of borderline. 
  • Intense mood swings and frequent feelings of emptiness (which are also part of a depressed mood) are likewise a core part of the symptomatic picture of BPD. 
Borderline personality disorder being a highly stigmatized personality disorder, it will be quite easy for anyone diagnosed with BPD to simply be "waved off" if they approach their doctor saying they think they are depressed. That is a problem for those who are indeed suffering from major depressive disorder, because having depression in addition makes the prognosis worse. Proper diagnosis and treatment is essential. 

What will be involved in the diagnosis of depression?

If your doctor find that you are suffering from depressive symptoms in addition to having borderline personality disorder, the next important thing is that they establish whether those symptoms are transient, temporary, or you meet the diagnostic criteria for major depressive disorder. 

Depressive symptoms that don't warrant a diagnosis of clinical depression usually strike in response to a distressing situation or event, and they may be a way to express anger. Such symptoms may subside on their own, or they can be handled in the context of treatment for borderline personality disorder. Antidepressants don't help in such cases. 

In the case of major depressive disorder, the symptoms someone with BPD can experience match those seen in anyone else with depression. A person will experience at least five of the depressive symptoms above on most days or most of the day for a period of at least two weeks, and must also have either or both of the first two symptoms — a depressed mood or loss of interest in activities. 

In addition, depressed people with borderline personality disorder will often:

  • Experience intense loneliness and feelings of alienation from the world. 
  • Have a sense that they are "bad people". 
  • Suffer from more intense suicidal feelings. 

They may or may not experience "melancholic" symptoms like insomnia, oversleeping, weight gain, or weight loss. 

How is depression with borderline personality disorder treated?

If a diagnosis of major depressive disorder is made, treatment is the next step. Some studies have indicated that antidepressants don't work as well in people with borderline personality disorder as they do in other people, while others conclude that this is not the case. One study therefore recommended that doctors prescribe antidepressants to people with BPD in the exact same manner as they would in people without borderline. 

In addition, however, there's some evidence that the following additional medications may help depressed people who also have BPD:

  • Aripiprazole (Abilify), an atypical antipsychotic. 
  • Olanzapine (Zyprexa), another atypical antipsychotic. 
  • Omega-3 fatty acid supplements. 

At the same time, research has concluded that prescribing lithium to depressed people with borderline personality disorder can be rather dangerous, because suicidal feelings may lead to overdose. This drug is also not particularly successful in alleviating depressive symptoms in folks with BPD. 

Other treatment options for people with a dual diagnosis of major depressive disorder and borderline personality disorder include:

  • Talk therapy, particularly the dialectic behavior therapy that was actually originally designed to help people with BPD. 
  • Electroconvulsive therapy — which is now a very safe and effective treatment administered under general anesthesia, though it can have some side effects.

A final word

If you have been diagnosed with borderline personality disorder and are feeling depressed, let your doctor know — and do not let them wave your symptoms off as "just a part of BPD". Similarly, if someone you love has borderline personality disorder, and you have noticed that they appear to be depressed, please encourage them to seek medical attention.

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