Suicide is a major public health crisis for which effective new interventions are needed. An innovative new brain stimulation technique called magnetic seizure therapy (MST) shows promise for treating suicidal thinking in chronically depressed individuals. Using a high-risk cohort of suicidal patients with borderline personality disorder (BPD) and treatment resistant major depressive disorder (MDD), this study will evaluate the effectiveness of MST for reducing suicidality and depressive symptoms in an open-label clinical trial of up to 15 treatment sessions. Based on research showing that functioning of the dorsolateral prefrontal cortex (DLPFC) may be disrupted in BPD and place individuals at risk for suicide, the DLPFC will be targeted for stimulation. Moderate-to-highly suicidal patients with BPD beginning dialectical behavioural therapy (DBT) will be recruited using a case-control design, comparing individuals receiving MST and DBT with matched patient control group receiving DBT alone.

MST is a novel modification of electroconvulsive therapy (ECT) with the potential for similar clinical effectiveness, fewer side-effects and a more rapid return of orientation and shorter duration of post-ictal confusion. In the proposed study, the investigators will evaluate the clinical effectiveness of MST for the treatment of treatment-resistant depression (TRD) and suicidal ideation in patients with BPD. The study will use a case-control design comparing symptom reports (depression severity and suicidal ideation) and cognitive functioning between outpatients receiving MST plus dialectical behavioral therapy (DBT) and matched patient controls receiving DBT alone. To evaluate potential biomarkers that may underlie the anticipated clinical benefits of MST, functional magnetic resonance imaging (fMRI) will be used to measure activation of the DLPFC and associated neural circuits subserving emotion regulation and cognitive functioning (e.g., impulse control, episodic memory) in BPD.

Objective 1: To evaluate the efficacy of MST as a treatment for suicidal ideation and TRD in BPD.

Hypothesis 1: MST will demonstrate substantial efficacy on objective measures of suicidal ideation and depression.

Objective 2: To evaluate the effects of MST on cognitive functioning in patients with BPD.

Hypothesis 2: MST will have limited, if any, effects on performance on standard neuropsychological measures of attention, memory and executive functioning in patients with BPD.

Objective 3: To explore potential neuroimaging-based biomarkers that may index any changes in suicidal ideation and depression that result from treatment with MST.

Hypothesis 3: On neuroimaging tasks assessing emotion processing and cognitive functioning, patients receiving DBT+MST will show increased activity in bilateral DLPFC after treatment relative to pre-treatment baseline activation, and more activation in this region than patients in DBT without concurrent MST (DBT-only).

Inclusion Criteria:

• MST+DBT Group

  1. English-speaking and able to provide informed consent to participate in the study
  2. Female and between the ages 18 and 50 years
  3. Current DSM-IV (Diagnostic and statistical manual of mental disorders-IV) diagnosis of BPD based on the International Personality Disorder Examination BPD Section (IPDE-BPD)
  4. Current DSM-IV diagnosis of a non-psychotic, major depressive episode, as part of a broader diagnosis of MDD (single episode or recurrent episode), based on the Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P)
  5. Score > 9 (equivalent to moderate-to-severe suicidal ideation) on the Modified Suicidal ideation Scale for at least the two weeks prior to enrolling in the study
  6. Hamilton Rating Scale for Depression (HRSD-24) score > 22 (classified as Very Severe Depression)
  7. Failed to achieve a clinical response to adequate treatment trials of two or more antidepressants during the current depressive episode OR have been unable to tolerate at least two antidepressants as assessed by the Antidepressant Treatment History Form (ATHF)
  8. Deemed appropriate to receive ECT as assessed by an ECT attending psychiatrist and an anesthesiologist
  9. Meets the MST safety criteria
  10. Agreeable to keeping their current antidepressant treatment (if any) constant during the intervention (unless clinically indicated)
  11. Has a close family member, friend, partner, or qualified chaperone able and willing to accompany the patient home after each MST treatment session and
  12. Able to adhere to the intervention schedule.

• DBT-Only Group

  1. English-speaking and able to provide informed consent to participate in the study
  2. Female and between the ages 18 and 50 years
  3. Current DSM-IV diagnosis of BPD based on the International Personality Disorder Examination BPD Section (IPDE-BPD)
  4. Current DSM-5 diagnosis of a non-psychotic, major depressive episode, as part of a broader diagnosis of MDD (single episode or recurrent episode), based on the Structured Clinical Interview for DSM-IV Axis I Disorders--Patient Edition (SCID-I)
  5. Score > 9 (equivalent to moderate-to-severe suicidal ideation) on the Modified Suicidal ideation Scale for at least the two weeks prior to enrolling in the study
  6. Baseline Hamilton Rating Scale for Depression (HRSD-24) score > 22
  7. Failed to achieve a clinical response to adequate treatment trials of two or more antidepressants during the current depressive episode OR have been unable to tolerate at least two antidepressants as assessed by the Antidepressant Treatment History Form (ATHF)
  8. Agreeable to keeping their current antidepressant treatment (if any) constant during the study (unless clinically indicated)

Exclusion Criteria:

• MST+DBT Group

  1. Acute suicidal intent that requires hospitalization to protect harm to self
  2. Any unstable medical and/or neurological condition
  3. Currently pregnant or lactating, or intention to get pregnant during the duration of the study
  4. Not considered sufficiently physically healthy to undergo general anesthesia for any reason
  5. Any significant neurological disorder or condition likely to be associated with increased intracranial pressure or cognitive impairment (e.g., a space occupying brain lesion, a history of stroke, a cerebral aneurysm, a seizure disorder, Parkinson's disease, Huntington's chorea, multiple sclerosis)
  6. Medical condition, medication, or laboratory abnormality that could cause a major depressive episode or significant cognitive impairment in the opinion of the investigator (e.g., hypothyroidism with low thyroid-stimulating hormone (TSH), rheumatoid arthritis requiring high dose prednisone, or Cushing's disease)
  7. Current diagnosis of delirium, dementia or another cognitive disorder secondary to a general medical condition
  8. Diagnosis of a developmental disorder (e.g. Down syndrome, autism-spectrum disorder)
  9. Non-correctable clinically significant sensory impairment (i.e., cannot hear or see well enough to complete the neuropsychological tests)
  10. Lower than eighth-grade reading level as assessed by the Wide Range Achievement Test-Fourth Edition
  11. Alcohol or substance use disorder (relating to opioids or cocaine) currently or within the past 1 month
  12. Diagnosis of a DSM-5 psychotic disorder
  13. Demonstrated a lack of response to ECT during the current or prior depressive episode.
  14. Requires a benzodiazepine with a dose equivalent to lorazepam 2 mg/day or higher or any anticonvulsant due to the potential of these medications to limit the efficacy of both MST and ECT
  15. Intracranial implant (e.g., aneurysm clips, shunts, stimulators, cochlear implants, or electrodes) or any other metal object within or near the head, excluding the mouth, that cannot be safely removed
  16. Has sustained a moderate-to-severe head injury (defined as ≥ 20 min loss of consciousness and/or > 24 hrs post-traumatic amnesia); or
  17. Does not qualify for MRI scanning

• DBT-Only Group

  1. Acute suicidal intent that requires hospitalization to protect harm to self
  2. Any unstable medical and/or neurological condition
  3. Currently pregnant or lactating, or intention to get pregnant during the duration of the study
  4. Any significant neurological disorder or condition likely to be associated with increased intracranial pressure or cognitive impairment (e.g., a space occupying brain lesion, a history of stroke, a cerebral aneurysm, a seizure disorder, Parkinson's disease, Huntington's chorea, multiple sclerosis)
  5. Medical condition, medication, or laboratory abnormality that could cause a major depressive episode or significant cognitive impairment in the opinion of the investigator (e.g., hypothyroidism with low TSH, rheumatoid arthritis requiring high dose prednisone, or Cushing's disease)
  6. Current diagnosis of delirium, dementia or another cognitive disorder secondary to a general medical condition
  7. Diagnosis of a developmental disorder (e.g. Down syndrome, autism-spectrum disorder)
  8. Non-correctable clinically significant sensory impairment (i.e., cannot hear or see well enough to complete the neuropsychological tests)
  9. Lower than eighth-grade reading level as assessed by the Wide Range Achievement Test--Fourth Edition
  10. Alcohol or substance use disorder (relating to opioids or cocaine use) currently or within the past 1 month
  11. Diagnosis of a DSM-5 psychotic disorder
  12. Intracranial implant (e.g., aneurysm clips, shunts, stimulators, cochlear implants, or electrodes) or any other metal object within or near the head, excluding the mouth, that cannot be safely removed
  13. Has sustained a moderate-to-severe head injury (defined as ≥ 20 min loss of consciousness and/or > 24 hrs post-traumatic amnesia)
  14. Does not qualify for MRI scanning