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Is research on borderline personality disorder underfunded by the National Institute of Health?
Psychiatry Research 220 (2014) 941–944
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Is research on borderline personality disorder underfunded by the National Institute of Health? Mark Zimmerman a,b,n, Doug Gazarian a,b a b
Department of Psychiatry and Human Behavior, Brown Medical School, USA Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 16 August 2014 Received in revised form 20 September 2014 Accepted 28 September 2014 Available online 7 October 2014
The relationship between bipolar disorder and borderline personality disorder has generated intense interest. Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, are chronically unemployed, abuse substances, attempt and commit suicide. However, one significant difference between the two disorders is that patients with borderline personality disorder are often viewed negatively by mental health professionals. In the present paper we examined whether this negative bias against borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder. The yearly mean number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder. Results were the same when focusing on newly funded grants. For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder. Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622 million vs. $55 million). These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder. & 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bipolar disorder Borderline personality disorder Funding
1. Introduction The relationship between bipolar disorder and borderline personality disorder has generated intense interest with several review articles and commentaries examining and discussing their interface and differential diagnosis (Dolan-Sewell et al., 2001; Paris, 2004; Smith et al., 2004; Sripada and Silk, 2007; Antoniadis et al., 2012; Belli et al., 2012; Coulston et al., 2012; Elisei et al., 2012; Barroilhet et al., 2013; Bayes et al., 2014; Ghaemi et al., 2014). Both bipolar disorder and borderline personality disorder are serious mental health disorders resulting in significant psychosocial morbidity, reduced health related quality of life, and excess mortality. In largely separate literatures both disorders have been associated with impaired occupational functioning (Skodol et al., 2002; Morgan et al., 2005; Kessler et al., 2006; Ansell et al., 2007; Zanarini et al., 2009; Zimmerman et al., 2010), impaired social functioning (Jovev and Jackson, 2006; Grant et al., 2008; Judd et al., 2008; Gunderson et al., 2011; Miklowitz, 2011;
n
Corresponding author at: 146 West River Street, Providence, RI 02904, USA. E-mail address: [email protected] (M. Zimmerman).
http://dx.doi.org/10.1016/j.psychres.2014.09.021 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
Jeung and Herpertz, 2014; Lazarus et al., 2014), substance use problems (Trull et al., 2000; Goldberg, 2001; Grant et al., 2008; Oquendo et al., 2010; Farren et al., 2012; Di Florio et al., 2014), high rates of suicide (Isometsa et al., 1994; Angst et al., 2002; Pompili et al., 2005; Baldessarini et al., 2006; McIntyre et al., 2008; Oquendo et al., 2010;) and suicide attempts, (Baldessarini et al., 2006; McIntyre et al., 2008; Oquendo et al., 2010; Zimmerman et al., 2014), and high health care utilization and costs (Bender et al., 2001; Morgan et al., 2005; Kessler et al., 2006; van Asselt et al., 2007; Soeteman et al., 2008; Dilsaver, 2011; Williams et al., 2011; Kleine-Budde et al., 2013). While both disorders are associated with high levels of morbidity and mortality, they are perceived differently. For some, bipolar disorder has been considered a desirable diagnosis (Chan and Sireling, 2010). Celebrities have appeared on the cover of popular press magazines with accompanying articles discussing their bipolar disorder diagnosis. In contrast, patients with personality disorders in general, and borderline personality disorder in particular, are viewed negatively and more difficult to treat by mental health professionals (Lewis and Appleby, 1988; Gallop et al., 1989; Cleary et al., 2002). They are the patients that some clinicians are reluctant to treat (Lewis and
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M. Zimmerman, D. Gazarian / Psychiatry Research 220 (2014) 941–944
Appleby, 1988; Black et al., 2011). Clinicians perceive patients with personality disorders as less mentally ill, more manipulative, and more able to control their behavior than patients with other psychiatric disorders (Lewis and Appleby, 1988; Markham and Trower, 2003). Consistent with this, clinicians have less sympathetic attitudes and behave less empathically towards patients with borderline personality disorder (Fraser and Gallop, 1993; Markham and Trower, 2003). The term borderline is sometimes used pejoratively to describe patients (Cleary et al., 2002). The question we raise in the present paper is whether the negative professional attitudes towards patients with borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder and tested the hypothesis that borderline personality disorder has received less funding.
2. Methods The NIH RePORT website was established in response to the 2009 Memorandum on Transparency and Open Government. The NIH RePORT provides statistics, data, and information about funded grants, and allows for different types of queries. For example, it is possible to search for grants based on the name of the principal investigator, location of the awardee, type of award, or date of the award. We focused our search on the title of grants. The search terms were “bipolar disorder” and “borderline.” A search on the term “borderline personality disorder” missed some relevant grants, therefore, we used the more inclusive term and then reviewed the selected titles. We also searched on the terms “BPD,” “personality disorder,” “bipolar I disorder” and “bipolar II disorder.” The RePORT site allows the user to identify grants funded for each year from 1990 to 2014. Both the year of grant funding and the amount of funding are listed. For each year we determined the number of new grants that were funded, the total number of grants that were funded, and the total dollar amount of funding.
Table 1 Number of National Institute of Health grants and amount of funding for bipolar disorder and borderline personality disorder from 1990 to 2014. Year
Bipolar disorder Total Newly grants funded grants (n) funded (n)
1990 3 1991 4 1992 9 1993 7 1994 3 1995 10 1996 7 1997 3 1998 15 1999 9 2000 13 2001 15 2002 11 2003 21 2004 17 2005 21 2006 17 2007 39 2008 27 2009 27 2010 19 2011 21 2012 25 2013 10 2014 2 Total 355
11 14 25 28 24 30 40 32 41 51 59 69 52 63 98 114 132 163 144 157 136 119 116 102 24 1844
Borderline personality disorder Total Total funding Newly grants funded grants (n) funded (n) $2,004,836 0 $3,003,492 1 $4,473,105 2 $5,159,879 1 $4,118,416 0 $3,557,420 3 $6,550,568 1 $5,740,694 2 $10,380,573 0 $14,050,899 4 $20,717,834 2 $21,603,689 0 $16,666,418 4 $20,376,447 2 $27,814,937 5 $33,271,837 3 $38,421,171 4 $63,375,970 3 $56,474,671 2 $64,744,825 2 $58,943,991 5 $49,792,298 1 $45,557,268 2 $38,367,856 2 $7,361,735 0 $622,530,829 52
1 1 3 3 5 7 5 11 6 11 10 5 9 8 17 17 19 22 25 22 20 15 11 9 2 264
Total funding
$84,568 $62,384 $284,859 $497,216 $630,408 $873,506 $710,548 $2,189,999 $1,156,326 $991,219 $1,871,688 $1,506,917 $2,879,515 $2,734,969 $3,826,255 $3,599,234 $2,939,448 $4,490,133 $4,622,208 $3,872,877 $4,555,618 $3,918,852 $4,057,320 $3,024,843 $334,986 $55,715,896
3. Results Across the 25 year period the yearly mean 7S.D. number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder (73.8 749.2 vs. 10.6 77.2, t(48) ¼6.36, p o0.001). For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder (Table 1). Focusing on newly funded grants, a similar 7-fold difference in funding favoring bipolar disorder was found across the 25 years (14.2 79.3 vs. 2.0 71.5, t(48) ¼6.46, p o0.001). Consistent with the difference in the number of grants funded, the amount of yearly funding support (in millions of dollars) was significantly greater for bipolar disorder (24.9721.3 vs. 2.2 71.6, t(48) ¼5.30, p o0.001). Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622.5 million vs. $55.7 million), and this was consistent throughout the 25 years (Fig. 1).
4. Discussion Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, visit emergency rooms, are chronically unemployed, abuse substances, attempt and commit suicide. The only study directly comparing patients with the two disorders found that the level of psychosocial morbidity in depressed patients with borderline personality disorder was as great, or greater, than that found in patients with bipolar depression (Zimmerman et al., 2013). Yet, borderline personality disorder has received less than one-tenth the research
Fig. 1. Funding levels from the National Institute of Health for bipolar disorder and borderline personality disorder over 5-year intervals of the past 25 years (in millions of dollars).
funding from NIH as has bipolar disorder, and this has persisted over the past 25 years. On average only 2 new grants have been funded per year for borderline personality disorder, and in some years no new grants were funded. In contrast, in the majority of the past 25 years more than 10 new grants were funded for bipolar disorder. These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate
M. Zimmerman, D. Gazarian / Psychiatry Research 220 (2014) 941–944
with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder, and that compared to bipolar disorder, borderline personality disorder has been significantly, and consistently, underfunded by the NIH during the past 25 years. Why has borderline personality disorder been less well funded compared to bipolar disorder? Perhaps our search strategy of the NIH website biased the results. That is, perhaps by focusing on the titles of grants we overlooked grants on topics such as parasuicidality, aggression, or impulsivity that were primarily focused on borderline personality disorder. We changed our search strategy to include borderline personality disorder and bipolar disorder in the abstracts as well as the titles of the grants. For the year 2013 the revised search strategy increased the number of grants to 26 for borderline personality disorder and 291 for bipolar disorder. However, broadening the search strategy in this manner was overinclusive. For example, for bipolar disorder this search strategy included grants entitled “Epigenetic Mechanisms of Memory Storage,” “Identification of Genetic Determinants of Schizophrenia Related Phenotypes,” and “Cholinergic Mechanism of REM Sleep Generation,” which are not primarily grants about bipolar disorder. For borderline personality disorder the revised search strategy included grants entitled “Course and Outcome of Bipolar Disorder in Youth,” “The Effects of Intranasal Oxytocin on Social Cognitive Functioning in Adolescents,” and “MARC: Risk Mechanisms in Alcoholism and Comorbidity,” which are not primarily grants about borderline personality disorder. Thus, we do not believe that limiting our search to the titles of grants was responsible for the results. Alternatively, perhaps our search terms were too narrow. That is, perhaps searching on the terms “personality disorders” or “personality” might have been more appropriate. For 2013, a search of grant titles with the term personality disorders or just personality yielded 5 and 23 grants, respectively. However, again the more expansive term included grants that were not focused on borderline personality disorder (e.g., “Basic Research in Personality: Aging,” “Personality and Health – a Longitudinal Study,” “Telomere Length as an Outcome in Lifespan Models of Personality and Health”). Thus, we do not believe that our search strategy was responsible for our results. Perhaps seven times fewer grants have been submitted on borderline personality disorder compared to bipolar disorder thus resulting in seven times fewer grants receiving funding. Or perhaps, the number of submitted grants was similar, but the quality of the grants for borderline personality disorder was poorer. We were unable to determine the number of grants submitted for each disorder, the percentage of grants funded, and the reasons for rejection. Greater financial support from grass roots organizations such as NARSAD might make bipolar disorder grants more competitive for federal funding. NARSAD provides seed money for pilot projects thereby allowing the collection of preliminary data which increases the likelihood of funding success. Borderline personality disorder is a relatively new diagnostic category, recognized in an official nomenclature for the first time in 1980. Bipolar disorder, on the other hand, has a much longer history, and the cadre of researchers is deeper and broader, and the pedigree of some researchers more prominent. This could contribute to possible differences in the number of grants submitted, and the quality of such grants. However, the differential in research funding has now sustained itself for 35 years after the official recognition of borderline personality disorder as a diagnostic entity, and its informal recognition predated DSM-III's publication in 1980. Moreover, if there were a desire to stimulate research commensurate with its morbidity and mortality, then NIH could incentivize grant submissions in the area. Rather than differences in the number or quality of the grants, perhaps the topic of the grants differed, and the focus of the
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bipolar disorder grants was more consistent with NIH funding priorities. Bipolar disorder is considered more of a biological and genetic disorder than is borderline personality disorder (Ghaemi et al., 2014), and the degree to which biological and genetic studies are prioritized over psychosocial studies might have favored funding studies of bipolar disorder. Related to the presumed more biogenetic nature of bipolar disorder compared to borderline personality disorder, perhaps there is a bias towards funding research for a disorder that is considered more representative of a medical illness and for which there is the hope of “finding a cure.” Analogous to patients' pursuit of alternative pharmacological treatments in their search for the “magic pill,” funding agencies might provide more research dollars for those disorders in which there is hope of one day discovering a brain lesion, genetic mutation, or biomarker. The stigma associated with borderline personality disorder might negatively bias reviewers against providing research support. As noted in Section 1, clinicians have a negative bias against borderline personality disorder. Why would such a negative professional attitude not be expected to also be present in grant reviewers and funding decision makers? Bipolar disorder has achieved greater public acceptance, with increasing numbers of public figures and celebrities acknowledging their bipolar disorder. Multiple websites identify well-known, respected, and admired, artists, actors, writers, and politicians who are thought to have had (or acknowledge having) bipolar disorder. Wikipedia has an entry entitled “List of people with bipolar disorder” which includes more than 150 names. A Google search lists numerous websites identifying famous people with bipolar disorder, and, in fact, there is a website “www.famousbipolarpeople.com”. In contrast, a search for “Famous people with borderline personality disorder” includes only a small number of sites that speculate about celebrities who might have the disorder. There is no Wikipedia entry, nor a “famousborderlinepeople.com” website. We cannot help but wonder whether a generally negative professional view of borderline personality disorder, and a more favorable public and professional perception of bipolar disorder, has influenced funding decisions and priorities. Some researchers question the validity of borderline personality disorder as a diagnostic entity. In fact, some experts of bipolar disorder suggest that borderline personality disorder should be subsumed under the bipolar spectrum rubric (Akiskal, 2004; Smith et al., 2004). While there may be questions about the boundary of bipolar disorder (Zimmerman, 2012), few question its validity. The longstanding controversy and indecision about how to define personality disorders, most recently reflected in the debate about how to define personality disorders in DSM-5 (Gunderson, 2013; Skodol et al., 2013; Widiger, 2013), might cause pause amongst funding agencies. Perhaps by selecting bipolar disorder as the comparator for evaluating the level of funding for borderline personality disorder we chose a disorder that has been particularly well funded and, therefore, our results were biased towards finding that borderline personality disorder has been relatively underfunded. However, even social anxiety disorder (social phobia), which has been considered a prime example of contemporary overpathologizing of normal variants (Wakefield et al., 2005), and which has not been generally linked to high rates of hospitalization, emergency room visits, suicide attempts, or completed suicide, has received nearly as much research funding during the past 25 years as borderline personality disorder ($51.2 million vs. $55.7 million). Whatever the reason, our analysis of the NIH research portfolio of grant support during the past 25 years suggests that despite the high public health costs of borderline personality disorder, that are comparable or greater than that of bipolar disorder, research funding lags far behind.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Is research on borderline personality disorder underfunded by the National Institute of Health? Mark Zimmerman a,b,n, Doug Gazarian a,b a b
Department of Psychiatry and Human Behavior, Brown Medical School, USA Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 16 August 2014 Received in revised form 20 September 2014 Accepted 28 September 2014 Available online 7 October 2014
The relationship between bipolar disorder and borderline personality disorder has generated intense interest. Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, are chronically unemployed, abuse substances, attempt and commit suicide. However, one significant difference between the two disorders is that patients with borderline personality disorder are often viewed negatively by mental health professionals. In the present paper we examined whether this negative bias against borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder. The yearly mean number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder. Results were the same when focusing on newly funded grants. For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder. Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622 million vs. $55 million). These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder. & 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Bipolar disorder Borderline personality disorder Funding
1. Introduction The relationship between bipolar disorder and borderline personality disorder has generated intense interest with several review articles and commentaries examining and discussing their interface and differential diagnosis (Dolan-Sewell et al., 2001; Paris, 2004; Smith et al., 2004; Sripada and Silk, 2007; Antoniadis et al., 2012; Belli et al., 2012; Coulston et al., 2012; Elisei et al., 2012; Barroilhet et al., 2013; Bayes et al., 2014; Ghaemi et al., 2014). Both bipolar disorder and borderline personality disorder are serious mental health disorders resulting in significant psychosocial morbidity, reduced health related quality of life, and excess mortality. In largely separate literatures both disorders have been associated with impaired occupational functioning (Skodol et al., 2002; Morgan et al., 2005; Kessler et al., 2006; Ansell et al., 2007; Zanarini et al., 2009; Zimmerman et al., 2010), impaired social functioning (Jovev and Jackson, 2006; Grant et al., 2008; Judd et al., 2008; Gunderson et al., 2011; Miklowitz, 2011;
n
Corresponding author at: 146 West River Street, Providence, RI 02904, USA. E-mail address: [email protected] (M. Zimmerman).
http://dx.doi.org/10.1016/j.psychres.2014.09.021 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
Jeung and Herpertz, 2014; Lazarus et al., 2014), substance use problems (Trull et al., 2000; Goldberg, 2001; Grant et al., 2008; Oquendo et al., 2010; Farren et al., 2012; Di Florio et al., 2014), high rates of suicide (Isometsa et al., 1994; Angst et al., 2002; Pompili et al., 2005; Baldessarini et al., 2006; McIntyre et al., 2008; Oquendo et al., 2010;) and suicide attempts, (Baldessarini et al., 2006; McIntyre et al., 2008; Oquendo et al., 2010; Zimmerman et al., 2014), and high health care utilization and costs (Bender et al., 2001; Morgan et al., 2005; Kessler et al., 2006; van Asselt et al., 2007; Soeteman et al., 2008; Dilsaver, 2011; Williams et al., 2011; Kleine-Budde et al., 2013). While both disorders are associated with high levels of morbidity and mortality, they are perceived differently. For some, bipolar disorder has been considered a desirable diagnosis (Chan and Sireling, 2010). Celebrities have appeared on the cover of popular press magazines with accompanying articles discussing their bipolar disorder diagnosis. In contrast, patients with personality disorders in general, and borderline personality disorder in particular, are viewed negatively and more difficult to treat by mental health professionals (Lewis and Appleby, 1988; Gallop et al., 1989; Cleary et al., 2002). They are the patients that some clinicians are reluctant to treat (Lewis and
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Appleby, 1988; Black et al., 2011). Clinicians perceive patients with personality disorders as less mentally ill, more manipulative, and more able to control their behavior than patients with other psychiatric disorders (Lewis and Appleby, 1988; Markham and Trower, 2003). Consistent with this, clinicians have less sympathetic attitudes and behave less empathically towards patients with borderline personality disorder (Fraser and Gallop, 1993; Markham and Trower, 2003). The term borderline is sometimes used pejoratively to describe patients (Cleary et al., 2002). The question we raise in the present paper is whether the negative professional attitudes towards patients with borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder and tested the hypothesis that borderline personality disorder has received less funding.
2. Methods The NIH RePORT website was established in response to the 2009 Memorandum on Transparency and Open Government. The NIH RePORT provides statistics, data, and information about funded grants, and allows for different types of queries. For example, it is possible to search for grants based on the name of the principal investigator, location of the awardee, type of award, or date of the award. We focused our search on the title of grants. The search terms were “bipolar disorder” and “borderline.” A search on the term “borderline personality disorder” missed some relevant grants, therefore, we used the more inclusive term and then reviewed the selected titles. We also searched on the terms “BPD,” “personality disorder,” “bipolar I disorder” and “bipolar II disorder.” The RePORT site allows the user to identify grants funded for each year from 1990 to 2014. Both the year of grant funding and the amount of funding are listed. For each year we determined the number of new grants that were funded, the total number of grants that were funded, and the total dollar amount of funding.
Table 1 Number of National Institute of Health grants and amount of funding for bipolar disorder and borderline personality disorder from 1990 to 2014. Year
Bipolar disorder Total Newly grants funded grants (n) funded (n)
1990 3 1991 4 1992 9 1993 7 1994 3 1995 10 1996 7 1997 3 1998 15 1999 9 2000 13 2001 15 2002 11 2003 21 2004 17 2005 21 2006 17 2007 39 2008 27 2009 27 2010 19 2011 21 2012 25 2013 10 2014 2 Total 355
11 14 25 28 24 30 40 32 41 51 59 69 52 63 98 114 132 163 144 157 136 119 116 102 24 1844
Borderline personality disorder Total Total funding Newly grants funded grants (n) funded (n) $2,004,836 0 $3,003,492 1 $4,473,105 2 $5,159,879 1 $4,118,416 0 $3,557,420 3 $6,550,568 1 $5,740,694 2 $10,380,573 0 $14,050,899 4 $20,717,834 2 $21,603,689 0 $16,666,418 4 $20,376,447 2 $27,814,937 5 $33,271,837 3 $38,421,171 4 $63,375,970 3 $56,474,671 2 $64,744,825 2 $58,943,991 5 $49,792,298 1 $45,557,268 2 $38,367,856 2 $7,361,735 0 $622,530,829 52
1 1 3 3 5 7 5 11 6 11 10 5 9 8 17 17 19 22 25 22 20 15 11 9 2 264
Total funding
$84,568 $62,384 $284,859 $497,216 $630,408 $873,506 $710,548 $2,189,999 $1,156,326 $991,219 $1,871,688 $1,506,917 $2,879,515 $2,734,969 $3,826,255 $3,599,234 $2,939,448 $4,490,133 $4,622,208 $3,872,877 $4,555,618 $3,918,852 $4,057,320 $3,024,843 $334,986 $55,715,896
3. Results Across the 25 year period the yearly mean 7S.D. number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder (73.8 749.2 vs. 10.6 77.2, t(48) ¼6.36, p o0.001). For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder (Table 1). Focusing on newly funded grants, a similar 7-fold difference in funding favoring bipolar disorder was found across the 25 years (14.2 79.3 vs. 2.0 71.5, t(48) ¼6.46, p o0.001). Consistent with the difference in the number of grants funded, the amount of yearly funding support (in millions of dollars) was significantly greater for bipolar disorder (24.9721.3 vs. 2.2 71.6, t(48) ¼5.30, p o0.001). Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622.5 million vs. $55.7 million), and this was consistent throughout the 25 years (Fig. 1).
4. Discussion Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, visit emergency rooms, are chronically unemployed, abuse substances, attempt and commit suicide. The only study directly comparing patients with the two disorders found that the level of psychosocial morbidity in depressed patients with borderline personality disorder was as great, or greater, than that found in patients with bipolar depression (Zimmerman et al., 2013). Yet, borderline personality disorder has received less than one-tenth the research
Fig. 1. Funding levels from the National Institute of Health for bipolar disorder and borderline personality disorder over 5-year intervals of the past 25 years (in millions of dollars).
funding from NIH as has bipolar disorder, and this has persisted over the past 25 years. On average only 2 new grants have been funded per year for borderline personality disorder, and in some years no new grants were funded. In contrast, in the majority of the past 25 years more than 10 new grants were funded for bipolar disorder. These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate
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with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder, and that compared to bipolar disorder, borderline personality disorder has been significantly, and consistently, underfunded by the NIH during the past 25 years. Why has borderline personality disorder been less well funded compared to bipolar disorder? Perhaps our search strategy of the NIH website biased the results. That is, perhaps by focusing on the titles of grants we overlooked grants on topics such as parasuicidality, aggression, or impulsivity that were primarily focused on borderline personality disorder. We changed our search strategy to include borderline personality disorder and bipolar disorder in the abstracts as well as the titles of the grants. For the year 2013 the revised search strategy increased the number of grants to 26 for borderline personality disorder and 291 for bipolar disorder. However, broadening the search strategy in this manner was overinclusive. For example, for bipolar disorder this search strategy included grants entitled “Epigenetic Mechanisms of Memory Storage,” “Identification of Genetic Determinants of Schizophrenia Related Phenotypes,” and “Cholinergic Mechanism of REM Sleep Generation,” which are not primarily grants about bipolar disorder. For borderline personality disorder the revised search strategy included grants entitled “Course and Outcome of Bipolar Disorder in Youth,” “The Effects of Intranasal Oxytocin on Social Cognitive Functioning in Adolescents,” and “MARC: Risk Mechanisms in Alcoholism and Comorbidity,” which are not primarily grants about borderline personality disorder. Thus, we do not believe that limiting our search to the titles of grants was responsible for the results. Alternatively, perhaps our search terms were too narrow. That is, perhaps searching on the terms “personality disorders” or “personality” might have been more appropriate. For 2013, a search of grant titles with the term personality disorders or just personality yielded 5 and 23 grants, respectively. However, again the more expansive term included grants that were not focused on borderline personality disorder (e.g., “Basic Research in Personality: Aging,” “Personality and Health – a Longitudinal Study,” “Telomere Length as an Outcome in Lifespan Models of Personality and Health”). Thus, we do not believe that our search strategy was responsible for our results. Perhaps seven times fewer grants have been submitted on borderline personality disorder compared to bipolar disorder thus resulting in seven times fewer grants receiving funding. Or perhaps, the number of submitted grants was similar, but the quality of the grants for borderline personality disorder was poorer. We were unable to determine the number of grants submitted for each disorder, the percentage of grants funded, and the reasons for rejection. Greater financial support from grass roots organizations such as NARSAD might make bipolar disorder grants more competitive for federal funding. NARSAD provides seed money for pilot projects thereby allowing the collection of preliminary data which increases the likelihood of funding success. Borderline personality disorder is a relatively new diagnostic category, recognized in an official nomenclature for the first time in 1980. Bipolar disorder, on the other hand, has a much longer history, and the cadre of researchers is deeper and broader, and the pedigree of some researchers more prominent. This could contribute to possible differences in the number of grants submitted, and the quality of such grants. However, the differential in research funding has now sustained itself for 35 years after the official recognition of borderline personality disorder as a diagnostic entity, and its informal recognition predated DSM-III's publication in 1980. Moreover, if there were a desire to stimulate research commensurate with its morbidity and mortality, then NIH could incentivize grant submissions in the area. Rather than differences in the number or quality of the grants, perhaps the topic of the grants differed, and the focus of the
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bipolar disorder grants was more consistent with NIH funding priorities. Bipolar disorder is considered more of a biological and genetic disorder than is borderline personality disorder (Ghaemi et al., 2014), and the degree to which biological and genetic studies are prioritized over psychosocial studies might have favored funding studies of bipolar disorder. Related to the presumed more biogenetic nature of bipolar disorder compared to borderline personality disorder, perhaps there is a bias towards funding research for a disorder that is considered more representative of a medical illness and for which there is the hope of “finding a cure.” Analogous to patients' pursuit of alternative pharmacological treatments in their search for the “magic pill,” funding agencies might provide more research dollars for those disorders in which there is hope of one day discovering a brain lesion, genetic mutation, or biomarker. The stigma associated with borderline personality disorder might negatively bias reviewers against providing research support. As noted in Section 1, clinicians have a negative bias against borderline personality disorder. Why would such a negative professional attitude not be expected to also be present in grant reviewers and funding decision makers? Bipolar disorder has achieved greater public acceptance, with increasing numbers of public figures and celebrities acknowledging their bipolar disorder. Multiple websites identify well-known, respected, and admired, artists, actors, writers, and politicians who are thought to have had (or acknowledge having) bipolar disorder. Wikipedia has an entry entitled “List of people with bipolar disorder” which includes more than 150 names. A Google search lists numerous websites identifying famous people with bipolar disorder, and, in fact, there is a website “www.famousbipolarpeople.com”. In contrast, a search for “Famous people with borderline personality disorder” includes only a small number of sites that speculate about celebrities who might have the disorder. There is no Wikipedia entry, nor a “famousborderlinepeople.com” website. We cannot help but wonder whether a generally negative professional view of borderline personality disorder, and a more favorable public and professional perception of bipolar disorder, has influenced funding decisions and priorities. Some researchers question the validity of borderline personality disorder as a diagnostic entity. In fact, some experts of bipolar disorder suggest that borderline personality disorder should be subsumed under the bipolar spectrum rubric (Akiskal, 2004; Smith et al., 2004). While there may be questions about the boundary of bipolar disorder (Zimmerman, 2012), few question its validity. The longstanding controversy and indecision about how to define personality disorders, most recently reflected in the debate about how to define personality disorders in DSM-5 (Gunderson, 2013; Skodol et al., 2013; Widiger, 2013), might cause pause amongst funding agencies. Perhaps by selecting bipolar disorder as the comparator for evaluating the level of funding for borderline personality disorder we chose a disorder that has been particularly well funded and, therefore, our results were biased towards finding that borderline personality disorder has been relatively underfunded. However, even social anxiety disorder (social phobia), which has been considered a prime example of contemporary overpathologizing of normal variants (Wakefield et al., 2005), and which has not been generally linked to high rates of hospitalization, emergency room visits, suicide attempts, or completed suicide, has received nearly as much research funding during the past 25 years as borderline personality disorder ($51.2 million vs. $55.7 million). Whatever the reason, our analysis of the NIH research portfolio of grant support during the past 25 years suggests that despite the high public health costs of borderline personality disorder, that are comparable or greater than that of bipolar disorder, research funding lags far behind.
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