five years through ICD-9-CM codes. Another strength of our study is its large sample size of 510,611 and the reliability of the data, given that the information is coded independently of the individual practitioner and therefore it is subjected to minimal reporting bias. Considering the adverse outcomes, it is clinically imperative to diagnose both bipolar disorder and BPD in patients, and it is also essential to differentiate between both the illnesses [6]. There is still a diagnostic bias for making the final diagnosis in bipolar patients with BPD, and often psychiatrists make the diagnosis that they feel comfortable managing [23]. Psychiatrists need to identify patients’ mood shifts, type of impulsivity, and duration of illness to avoid misdiagnosis of these comorbidities [24,25]. The treatment of bipolar disorder with comorbid BPD can often be challenging due to the lack of evidence-based treatment strategies for optimal management, especially in inpatient settings. The primary treatment for the management of BPD in bipolar patients is psychotherapy [9], which includes psychoanalytic and dialectical behavioral therapies [26]. However, effective psychotropic medication management improves the overall functioning of bipolar patients [9]. In addition, Perugi et al. reported the efficacy of ECT with a favorable clinical outcome in 68.8%
