Dropout from psychological treatment for borderline personality disorder: a multilevel survival meta-analysis

Abstract

Background Dropout from psychotherapy for borderline personality disorder (BPD) is a notorious problem. We investigated whether treatment, treatment format, treatment setting, substance use exclusion criteria, proportion males, mean age, country, and other variables influenced dropout. Methods From Pubmed, Embase, Cochrane, Psycinfo and other sources, 111 studies (159 treatment arms, N = 9100) of psychotherapy for non-forensic adult patients with BPD were included. Dropout per quarter during one year of treatment was analyzed on participant level with multilevel survival analysis, to deal with multiple predictors, nonconstant dropout chance over time, and censored data. Multiple imputation was used to estimate quarter of drop-out if unreported. Sensitivity analyses were done by excluding DBT-arms with deviating push-out rules. Results Dropout was highest in the first quarter of treatment. Schema therapy had the lowest dropout overall, and mentalization-based treatment in the first two quarters. Community treatment by experts had the highest dropout. Moreover, individual therapy had lowest dropout, group therapy highest, with combined formats in-between. Other variables such as age or substance-use exclusion criteria were not associated with dropout. Conclusion The findings do not support claims that all treatments are equal, and indicate that efforts to reduce dropout should focus on early stages of treatment and on group treatment.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis

“…On the other hand, more large-scale RCTs are currently underway. For example, Arntz et al ( 2022 ) published an RCT ( n = 495), and reported similar effect sizes for ST compared to TAU on BPD-severity as the present NMA. Fourth, we noticed that not all RCTs including participants with BPD actually measured overall BPD severity.…”

“…To gain more insight into the actual treatment acceptability, future studies should measure treatment drop-out more homogeneously, for example by using similar definitions. A recent meta-analysis by Arntz et al ( 2022 ) investigated dropout rates from psychological treatments for BPD. Based on their findings, they also recommend future studies to better distinguish between different types of dropout (treatment dropout v. study dropout), by defining them more clearly according to guidelines [e.g.…”

Compassion Focused Group Psychotherapy for attachment and relational trauma: Engaging people with a diagnosis of personality disorder

“…It is possible that the attendance level positively correlates with the sustained outcome data and specific attention to the cultivation of safeness in the therapeutic process in CFGP which has been cited as a missing component in other therapies (Barnicot et al, 2022). This attrition rate was lower than that of published literature reviews of treatments for people with a diagnosis of personality disorder which indicated 37% non-completion rate (Arntz et al, 2023;Hummelen et al, 2007;McMurran & Ward, 2010). This study and others have also recommended the use of preparation and engagement programmes to reduce attrition (Barnicot et al, 2022;Haigh &Pearce, 2017;McMurran, 2012;Webb & McMurran, 2009).…”

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

“…"Limited reparenting" is regarded as the most important change mechanism 235 . Therapists try to compensate for the deficits in par enting that patients with BPD experienced during their childhood, while maintaining professional boundaries.…”

“…In many studies, risk of bias was high 17,205 , possibly inflating effect sizes 205 . Dropout rates are high 234 and differ considerably between studies 235 . Furthermore, treatment effects are found to be unstable at follow‐ups 17,205 .…”