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

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.

Effectiveness of Psychological Treatments for Borderline Personality Disorder and Predictors of Treatment Outcomes: A Multivariate Multilevel Meta-Analysis of Data from All Design Types.

We examined the effectiveness of psychotherapies for adult Borderline Personality Disorder (BPD) in a multilevel meta-analysis, including all trial types (PROSPERO ID: CRD42020111351). We tested several predictors, including trial- and outcome type (continuous or dichotomous), setting, BPD symptom domain and mean age. We included 87 studies (N = 5881) from searches between 2013 and 2019 in four databases. We controlled for differing treatment lengths and a logarithmic relationship between treatment duration and effectiveness. Sensitivity analyses were conducted by excluding outliers and by prioritizing total scale scores when both subscale and total scores were reported. Schema Therapy, Mentalization-Based Treatment and reduced Dialectical Behavior Therapy were associated with higher effect sizes than average, and treatment-as-usual with lower effect sizes. General severity and affective instability showed the strongest improvement, dissociation, anger, impulsivity and suicidality/self-injury the least. Treatment effectiveness decreased as the age of participants increased. Dichotomous outcomes were associated to larger effects, and analyses based on last observation carried forward to smaller effects. Compared to the average, the highest reductions were found for certain specialized psychotherapies. All BPD domains improved, though not equally. These findings have a high generalizability. However, causal conclusions cannot be drawn, although the design type did not influence the results.