Dropout in Psychotherapy for Personality Disorders: A Systematic Review of Predictors

Introduction: Dropout in psychotherapy for personality disorders is a major challenge, affecting treatment efficacy and mental\r\nhealth care delivery. Influenced by patient characteristics, therapist factors and treatment dynamics, dropout remains prevalent.\r\nThis systematic review identifies predictors of psychotherapy dropout in individuals with personality disorders to inform strate-\r\ngies that enhance treatment engagement.\r\nMethod: A systematic search in PsycINFO, PubMed and Scopus identified 22 studies from 1976 articles. Inclusion criteria re-\r\nquired DSM/ICD-based personality disorder assessments and dropout predictors in psychotherapy. Non-English or non–peer-\r\nreviewed studies were excluded. Screening followed PRISMA guidelines using Rayyan, and study quality was assessed with the\r\nNewcastle–Ottawa Scale (NOS).\r\nResults: Dropout rates ranged from 10.4% to 58%, depending on treatment modality and patient characteristics. Younger age,\r\ncomorbid substance use disorders, emotional dysregulation, distress tolerance difficulties, childhood emotional abuse, therapist\r\nturnover and low motivation were significant predictors of dropout. Conversely, strong therapeutic alliances, mindfulness-based\r\nskills and engagement in phone coaching were associated with improved retention. Other relevant factors included low reflective\r\nfunctioning, lower education levels and socio-economic adversity, such as receiving disability benefits. Only one study identified\r\nlow reflective functioning as a dropout predictor. Systemic factors, including treatment organization and care coordination, also\r\nplayed a crucial role.\r\nConclusions: Addressing dropout requires early engagement strategies, therapist continuity and treatment flexibility. Enhancing\r\ntherapeutic alliance and reflective functioning may be particularly effective in reducing dropout. Systemic improvements, such\r\nas better care coordination and accessibility, are crucial for sustaining engagement and improving psychotherapy outcomes for\r\nindividuals with personality disorders.\r\nRegistration: PROSPERO number: CRD42024509283