Personality Disorders: Theory, Research, and Treatment

© 2021 American Psychological Association

ISSN: 1949-2715 https://doi.org/10.1037/per0000453

Dropout Rates From Psychotherapy Trials for Borderline Personality

Disorder: A Meta-Analysis

Evan Alexander Iliakis1, Gabrielle Silva Ilagan1, and Lois Wonsun Choi-Kain1, 2
1
Gunderson Personality Disorders Institute, McLean Hospital, Belmont, Massachusetts, United States
2
Department of Psychiatry, Harvard Medical School

Borderline personality disorder (BPD) is a serious mental illness associated with heightened disability,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

risk for suicide, and costs to society. This study aims to meta-analytically quantify dropout rates from
This document is copyrighted by the American Psychological Association or one of its allied publishers.

psychotherapies of BPD, identify moderators, and assess reasons for dropout and time taken to dropout.
PubMed, PsycINFO, and MEDLINE were screened from database inception to March 2020 for trials
that investigated psychotherapies for individuals with BPD reporting dropout rates. The primary out-
comes were pooled dropout rates and differential treatment retention across all studies, all randomized
controlled trials (RCT), all outpatient studies, and all outpatient RCTs. Random effects meta-analysis,
metaregression analyses, and publication bias tests were conducted. Information on reasons for dropout
and time to dropout was synthesized qualitatively. Dropout rates were 22.3% considering all studies,
and 28.2% when only considering outpatient randomized controlled trials. Odds of dropout were not sig-
nificantly higher in the control condition than in the intervention condition. Longer duration, randomiza-
tion, phone coaching, and outpatient setting were associated with higher dropout rates, but only when
considering all studies. Publication bias-adjusted dropout rates were as high as 29.9%. Reasons for drop-
out included dissatisfaction with treatment, expulsion from treatment, and lack of motivation. Most
dropouts occurred in the first half of treatment. Dropout is an important and prevalent issue in BPD psy-
chotherapies. Reported rates are minimized by publication bias, and moderators of dropout rates are
inconsistent. Subsequent research should identify obstacles to completing treatment and investigate
ways to organize treatment allocation to enhance treatment retention.

Keywords: borderline personality disorder, dropout, psychotherapy, meta-analysis, treatment

Borderline personality disorder (BPD) is associated with signifi-
cant psychosocial impairment (Grant et al., 2008; Skodol et al.,
Gabrielle Silva Ilagan https://orcid.org/0000-0002-1984-1585
Lois Wonsun Choi-Kain https://orcid.org/0000-0003-4459-0412
Evan A. Iliakis is now at the Perelman School of Medicine, University of
Pennsylvania.
There has been no prior dissemination of the data and narrative
interpretations of the data/research appearing in this article. Lois Wonsun
Choi-Kain served as the lead for critical revision of the manuscript for
important intellectual content and for supervision of the study. Evan
Alexander Iliakis, Gabrielle Silva Ilagan, and Lois Wonsun Choi-Kain
contributed equally to study concept and design. Evan Alexander Iliakis and
Gabrielle Silva Ilagan contributed equally to acquisition, analysis, and
interpretation of data. Evan Alexander Iliakis, Gabrielle Silva Ilagan, and Lois
Wonsun Choi-Kain contributed equally to the drafting of the manuscript.
Evan Alexander Iliakis and Gabrielle Silva Ilagan contributed equally to
statistical analysis. Evan Alexander Iliakis and Gabrielle Silva Ilagan served
as co-first authors, each with equal contribution to the manuscript. Both had
full access to all the data in the study and take responsibility for the integrity
of the data and the accuracy of the data analysis.
Correspondence concerning this article should be addressed to Lois
Wonsun Choi-Kain, Gunderson Personality Disorders Institute, McLean
Hospital, 115 Mill Street, Belmont, MA 02478, United States. Email:
lchoikain@partners.org
2005; Zanarini et al., 2005), costs to society (van Asselt et al.,
2007), and mortality (Paris, 2019; Temes et al., 2019). The preva-
lence of BPD in the general population is estimated at 1% to 3%
(Trull et al., 2010; Volkert et al., 2018) and is 10 to 20 times
higher in outpatient and inpatient psychiatric settings (Korzekwa
et al., 2008; Lewis et al., 2019; Soeteman et al., 2008; Zimmerman
et al., 2008). Evidence-based psychotherapies designed specifi-
cally to treat BPD have demonstrated effectiveness in clinical tri-
als in reducing its most self-destructive, disabling, and costly
features (Cristea et al., 2017; Storebø et al., 2020). The opportu-
nity for effective intervention exists, but engagement in treatment
remains challenging (Bender et al., 2006; Lewis et al., 2019).
BPD has been associated with high dropout rates from treatment.
Before the development and testing of manualized psychotherapies
tailored to manage BPD’s self-destructive and interpersonally
unstable features, naturalistic reports on the characteristic treatment
histories described low rates of treatment completion (Gunderson,
et al., 1989; Skodol et al., 1983). In more systematic research pub-
lished after the introduction of BPD specific therapies, meta-
analyses report dropout rates that range from 24% to 32% on av-
erage in medication trials (Vita et al., 2011) and from 25% to
34% in psychotherapy studies (Barnicot et al., 2011; Cristea et
al., 2017; Dixon & Linardon, 2020; Swift & Greenberg, 2012,
2014). There is significant publication bias favoring lower drop-
out rates (Barnicot et al., 2011; Dixon & Linardon, 2020),

1
 2 ILIAKIS, ILAGAN, AND CHOI-KAIN
suggesting that the true dropout rates are likely to be higher.
Dropout from psychotherapy is generally associated with not
only adverse patient outcomes but also systematic drain on time
and resources, which constricts health care access (Barrett et al.,
2008). For personality disorders specifically, dropout has been
associated with more functional impairment and increased hospital-
ization rates, resulting in triple the hospital costs compared to treat-
ment completers (Karterud et al., 2003; Webb & McMurran, 2009).
Evidence-based psychotherapies for BPD are designed to improve
retention using specific treatment strategies that stabilize the work-
ing alliance and attend to risk for dropout (Bornovalova & Daugh-
ters, 2007; Chalker et al., 2015). However, there is insufficient
evidence that these specific measures improve retention (Cristea
et al., 2017; Storebø et al., 2020).
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A recent systematic review of noncompletion of personality dis-
order treatments identified factors associated with dropout, includ-
ing higher personality disorder comorbidity, greater personality
disorder severity, poorer psychosocial functioning, current sub-
stance use, earlier treatment stage, and poor therapeutic alliance
(McMurran et al., 2010). A quantitative meta-analytic review of
dropout in 45 BPD treatment studies (Barnicot et al., 2011) found
minimal evidence on predictors of dropout. Moderators of dropout
identified by a more recent meta-analysis of 40 dialectical behav-
ior therapy (DBT) trials across diagnoses (Dixon & Linardon,
2020) were limited to the availability of phone coaching and a
consultation team, both of which were associated with higher
dropout rates.
This meta-analysis aims to extend the work of previous studies
to provide an updated estimated dropout rate of individuals with
BPD from psychotherapy studies using a comprehensive sample
of controlled and uncontrolled treatment trials published up until
2020. It is the first meta-analysis to do so in depth for BPD psy-
chotherapies since a report published by Barnicot et al. (2011),
which did not include larger and more methodologically rigorous trials
of DBT and MBT (Bateman and Fonagy, 2009; McMain et al., 2009,
2012). This report includes a total of 33 trials published since the
meta-analysis conducted by Barnicot et al. (2011), which enlarged the
number of participants included fourfold (from less than 1,250 to over
4,850). The inclusion of studies published between 2009 and 2020 is
especially relevant, as the past decade has advanced knowledge of
what works in the treatment of BPD (Choi-Kain et al., 2017) and has
improved clinicians’ attitudes toward the diagnosis (Day et al., 2018).
We also aim to investigate the moderating role of several candidate
predictors of dropout and qualitatively examine reasons for and timing
of dropout to evaluate its determinants.
Methods
Identification and Selection of Studies
We screened PubMed, PsycINFO, and MEDLINE from data-
base inception to March 4, 2020, with the search terms (“border-
line personality” OR “borderline personality disorder”) AND
(treatment OR therapy OR intervention) AND trial. Inclusion cri-
teria were as follows: (a) a psychotherapy trial, where psychother-
apy is defined by verbal communication between provider and
patient as well as structured and purposeful therapist–patient
encounters, and therapeutic relationship is established; (b) all study
participants must meet five or more BPD criteria; and (c) treatment
dropout rates (i.e., number starting treatment and number complet-
ing treatment) must be reported. Exclusion criteria were as follows:
(a) a medication trial or combined psychotherapy and medication
trial; (b) a systematic review or meta-analysis; (c) a case report or
case series; and (d) an intervention for families of individuals with
BPD. Study language other than English was not an exclusion crite-
rion. There were no stipulations on follow-up length. To avoid
introducing bias by decoupling study arms and aggregating them in-
dependently, only the intervention arm from each study was
abstracted, and the control arm was only used to compute differen-
tial odds of dropout between group. This led to the exclusion of
studies in which it was impossible to systematically select a single
intervention arm, such as (a) head-to-head designs (e.g., transfer-
ence-focused psychotherapy vs. DBT) and (b) components designs
(DBT-mindfulness vs. DBT-interpersonal effectiveness), unless one
of the components was the standard treatment (e.g., standard DBT
vs. DBT skills vs. DBT individual). Evan Alexander Iliakis and
Gabrielle Silva Ilagan screened all records and assessed risk of bias
in the randomized controlled trials (RCTs); any disagreement was
resolved consensus. This meta-analysis was conducted in accord-
ance with the PRISMA guidelines (Moher et al., 2009). The meta-
analysis was not registered.
Assessment of Bias
We assessed risk of bias in the RCTs included in this analysis at
the study level using the Cochrane Collaboration Risk of Bias
Assessment Tool (Higgins & Green, 2011, Figure 1). We assessed
bias in the following criteria: adequacy of random sequence gener-
ation; allocation concealment; blinding of participants, clinical
personnel, and outcome assessors; incomplete data; selective out-
come reporting; and investigator treatment allegiance.
Data Extraction
Data were extracted using piloted forms. Any disagreements
were resolved through consensus. In addition to dropout rates,
we abstracted information on treatment duration, treatment in-
tensity in the form of weekly clinical facetime, treatment setting
(inpatient, outpatient, partial hospital), treatment orientation
(cognitive–behavioral, psychodynamic, other), trial randomiza-
tion, use of phone coaching, presence of consultation team, and
whether the treatment also targeted a comorbid condition in
addition to BPD. Patient-related variables were not abstracted
because considering these at the study level rather than the indi-
vidual level could misleadingly obscure true effects. For the
purposes of this meta-analysis, we abstracted dropout as the pro-
portion of those starting treatment (i.e., attending at minimum
one session) that did not complete treatment. Where reported,
we also abstracted reasons for dropout, number of people drop-
ping out for each reason, and time to dropout.
Meta-Analysis
Comprehensive Meta-Analysis V3 was used to compute a
weighted pooled event (i.e., dropout) rate in the treatment arms of
included trials. For controlled trials, dropout rates were additionally
compared in treatment and control arms through Comprehensive
 BORDERLINE PERSONALITY DISORDER THERAPY DROPOUT 3

Figure 1
Risk of Bias Ratings by Study
Random Blinding of Blinding of Incomplete
Allocation Selective Allegiance
Sequence Participants Outcome Outcome
Concealment Reporting Effect
Generation & Personnel Assessment Data
Amianto et al., 2011
Bateman & Fonagy, 1999
Bateman & Fonagy, 2009
Bateman et al., 2016
Blum et al., 2008
Bos et al., 2010
Doering et al., 2010
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Farrell et al., 2009

Gregory et al., 2008
Harned et al., 2014

Jahangard et al., 2012

Jørgensen et al., 2013
Kramer et al., 2011
Kramer et al., 2014
Kramer et al., 2016
Laurenssen et al., 2018
Leppänen et al., 2016
Linehan et al., 1991
Linehan et al., 1999
Linehan et al., 2002
Linehan et al., 2006
Linehan et al., 2015
McMain et al., 2009
McMain et al., 2017

Morey et al., 2010

Pascual et al., 2015
Reneses et al., 2013
Soler et al., 2009
OC van Wel et al., 2009
NO
L L Verheul et al., 2003
I O Weinberg et al., 2006
NR
E
Note. Risk of bias was rated as low (þ), high (), or unclear (?) using the Cochrane Collaboration Risk of Bias Assessment
Tool. See the online article for the color version of this figure.

Meta-Analysis V3 by means of a weighted pooled odds ratio, where
odds of .1 indicated higher dropout rate in the treatment group.
The computation of weighted pooled odds ratios excluded studies
that reported study dropout but not treatment dropout from control
arms and three studies with head-to-head and components-only
designs because the control conditions in these cases were not
standard treatments as usual or by community experts, as in other
studies. All analyses used random effects models given expected
heterogeneity across trials reported in previous meta-analyses
(Barnicot et al., 2011; Dixon & Linardon, 2020; Swift & Greenberg,
2012). Publication bias was assessed using Egger’s test (Egger et
al., 1997) and Duval and Tweedie’s trim and fill procedure
(Duval & Tweedie, 2000). Using the Knapp-Hartung method
(Tipton et al., 2019), metaregression analysis was conducted on
the study characteristics extracted and the number of risk of bias
criteria that were scored “low”.
 4 ILIAKIS, ILAGAN, AND CHOI-KAIN

Results represented in 13 studies each. Total number of participants was

Selection and Inclusion of Studies
Database screening yielded 2,034 records (1,119 records after
removing duplicates; Figure 2). After an initial screening of titles
and abstracts, 242 full-text articles were assessed for eligibility,
and of these, 62 articles covering 64 studies were included for
quantitative and qualitative synthesis (Table 1). Of these articles,
one (Harned et al., 2014) did not appear in the original search and
was identified as the primary study of a secondary analysis that
did appear in the search. Thirty-nine studies were controlled trials,
with 32 randomized controlled trials; the rest were uncontrolled
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4,888 (84% female) with an average age of 31.3 years.
Meta-Analysis
Meta-analysis of all 64 included studies revealed a dropout rate
of 22.3% (95% confidence interval [CI] [18.7, 26.2], N = 64;
Figure 3). When considering only RCTs, the dropout rate was
27.7% (95% CI [24.1, 31.7], N = 32). When only outpatient
studies were considered, the resulting rates were 25.1% (95% CI
[21.7, 28.9], N = 50) for all outpatient studies and 28.2% (95%
CI [24.5, 32.2], N = 29) for outpatient RCTs. Heterogeneity was
variable depending on what subset of studies was analyzed:

(N = 25). Fifty trials involved outpatient psychotherapy, with the There was considerable heterogeneity when analyzing all stud-
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rest involving inpatient/partial hospital psychotherapy. Treatment ies x 2(63) = 295.7; I2 = 78.7%; p , .001, substantial heteroge-
modality was most often a combination of individual and group neity in the subset of all outpatient studies x 2(49) = 120.0; I2 =
therapy (N = 38), with individual-only and group-only modalities 59.2%; p , .001, and moderate heterogeneity in the subset of

Figure 2
PRISMA Flow Diagram of Included Trials.

Records idenfied through

database searching
(n = 2,034)
Idenficaon

MEDLINE (n = 607)
PsycINFO (n = 734)
PubMed (n = 693)

Records aer duplicates removed

(n = 1,119)
Screening

Records screened Records excluded

(n = 1,119) (n = 877)

Full-text arcles assessed Full-text arcles excluded, with

Arcles that did not for eligibility reasons
Eligibility

appear in search but were (n = 242) (n = 181)

the primary publicaon Secondary analysis (n = 59)
for secondary analyses Not all parcipants had BPD (n = 40)
that did appear in search Tx Dropout not reported (n = 25)
(n = 1; Harned et al. (40)) Studies included in Not a psychotherapy trial (n = 13)
qualitave synthesis Follow-up study (n = 12)
(n = 62 papers, 64 studies) Head-to-head (n = 5)
Not peer-reviewed (n = 5)
Study protocol (n = 4)
Included

Also medicaon trial (n = 3)

Studies included in Case study/series (n = 3)
quantave synthesis Review (n = 3)
(meta-analysis) Corrigendum (n = 2)
(n = 62 papers, 64 studies) Dismantling/Components (n = 2)
OC For relaves (n = 2)
NO Cannot access (n = 1)
L L Clinician acceptability (n = 1)
I O Confounding seng (n = 1)
NR
E
Note. Flow chart of study selection and inclusion process in line with PRISMA statement. See the online article
for the color version of this figure.
 BORDERLINE PERSONALITY DISORDER THERAPY DROPOUT 5

Table 1
Characteristics of Included Trials
Duration N starting N dro-
Study Country Treatment Comparison condition (months) txc poutc
Amianto et al. (2011)a Italy SBAPPþSTM Outpt I STM 10.5 17 1
Barnicot and Priebe UK DBT Outpt G þ I — 12 89 50
(2013)
Bateman and Fonagy UK MBT Partial Hospital G þ I Standard psychiatric care 18 22 3
(1999)a
Bateman and Fonagy UK MBT Outpt G þ I SCM 18 71 19
(2009)a
Bateman et al. (2016)a UK MBT Outpt G þ I SCM 18 21 6
Blum et al. (2008)a USA STEPPS Outpt G TAU 4.6 65 20
Bohus et al. (2004) Germany DBT Inpt G þ I TAUþWL 1.4 40 9
Bos et al. (2010)a Netherlands STEPPS Outpt G TAU 5.5 42 9
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Comtois et al. (2010) USA DBT-ACES Outpt G þ I — 12 30 6

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del Pozo et al. (2018) Germany POMT Inpt G þ I — 2.5 269 75

Dickhaut and Arntz Netherlands ST Outpt G þ I — 24 18 7
(2014)
Doering et al. (2010)a Austria, Germany TFP Outpt I TBCE 12 45 13
Eckert et al. (2000) Germany Client-centered group therapy — 12 14 2
Outpt G
Farrell et al. (2009)a United States SFT group þ TAU Outpt G TAU 8 16 0
Fassbinder et al. (2016) Germany ST Outpt G þ I — 12 10 1
Flynn et al. (2017) Ireland DBT Outpt G þ I — 12 71 17
Gregory et al. (2008)a United States DDP Outpt I TAU 12 15 5
Harned et al. (2014)a United States DBTþPE Outpt G þ I DBT 12 17 11
Jacob et al. (2010) Germany PGTM þ TAU Outpt G TAU 1.4 19 3
Jahangard et al. (2012)a Iran EIT Inpt G Standard treatment þ “simple” 1 15 0
social contacts
Jørgensen et al. (2013)a Denmark MBT Outpt G þ I Supportive psychotherapy 24 58 16
Kellett et al. (2013) United Kingdom CAT Outpt I — 5.5 17 2
Kramer et al. (2011)a Switzerland GPMþMOTR Outpt I GPM 2.3 11 2
Kramer et al. (2014)a Switzerland GPMþMOTR Outpt I GPM 3 43 11
Kramer et al. (2016)a Switzerland DBT-informed skills training TAU 4.6 21 5
Outpt G
Kröger et al. (2010) Germany DBTþAdded CBT for — 3 24 0
BPDþEDs Inpt G þ I
Kröger et al. (2013) Germany DBT Inpt G þ I — 2.1 1,423 142
Laurenssen et al. (2018)a The Netherlands MBT Partial Hospital G þ I Specialist TAU 18 49 16
Leppänen et al. (2016)a Finland DBTþST Outpt G þ I TAU 12 24 4
Linehan et al. (1991)a United States DBT Outpt G þ I TAU 12 24 4
Linehan et al. (1999)a United States DBT Outpt G þ I TAU 12 11 4
Linehan et al. (2002)a United States DBT Outpt G þ I CVT þ 12 step 12 11 3
Linehan et al. (2006)a United States DBT Outpt G þ I CTBE 12 52 10
Linehan et al. (2015)a United States DBT Outpt G þ I c
12 33 8
Löf et al. (2018) Sweden MBT Outpt G þ I — 18 75 9
Markowitz et al. (2007) United States Interpersonal therapy Outpt I — 8 8 3
McMain et al. (2009)a Canada DBT Outpt G þ I GPM 12 90 35
McMain et al. (2017)a Canada DBT skills training group WL 4.6 42 12
Outpt G
Meares et al. (1999) Australia Interpersonal-psychodynamic WL 12 48 8
Outpt I
Morey et al. (2010)a United States MACT Outpt I c
NR 8 4
Navarro-Haro et al. Spain DBT Outpt or Day Hospital TAU CBT 6 71 7
(2018) GþI
Nordahl and Wells Norway MACT Outpt I — 11.5 12 0
(2019)
Pascual et al. (2015)a Spain Cognitive rehabilitation group Psychoeducational group 3.7 36 14
Outpt G
Pasieczny and Connor Australia DBT Outpt G þ I TAU/WL 6 43 3
(2011)
Prada et al. (2018) Switzerland MBT psychoeducation group — 2.8 14 4
Outpt G þ I
Reiss et al. (2014) United States ST Inpt G þ I — 4.1 41 1
Reiss et al. (2014) United States ST Inpt G þ I — 2.8 36 1
Reiss et al. (2014) United States ST Inpt G þ I — 2.3 15 1
Reneses et al. (2013)a Spain PRFP Outpt I TAU 4.6 25 3
(table continues)
 6 ILIAKIS, ILAGAN, AND CHOI-KAIN

Table 1 (Continued)
Duration N starting N dro-
Study Country Treatment Comparison condition (months) txc poutc
Rizvi et al. (2017) United States DBT Outpt G þ I — 6 50 16
Ryle and Golynkina United Kingdom CAT Outpt I — 6 33 6
(2000)
Salzer et al. (2014) Germany Psychodynamic therapy Inpt — 6.9 28 7
GþI
Sinnaeve et al. (2018) The Netherlands DBT Outpt G þ I c
12 19 7
Soler et al. (2009)a Spain DBT skills Outpt G Standard group 3 29 10
Soler et al. (2012) Spain GPMþDBT-Mindfulness GPM 2.3 40 11
Outpt G
Sollberger et al. (2015) Switzerland TFP Inpt G þ I Inpatient TAU 2.8 32 1
Stanley et al. (2007) United States Brief DBT Outpt G — 6 20 1
Steuwe et al. (2016) Germany NETþstandard inpatient care — 2.3 11 1
Inpt G þ I
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Stiglmayr et al. (2014) Germany DBT Outpt G þ I — 12 70 17

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van den Bosch et al. The Netherlands Brief DBT Partial Hospital — 3.2 39 13
(2013) GþI
van Wel et al. (2009)a The Netherlands STEPPS Outpt G TAU 4.5 42 9
Verheul et al. (2003)a The Netherlands DBT Outpt G þ I TAU 12 27 10
Weinberg et al. (2006)a United States MACT Outpt I TAU 1.4 15 0
Wetterborg et al. (2020) Sweden DBT Outpt G þ I — 12 30 9
Note. ACES = accepting the challenges of exiting the system; BPD = borderline personality disorder; CAT = cognitive analytic therapy; CBT = cognitive–
behavioral therapy; CTBE = community treatment by experts; CVT = comprehensive validation therapy; DBT = dialectical behavior therapy; DDP =
dynamic deconstructive therapy; ED = eating disorder; EIT = emotional intelligence training; G = group; GPM = general psychiatric management; I = indi-
vidual; Inpt = inpatient; MACT = manual-assisted cognitive therapy; MBT = mentalization-based treatment; MOTR = motive-oriented therapeutic relation-
ship; NET = narrative exposure therapy; NR = not reported; Outpt = outpatient; PE = prolonged exposure; PGTM = psychoeducative group therapy module;
POMT = psychodynamically oriented multimodal therapy; PRFP = psychic representation focused psychotherapy; SBAPP = sequential brief Adlerian psy-
chodynamic psychotherapy; SCM = structured clinical management; S(F)T = schema(-focused) therapy; STEPPS = systems training for emotional predict-
ability and problem-solving; STM = supervised team management; TAU = treatment-as-usual; TBCE = treatment by community experts; TFP =
transference-focused psychotherapy; WL = waitlist.
a
RCT. b head-to-head/components design—no comparator included in meta-analysis. c in the intervention arm only.

RCTs, x 2(31) = 47.9; I2 = 35.2%; p = .027, and the subset of
outpatient RCTs more specifically x 2(28) = 41.6; I2 = 32.7%;
p = .047.
Although odds ratios trended toward indicating higher dropout
rates in the study control arm than in the treatment arm in all con-
ditions outlined earlier, none of the odds ratios were significant,
with an overall odds ratio of .818 (95% CI [.590, 1.133], N = 30;
Figure 4), an RCT-only odds ratio of .789 (95% CI [.555, 1.123],
N = 25), an outpatient-only odds ratio of .797 (95% CI [.567,
1.119], N = 26), and an outpatient RCT-only odds ratio of .778
(95% CI [.537, 1.127], N = 23). There was moderate heterogeneity
in the all studies, x 2(29) = 55.8; I2 = 48.1%; p , .01; RCT-only,
x 2(24) = 48.9; I2 = 50.9%; p , .01; outpatient-only, x 2(25) =
49.1; I2 = 49.1%; p , .01; and outpatient RCT conditions, x 2(22) =
46.7; I2 = 52.9%; p , .01.
Metaregression analyses revealed significant associations of longer
study duration, F(1, 61) = 4.12; p , .05, study randomization, F(1,
62) = 4.52; p = .04, availability of phone coaching, F(1, 60) = 6.14,
p = .02, and outpatient treatment setting, F(2, 61) = 4.68, p = .01,
with higher dropout rates. Bonferroni correction for multiple compar-
isons with an a of 10 and threshold of p , .005 obscures the effects
of these moderators, however. All other moderators (treatment inten-
sity gauged through clinical facetime per week, treatment orientation,
i.e., cognitive–behavioral vs. psychodynamic vs. other, targeting
comorbidity in addition to BPD, presence of a consultation team, num-
ber of risks of bias criteria rated low, and modality, group vs. individ-
ual vs. combination) were not significantly associated with dropout
rates. No significant moderation effects were found for the RCTs, out-
patient studies, and outpatient RCTs, and none of the moderators were
significantly associated with odds of dropout from the treatment arm
of a study relative to the control arm in all controlled studies.
Publication Bias
There was evidence of significant publication bias in favor of
lower dropout rates. Egger’s test reached significance for the RCTs
only (« i = 1.60, 95% CI [2.61, .59], one-tailed p = .002), outpa-
tient only (« i = 2.00, 95% CI [3.00, 1.00], one-tailed p =
.0001), and outpatient RCTs only (« i = 1.37, 95% CI [2.52,
.23], one-tailed p = .01) conditions. Duval and Tweedie’s trim and
fill procedure imputed 11 studies for the all-studies condition, six
studies for the RCTs only condition, 13 studies for the outpatient
only condition, and five studies for the outpatient RCTs only condi-
tion. Adjusted dropout rates were 25.0% (95% CI [21.2, 29.3]),
29.6% (95% CI [25.4, 34.1]), 29.3% (95% CI [25.3, 33.6]), and
29.9% (95% CI [25.7, 34.4]) for the four conditions, respectively.
Reasons for Dropout and Time to Dropout
Of the 64 included studies, 26 reported reasons for an aggregate of
238 dropouts from treatment arms. In order of frequency, reported
reasons for dropout were as follows: unclear (30.7%), dissatis-
faction with treatment (15.1%), expulsion from treatment
(13.4%), lack of motivation or interest (12.3%), life events or
change in life/living situation (10.1%), fear of treatment (9.5%),
 BORDERLINE PERSONALITY DISORDER THERAPY DROPOUT 7

Figure 3
Forest Plot of Dropout Rates in Study Intervention Arms
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NO
L L
I O
NR
E
Note. Dropout rates in intervention conditions of 64 studies are shown as a proportion of 1, with .2 indicating 20% dropout, .3
indicating 30% dropout, and so on. Error bars indicate 95% confidence intervals of these rates. See the online article for the color
version of this figure.
 8 ILIAKIS, ILAGAN, AND CHOI-KAIN

Figure 4
Forest Plot of Odds to Dropout in Controlled Studies
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

OC
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L L
I O
NR
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Note. Odds ratios of dropout from the intervention vs. control conditions are shown. Odds ratios .1 indicate higher dropout rates
from the intervention arm. Error bars indicate 95% confidence intervals of these odds ratios. See the online article for the color
version of this figure.

treatment was not helpful (8.9%), logistical including scheduling
and transportation (7.8%), improvement in symptoms (7.3%),
fear of/unwillingness regarding group treatment (5.6%), conflicts
with educational/vocational responsibilities (4.5%), hospitaliza-
tion/step-up (3.9%), disagreement or conflicts with staff (2.8%),
unwillingness to accept treatment frame (2.8%), ongoing sub-
stance use (1.1%), suicidality (1.1%), incarceration (0.6%), pro-
longed travel (0.6%), severe somatic illness (.6%), and starting
another treatment (0.6%).
Twenty-eight studies reported on timing of dropouts from treat-
ment arms. Of these, 16 reported time to dropout for each individ-
ual case, eight reported average time to dropout among dropouts,
and four presented dropouts graphically using survival plots or
similar methods. Qualitative synthesis reveals that the majority of
dropouts occur early in treatment. In the 16 studies reporting on
individual cases, the majority of participants dropped out within the
first half of treatment in 14 studies or within the first two thirds of
treatment in two studies. In all but three of these studies, most drop-
outs occurred by the 6-month mark. In the eight studies reporting
on average time to dropout, the average time to dropout was before
the first half of treatment in all but one study, in which average time
to dropout was within the first two thirds of treatment (Comtois et
al., 2010). In studies reporting dropouts graphically (n = 4), three
studies showed qualitatively steeper dropout rates near the begin-
ning of treatment before leveling off. In the remaining study (Line-
han et al., 1991), dropout rates peaked at the 4- to 8-month mark.
 BORDERLINE PERSONALITY DISORDER THERAPY DROPOUT
Discussion
Dropout rates from BPD psychotherapies ranged from 22.3% to
28.2% and were as high as 29.9% when correcting for publication
bias. Longer study duration, study randomization, availability of
phone coaching, and outpatient treatment setting were significant
moderators of dropout rates when analyzing all studies, but these
associations were not sustained when the analysis was restricted to
outpatient studies only, RCTs only, or outpatient RCTs only. Main
reasons for dropout included dissatisfaction with treatment, expul-
sion from treatment, lack of motivation, and life events or change
in life situation. Most dropouts occurred in the first half of
treatment.
The dropout rates found in this meta-analysis are consistent
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with what has been found in previous studies (Barnicot et al.,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
2011; Cristea et al., 2017; Dixon & Linardon, 2020; Swift &
Greenberg, 2014). The overall dropout rate of 22.3% to 29.9% is
higher than that of psychotherapies for major depressive disorder
(17.5%; Cooper & Conklin, 2015), generalized anxiety disorder
(17%; (Gersh et al., 2017), and PTSD (18%; Imel et al., 2013.
BPD-specific dropout rates approach the rates seen in other disor-
ders associated with problems of treatment adherence and comple-
tion, such as substance use disorder (30.4%; Lappan et al., 2020),
schizophrenia (30%; Leucht et al., 2012), and bipolar disorder
(33.8% after 1 year; Moon et al., 2012). The problem of retention
in effective treatments of choice for serious mental illness reflects
a gap between the need for treatment and the ability for patients to
continuously engage in care.
Despite some evidence-based treatments including components
of care that are hypothesized to minimize dropouts, there was no
significant moderating effect of treatment orientation, in line with
previous findings (Barnicot et al., 2011; Swift & Greenberg,
2012). Just as there is no evidence that any one psychotherapeutic
treatment for BPD is superior to another in terms of outcomes
(Cristea et al., 2017), there is also no evidence any is superior in
terms of retention, even compared to treatments as usual or treat-
ment by community experts in this study or others (Cristea et al.,
2017; Dixon & Linardon, 2020; Storebø et al., 2020). These find-
ings of nonsuperiority do not necessarily indicate that retention
rates are equivalent across these different treatment orientations or
across the intervention and control groups in RCTs.
Our results also show that intensity and duration not only appear
to have no effect on treatment outcomes in BPD (Cristea et al.,
2017) but also appear to confer no advantage in keeping patients
with BPD engaged in treatment. That shorter psychotherapies
were associated with lower dropouts may be unsurprising, as lon-
ger treatments by nature have more opportunity to drop out and
may be implemented with more complex clients who are more
likely to drop out. However, this suggests that brief or low-inten-
sity treatments are feasible and perhaps preferable alternatives,
particularly for patients who have a high risk of prematurely termi-
nating treatment. There is increasing evidence of the efficacy of
briefer treatments for BPD (Kramer et al., 2014, 2016; Koons et
al., 2001; Laporte et al., 2018) and evidence that there are different
rates of improvement for different groups of patients, suggesting
that some patients reach “good enough” levels of improvement
faster than others (Barkham et al., 2006).
Rather than uniformly assuming that the most advantageous
treatment for all patients with BPD are intensive, lengthy
9
psychotherapies, research can help identify which patients with
BPD would optimally improve in briefer or less intensive treat-
ments and which would optimally improve in lengthier or more
intensive treatments (Keefe et al., 2020). More research is neces-
sary to determine predictors of which patients would have equiva-
lent outcomes in shorter versus longer treatments and whether
shorter duration would significantly alter dropouts rates without
compromising effectiveness, with trials of 6-month DBT versus
1-year DBT (McMain et al., 2018) and a low-resource psycholog-
ical support versus treatment-as-usual (Crawford et al., 2018) cur-
rently underway. Briefer and less intensive treatment could alter
treatment motivation, satisfaction, and expulsion, the most com-
mon reasons for dropout identified in this review.
Other future directions for research include clarification on why
patients leave treatments prematurely. Only 41% of included stud-
ies reported reasons for dropout. In these trials, the most frequently
listed reason was “unclear,” (30.7%), followed by dissatisfaction
with treatment (15.1%). Systematically and routinely reporting
reasons for dropout would help better identify the obstacles to
completing treatment and the specific aspects of treatment incom-
patible with patient levels of motivation, effort, and preferences.
Future research should aim to address these questions, with the
eventual goal of determining which patients might respond better
to alternative treatment packages, so that developing other treat-
ment options that would provide a better fit for those patients most
likely to drop out of existing forms of care.
Importantly, this and other studies confirm the majority of those
with BPD complete both experimental and control interventions.
At the same time, a substantial subset of treatment-seeking indi-
viduals with BPD will drop out of therapy and be subject to higher
rates of functional impairment and increased hospitalization rates
than those who remain in treatment (Karterud et al., 2003; Webb
& McMurran, 2009). Individuals with BPD are treatment-seeking
and are more likely to make use of services such as psychophar-
macology and emergency or inpatient admissions than individuals
with other personality disorders or major depression (Bender et
al., 2001, 2006; Lewis et al., 2019; Zanarini et al., 2004). Treat-
ment guidelines recommending psychotherapies as the mainstay
of treatment (American Psychiatric Association, 2001; National
Institute for Health and Care Excellence, 2018) have contributed
to a problem of fit between treatments and patients with BPD who
vary in terms of acuity, access to care, motivation, and preferen-
ces. This one-size-fits-all assumption between the BPD diagnosis
and lengthy intensive psychotherapies may contribute to the find-
ing that one in four to five patients will drop out of indicated care.
High psychotherapy dropout rates necessitate systems of care that
can accommodate BPD flexibly across varying levels of service
intensity and facilitate continuity of care between these levels
(Grenyer et al., 2018) and adequate dosing of care (Laporte et al.,
2018). Diversifying treatment options to include briefer treatments
and step-down services can be part of the effort to maximize treat-
ment retention, although more research is necessary to test
whether these can in fact reduce dropouts.
This meta-analysis has several limitations. First, it aggregates
trials investigating a range of treatments for BPD across a range
of orientations, modes of delivery, and regions of varying meth-
odological quality, leading to significant heterogeneity that was
not robustly accounted for by our candidate moderators. Second,
moderators should be interpreted with caution, as they are
 10 ILIAKIS, ILAGAN, AND CHOI-KAIN
inconsistent across conditions and correction for multiple com-
parisons obscures their effects. Drawing definitive conclusions
about treatment on the basis of moderators such as outpatient ver-
sus inpatient mode of delivery and phone coaching would be mis-
leading, as these factors might artifactually reflect differences in
freedom of motion or symptom severity. However, the higher
dropout rate in trials with phone coaching and consultation teams
replicates the findings of Dixon and Linardon (2020), who sug-
gest that these additional components of DBT may be demanding
and thus reduce patients’ willingness or motivation to stay in
treatment. In addition, this meta-analysis only considered moder-
ators on the study level rather than on the participant level, which,
given prior research on this area more broadly and in BPD, is
likely to be more meaningful. Third, dropout was counted or
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
reported inconsistently across trials, with different degrees of
stringency in excluding individuals from treatment (e.g., missing
four consecutive sessions, attending less than half of available
sessions over a year), leading to potential inflation of dropout
rates in trials with more stringent attendance criteria. Further-
more, due to the nature of the available data, the definition of
dropout was relatively restrictive (i.e., patients who fail to com-
plete treatment). Different definition of dropout has been shown
to moderate dropout rates (Swift & Greenberg, 2012), and some
studies report a subset of participants who drop out due to early
remission (Bohus et al., 2020). At the same time, patients with
BPD have a high likelihood of having impaired psychosocial
functioning despite symptomatic remission (Zanarini et al. 2005),
suggesting that we do not have enough evidence to presume there
is a large enough number of patients with BPD that prematurely
terminate treatment due to sufficient gains.
In summary, treatment dropout rates in psychotherapy trials for
BPD ranged from 22.3% considering all studies to 28.2% when
only considering outpatient RCTs, with publication bias-adjusted
dropout rates ranging from 25.0% to 29.9%. Further research is
needed to identify obstacles to completing treatment and investi-
gate how systems of care can be adapted and tailored to retain this
population that is treatment-seeking but at elevated risk for drop-
out. What works for whom, when, and for how long remain ques-
tions that treatment research must still investigate. Efforts to
answer these essential questions will provide an evidence base for
a stepped care system of assigning alternative types of care for
patients in a more personalized way to counteract the current one-
size-fits-all standards of care. Whether such tailoring of interven-
tions reduces dropout requires further study.
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