De Salve Francesca, Rossi Chiara, Gioacchini Elena, Messina Irene, Oasi Osmano
Department of Psychology, Catholic University of Sacred Heart, Milan, Italy.
Faculty of Social and Communication Sciences, Universitas Mercatorum, Rome, Italy.
Clin Psychol Psychother. 2025 May-Jun;32(3):e70080. doi: 10.1002/cpp.70080.
Dropout in psychotherapy for personality disorders is a major challenge, affecting treatment efficacy and mental health care delivery. Influenced by patient characteristics, therapist factors and treatment dynamics, dropout remains prevalent. This systematic review identifies predictors of psychotherapy dropout in individuals with personality disorders to inform strategies that enhance treatment engagement.
A systematic search in PsycINFO, PubMed and Scopus identified 22 studies from 1976 articles. Inclusion criteria required DSM/ICD-based personality disorder assessments and dropout predictors in psychotherapy. Non-English or non-peer-reviewed studies were excluded. Screening followed PRISMA guidelines using Rayyan, and study quality was assessed with the Newcastle-Ottawa Scale (NOS).
Dropout rates ranged from 10.4% to 58%, depending on treatment modality and patient characteristics. Younger age, comorbid substance use disorders, emotional dysregulation, distress tolerance difficulties, childhood emotional abuse, therapist turnover and low motivation were significant predictors of dropout. Conversely, strong therapeutic alliances, mindfulness-based skills and engagement in phone coaching were associated with improved retention. Other relevant factors included low reflective functioning, lower education levels and socio-economic adversity, such as receiving disability benefits. Only one study identified low reflective functioning as a dropout predictor. Systemic factors, including treatment organization and care coordination, also played a crucial role.
Addressing dropout requires early engagement strategies, therapist continuity and treatment flexibility. Enhancing therapeutic alliance and reflective functioning may be particularly effective in reducing dropout. Systemic improvements, such as better care coordination and accessibility, are crucial for sustaining engagement and improving psychotherapy outcomes for individuals with personality disorders.
PROSPERO number: CRD42024509283.
人格障碍心理治疗中的脱落问题是一项重大挑战，影响治疗效果和心理健康服务的提供。受患者特征、治疗师因素和治疗动态的影响，脱落现象仍然普遍存在。本系统评价确定了人格障碍患者心理治疗脱落的预测因素，以为增强治疗参与度的策略提供依据。
在PsycINFO、PubMed和Scopus中进行系统检索，从1976篇文章中识别出22项研究。纳入标准要求基于DSM/ICD的人格障碍评估以及心理治疗中的脱落预测因素。排除非英文或非同行评审的研究。使用Rayyan按照PRISMA指南进行筛选，并使用纽卡斯尔-渥太华量表（NOS）评估研究质量。
脱落率在10.4%至58%之间，具体取决于治疗方式和患者特征。年龄较小、合并物质使用障碍、情绪调节障碍、痛苦耐受困难、童年期情感虐待、治疗师更换和动机不足是脱落的显著预测因素。相反，强大的治疗联盟、基于正念的技能以及参与电话辅导与更高的留存率相关。其他相关因素包括低反思功能、较低的教育水平和社会经济逆境，如领取残疾福利。只有一项研究将低反思功能确定为脱落预测因素。包括治疗组织和护理协调在内的系统因素也起着关键作用。
解决脱落问题需要早期参与策略、治疗师的连续性和治疗灵活性。增强治疗联盟和反思功能可能对减少脱落特别有效。系统改进，如更好的护理协调和可及性，对于维持人格障碍患者的参与度和改善心理治疗效果至关重要。
PROSPERO编号：CRD42024509283。
