Global estimates of natural, unnatural, and all-cause mortality in patients with personality disorders: A meta-analysis of longitudinal studies and meta-regression of potential moderators in a sample of 34 million people

Introduction: Personality disorders (PDs) influence various life aspects and health outcomes, necessitating a deeper understanding of how they affect mortality rates and the factors that contribute to these differences. This meta-analysis aims to make global estimates of natural, unnatural, and all-cause mortality in patients with PD by synthesizing data from longitudinal studies and identifying potential moderators influencing these outcomes Methods: This meta-analysis followed PRISMA guidelines (PROSPERO-CRD42025636341), including a systematic search of English-language records from PubMed, Scopus, PsycNET, and Google scholar. Standardized mortality ratio (SMR) for natural, unnatural, and all-cause mortality was calculated using the random-effects method. We used meta-regression and subgroup analyses to explore potential sources of heterogeneity. Publication bias and the risk of bias also were evaluated Results: Approximately 2,368,000 deaths were reported by 35 eligible studies. The pooled SMR for all-cause mortality was 4.16 (95 % CI: 3.74–4.62), indicating a significantly elevated risk. The SMR for natural causes of death was 2.95 (95 % CI: 2.70–3.21) whereas the SMR for unnatural causes of death (suicide being the primary contributor = 22.69) was 14.27 (95 % CI: 12.79–15.92). We found that 12 potential moderators differentially affected each of the natural, unnatural, and all causes of death Conclusions: This meta-analysis highlights a significantly elevated mortality risk in patients with PD, particularly from unnatural causes like suicide. Identifying key moderators can guide targeted interventions and inform health policies to enhance care and prevention strategies for this vulnerable population, emphasizing the need for ongoing research into mortality trends