START intervention for dementia caregivers linked to reduction of depression symptoms

1. The STrAtegies for RelaTives (START) intervention provided to caregivers of dementia patients was linked to a seven-fold reduction in clinically significant depression than compared to receiving treatment as usual.

2. The START intervention was demonstrated to be cost effective as defined by National Institute for Health and Care thresholds for both caregivers and patients as costs did not significantly differ between groups receiving the intervention and those receiving treatment as usual.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Two-thirds of dementia patients live at home and are cared for by family members. Caregivers of dementia patients frequently develop anxiety and depression, which can lead to breakdown in quality caregiving. The START intervention study aimed to assess the clinical effectiveness (reduction in depression and anxiety symptoms) and cost effectiveness of a psychological intervention for caregivers. Caregivers were randomly assigned to either the experimental START group, a manual-based coping intervention, or the control group who received treatment as usual (TAU). The caregivers who participated in START were significantly less likely to have depression and anxiety symptoms, and the intervention was found to be cost-effective for both caregivers and patients. Policymakers are urged to consider this effective approach for the prevention of depression in caregivers as well as the continuance of quality care for people with dementia. Sociodemographic and clinical characteristics of participants were heterogeneous, lending strength to this study. Though the difference in cost effectiveness between TAU and START did not significantly differ, the study was limited in that the trial was not powered for the economic evaluation.

This study was funded by the National Institute for Health Research Health Technology Assessment program.

Click to read the study, published today in The Lancet Psychiatry

Relevant Reading: Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial

In-Depth [randomized controlled trial]: This study assessed the long-term clinical effectiveness and cost effectiveness of the psychological intervention START (STrAtegies for RelaTives) in self-identified caregivers of dementia patients who provided support at least once per week. START consists of 8 sessions of manual-based, individual coping interventions. Primary long-term outcome at 2 years after randomization for clinical effectiveness was measured via affective symptoms (Hospital Anxiety and Depression Scale total score [HADS-T]). Primary outcome for cost effectiveness was measured via National Institute for Health and Care (NICE) thresholds.

260 British caregivers were enrolled in the study and were randomized (2:1) with 173 allotted to the START group and 87 to the TAU group. Of the 260 participants, 209 (80%) were included in the final analysis (140 START, 69 TAU). Caregivers met 8 times with non-clinically trained psychology graduates who had been trained to deliver the START intervention. At 2 years, the START group reported significantly better HADS-T scores than the TAU group (mean difference –2.58 points, 95% CI –4.26 to –0.90; p=0.003). Cost effectiveness measures demonstrated that START is cost effective for both caregivers and patients (67% probability of cost-effectiveness at the £20,000 per QALY willingness-to-pay threshold, and 70% at the £30,000 threshold).

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