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Systematic Review
The purpose of this evidence appraisal report was to identify and summarise evidence that addresses the following question: What is the clinical effectiveness and cost effectiveness of the Strategies for Relatives (START) intervention aimed at improving the mental health of carers of people with dementia?
Evidence on the effectiveness and cost-effectiveness of the START programme is available from one RCT conducted in the UK. There is also a large body of evidence on the effectiveness of psychoeducation and cognitive behavioural approaches that supports the plausibility of the findings seen in the START trial. A series of studies that report on a UK-based trial of the START intervention were identified with differing findings across outcomes.In particular, START appears effective in reducing symptoms and cases of depression and improving the quality of life of carers compared with TAU, but there was no difference in symptoms or cases of anxiety, quality of life for recipients of care, or time to placement in residential care. Follow-up of up to six years suggests that improvements can be maintained over time and that the intervention has long lasting impact.
Economic evidence from the START trial suggests that, in the short term, this intervention is cost-effective if only carer costs are considered and cost-saving if the costs of both carer and recipient of care are included. As benefits have been shown to be maintained over longer follow-up, these findings may become more favourable over the long term. Recent meta-analyses on the effectiveness of similar interventions are available. A recent comprehensive review of evidence on CBT and psychoeducation interventions was identified as the highest priority evidence based on our selection criteria. The review suggests that interventions of this type have small to medium effects on reducing the burden felt by carers, depression, and wellbeing compared to TAU. Results for anxiety were more equivocal and interventions did not appear to improve care recipients symptoms over the longer term orreduce placement in residential care. In addition, a further review that focused on HRQoL was identified and suggested that intervention of this type could lead to improvements on these measures compared to TAU.
A series of studies that report on a UK-based trial of the START intervention were identified. START appears effective in reducing symptoms and cases of depression and improving the quality of life of carers compared with usual care. Recent meta-analyses on the effectiveness of similar interventions were also included to provide evidence on whether the findings of the START trial are plausible and reflective of findings with similar interventions. Economic evidence from the START trial suggests that the use of START is cost-effective for carers of people with dementia with an incremental cost effectiveness ratio (ICER) of £12,400 per QALY. When the costs accrued to both carer and recipient of care are included, START may be cost saving