Non-pharmacological Interventions for Caregivers with Depression and Caregivers of Care Recipients with Co-morbid Depression: Systematic Review and Meta-analysis

May combine two claims.

Care recipients with a mental illness or advanced or palliative disease have different needs, and in advanced disease grief and bereavement play a role.

“Care recipients with a mental illness (e.g., schizophrenia) or advanced or palliative disease were excluded as the needs of these groups differ and in the case of advanced disease grief and bereavement play a role.[21][22][23]”

• cites [21] Wang T, Molassiotis A, Chung BPM, Tan J-Y. Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review. BMC Palliative Care. 2018;17(1):96. sourcePartly supported

  The Background (page unavailable) says patients with advanced cancer commonly experience different symptoms from those with early-stage cancer, and the Results include studies of bereaved caregivers. This supports distinct needs in advanced cancer and the relevance of bereavement, but the paper does not establish the claim for mental illness or advanced diseases generally, or specifically discuss grief as a factor. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [22] Moghaddam N, Coxon H, Nabarro S, Hardy B, Cox K. Unmet care needs in people living with advanced cancer: a systematic review. Supportive Care in Cancer. 2016;24(8):3609-22. sourcePartly supported

  The Abstract (page unavailable) says support needs vary by stage of the cancer journey and that advanced cancer brings changes in patient support needs. This supports the advanced-disease part of the rationale, but the paper does not establish different needs for people with mental illness or say that grief and bereavement play a role in advanced disease. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites [23] Waller A, Girgis A, Johnson C, Lecathelinais C, Sibbritt D, Forstner D, et al. Improving outcomes for people with progressive cancer: interrupted time series trial of a needs assessment intervention. Journal of Pain and Symptom Management. 2012;43(3):569-81. sourcePartly supported

  The Introduction (page unavailable) says people with advanced cancer often have greater unmet needs than those with localized disease, and the Materials section includes caregiver bereavement issues in its needs-assessment tool. The paper does not establish that care recipients with mental illness, such as schizophrenia, have different needs, or give these needs as a reason to exclude either group. (LLM, conf=0.87)

  Experimental — accuracy not yet measured

May combine two claims.

There is a bidirectional relationship between care recipients' and caregivers' depression; those caring for someone who is depressed are more likely to be depressed themselves, and vice versa.

“This is in line with studies demonstrating a bidirectional relationship between care recipients' and caregivers' depression; those caring for someone who is depressed are more likely to be depressed themselves, and vice versa.18,19”

• cites [18] Hagedoorn M, Sanderman R, Bolks HN, Tuinstra J, Coyne JC. Distress in Couples Coping With Cancer: A Meta-Analysis and Critical Review of Role and Gender Effects. Psychological Bulletin. 2008;134(1):1-30. sourceNot checked — no full text of the source
• cites [19] Northouse LL, Katapodi MC, Schafenacker AM, Weiss D. The impact of caregiving on the psychological well-being of family caregivers and cancer patients. Seminars in oncology nursing. 2012;28(4):236-45. sourcePartly supported

  The Overview of Patient and Caregiver Emotional Distress (page unavailable) reports a significant correlation between cancer patients’ and caregivers’ distress and says that when one was distressed, the other was likely to be distressed, and vice versa. It does not establish the same relationship specifically for depression or show that either person’s depression causes the other’s. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

The effect sizes for both depression and anxiety in the present meta-analysis were in the small to moderate range in comparison to mostly small effect sizes in previous meta-analyses.

“However, the ESs for both depression and anxiety in the present meta-analysis were in the small to moderate range in comparison to mostly small ESs in previous meta-analyses.37,69”

• cites [37] Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventions for caregivers of people with dementia. Journal of the American Geriatrics Society. 2003;51(5):657-64. sourceNot checked — no full text of the source
• cites [69] Northouse LL, Katapodi MC, Song L, Zhang L, Mood DW. Interventions with family caregivers of cancer patients: meta-analysis of randomized trials. CA: a Cancer Journal for Clinicians. 2010;60(5):317-39. sourcePartly supported

  In Results > Depression, Northouse et al. report small, nonsignificant effect sizes for caregiver depression. But the Discussion describes moderate effects on anxiety in prior meta-analyses, so this source does not support characterizing the previous findings for both depression and anxiety as mostly small. The citing authors’ description of their own meta-analysis is not a finding attributed to Northouse et al. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

May combine two claims.

The studies included a total of 2178 participants (mean = 94, SD = 129.18, range = 25-518); this included 2123 caregivers and 57 care recipients.

“Overall, the studies included a total of 2178 participants (mean = 94, SD = 129.18,range = 25-518); this included 2123 caregivers (51-66) and 57 care recipients.52,66”

• cites [52] Horton-Deutsch SL, Farran CJ, Choi EE, Fogg L. The PLUS Intervention: a pilot test with caregivers of depressed older adults. Archives of Psychiatric Nursing. 2002;16(2):61-71. sourceNot checked — no full text of the source
• cites [66] Yoo R, Yeom J, Kim GH, Park HK, Jeong JH, Kang Y, et al. A multicenter, randomized clinical trial to assess the efficacy of a therapeutic intervention program for caregivers of people with dementia. Journal of Clinical Neurology (Korea). 2020;15(2):235-42. sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

The remaining intervention was also delivered to the dyad and was the only one with the dual focus on assisting caregivers manage their own depression as well as supporting them in managing the care recipients' depression.

“The remaining intervention was also delivered to the dyad and was the only one with the dual focus on assisting caregivers manage their own depression as well as supporting them in managing the care recipients' depression.67”

• cites [67] Smith G, Egbert N, Dellman-Jenkins M, Nanna K, Palmieri PA. Reducing depression in stroke survivors and their informal caregivers: a randomized clinical trial of a Web-based intervention. Rehabilitation Psychology. 2012;57(3):196-206. sourcePartly supported

  The Methods (Intervention Condition; page unavailable) describe a dual focus: helping caregivers reduce their own distress and provide emotional care to stroke survivors. But the Discussion (page unavailable) says stroke survivors were not directly involved, apart from homework interactions with caregivers, so describing the intervention as delivered to the dyad overstates their participation. The source also does not establish that it was the only intervention with this focus among those reviewed by the citing paper. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Self-management skills were retrieved from 17 interventions, with a mean of 4.29 self-management skills per intervention (SD = 4.18, range = 1-13).

“Self-management skills were retrieved from 17 interventions (one did not have enough information 62 ), with a mean of 4.29 self-management skills per intervention (SD = 4.18, range = 1-13).”

• cites [62] Núñez-Naveira L, Alonso-Búa B, C. L, Gregersen R, Maibom K, Mojs E, et al. UnderstAID, an ICT Platform to Help Informal Caregivers of People with Dementia: A Pilot Randomized Controlled Study. BioMed Research International; 2016. sourceCould not verify

  The citation is attached to the parenthetical claim that one intervention lacked enough information, not to the review’s counts and averages. The Methods (2.5.2) and Results (3.2) describe the UnderstAID intervention, but neither those passages nor a search for information about self-management skills establishes whether it had enough detail for the citing authors to extract those skills. (LLM, conf=0.72)

  Experimental — accuracy not yet measured

May combine two claims.

Only one RCT in the present meta-analysis included a booster session, and the final outcome measurement was performed prior to the booster, precluding conclusions about its impact.

“Only one RCT in the present metaanalysis included a booster session 54 ; however, the final outcome measurement was performed prior to the booster, precluding any conclusions about its impact.”

• cites [54] Blom MM, Zarit SH, Groot Zwaaftink RB, Cuijpers P, Pot AM. Effectiveness of an Internet intervention for family caregivers of people with dementia: results of a randomized controlled trial. PloS One. 2015;10(2):e0116622. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Typically, generic caregiver interventions provide a range of information and coping skills training to help caregivers feel better equipped to manage the challenges of their role, which in turn might result in lowering depression and anxiety.

“Typically, generic caregiver interventions provide a range of information and coping skills training to help caregivers feel better equipped to manage the challenges of their role, which in turn might result in lowering depression and anxiety.37,69”

• cites [37] Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventions for caregivers of people with dementia. Journal of the American Geriatrics Society. 2003;51(5):657-64. sourceNot checked — no full text of the source
• cites [69] Northouse LL, Katapodi MC, Song L, Zhang L, Mood DW. Interventions with family caregivers of cancer patients: meta-analysis of randomized trials. CA: a Cancer Journal for Clinicians. 2010;60(5):317-39. sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

A previous systematic review by our team showed that dyadic caregiver interventions are more efficacious than caregiver-only intervention.

“A previous systematic review 74 by our team showed that dyadic caregiver interventions are more efficacious than caregiver-only intervention.”

• cites [74] Regan T, Lambert SD, Girgis A, Kelly B, Turner J, Kayser K. Do couple-based interventions make a difference for couples affected by cancer? A systematic review. BMC Cancer. 2012;12:279. sourcePartly supported

  The Abstract Conclusion (page not specified) says couple-based interventions may be at least as efficacious as caregiver-only interventions, based on similar effect sizes—not that they are more efficacious. The Discussion reports stronger outcomes in two comparisons with patient-only interventions, but that is a different comparator. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

A systematic review by Schaffler et al. suggested that self-management interventions were more efficacious when these included problem-solving, taking action, and resource utilization.

“For instance, a systematic review by Schaffler et al. 73 suggested that self-management interventions were more efficacious when these included problem-solving, taking action, and resource utilization.”

• cites [73] Schaffler J, Leung K, Tremblay S, Merdsoy L, Belzile E, Lambrou A, et al. The Effectiveness of self-management interventions for individuals with low health literacy and/or low income: A descriptive systematic review. Journal of General Internal Medicine. 2018;33(4):510-23. sourceSupported

May combine two claims.

At T1, the pooled effect size of interventions on caregivers' depression was -0.62 (95% CI -0.81, -0.44) and statistically significant.

“At T1, eight studies were included in the meta-analysis (see Fig. 2) and the pooled ES of -0.62 (95% CI -0.81, -0.44) was statistically significant.”

May combine two claims.

At T2, the pooled effect size of interventions on caregivers' depression was -0.19 (95% CI -0.29, -0.09) and statistically significant.

“At T2, the pooled ES for the 10 studies in the metaanalysis (see Fig. 2) was also statistically significant (-0.19, 95% CI -0.29, -0.09) with no heterogeneity (p = 0.513).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The most common condition of the care recipient was dementia (n = 10/16).

“The most common condition (n = 10/16; see Table 1) of the care recipient was dementia.”

May combine two claims.

A total of 16 full texts were included in this review, 15 had sufficient data to be included in the meta-analysis, and the remaining one is reported descriptively only.

“A total of 16 full texts were included in this review, 15 had sufficient data to be included in the meta-analysis, and the remaining one is reported descriptively only.52”

• cites [52] Horton-Deutsch SL, Farran CJ, Choi EE, Fogg L. The PLUS Intervention: a pilot test with caregivers of depressed older adults. Archives of Psychiatric Nursing. 2002;16(2):61-71. sourceNot checked — no full text of the source

May combine two claims.

All studies were associated with a significant improvement of anxiety baseline post-intervention and were based on similar interventions.

“However, all studies were associated with a significant improvement of anxiety baseline post-intervention and were based on similar interventions.”

Classified as probably not a substantial claim. May combine two claims.

Over 30 secondary outcomes were extracted; the only secondary outcome that qualified was anxiety.

“Over 30 secondary outcomes were extracted; however, based on our a priori criteria outlined in the methods, the only secondary outcome that qualified was anxiety.”

May combine two claims.

At T1, the pooled effect size of interventions on caregivers' anxiety was -0.65 (95% CI -1.14, -0.15) and statistically significant.

“At T1, a significant pooled ES of -0.65 (95% CI -1.14, -0.15) favoring the interventions was obtained (see Fig. 3).”

May combine two claims.

At T1, neither of the two mediators analyzed (control group and mode of delivery) was significant.

“At T1, there were enough data to analyze two mediators (control group and mode of delivery); neither was significant.”

May combine two claims.

At T2, the pooled effect size of interventions on caregivers' anxiety was -0.17 (95% CI -0.32, -0.01) and statistically significant.

“At T2, the pooled ES was also statistically significant (-0.17, 95% CI -0.32, -0.01) with no heterogeneity (p = 0.458) (see Fig. 3).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The only study not included in the meta-analysis was a pilot reporting no significant overall differences between the intervention and control groups.

“The only study not included in the meta-analysis 52 was a pilot reporting no significant overall differences between the intervention and control groups.”

• cites [52] Horton-Deutsch SL, Farran CJ, Choi EE, Fogg L. The PLUS Intervention: a pilot test with caregivers of depressed older adults. Archives of Psychiatric Nursing. 2002;16(2):61-71. sourceNot checked — no full text of the source

May combine two claims.

At T2, meta-regression on 17 mediators showed significant results for three self-management skills: taking action (p = 0.038), problem-solving (p = 0.022), and decision-making (p = 0.035).

“At T2, there were enough data to conduct a meta-regression on 17 mediators (see Table 2), and results were significant for three self-management skills: (a) taking action (yes/no) (p = 0.038); (b) problem-solving (yes/no) (p = 0.022); and (c) decision-making (yes/no) (p = 0.035).”

May combine two claims.

In the meta-analysis, interventions with 7-13 skills had a pooled effect size of -0.96 on caregiver depression at post-intervention to ≤3 months, with p < 0.001, 95% CI [-1.35, -0.58], I2 = 0%, based on 3 studies.

“| 7-13 | 3 | -0.96 | < 0.001 [-1.35; - | 0% | 5 | -0.13 | 0.049 [-0.26; 0.00] | 0%”

The quote only partly states this claim.

In the meta-analysis, interventions including behavioral activation had a pooled effect size of -0.86 on caregiver depression at post-intervention to ≤3 months, with p < 0.001, 95% CI [-1.14, -0.58], I2 = 0%, based on 5 studies.

“| Yes | 5 | -0.86 | < 0.001 [-1.14; - | 0% | 7 | -0.18 | 0.004 [-0.30; -0.06] 14%”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Data were extracted using a standardized Excel form based on the Cochrane Handbook, piloted on the first three studies, and for remaining studies extracted by a trained RA and verified by at least one RA or other author.

“Data were extracted using a standardized Excel form based on the Cochrane Handbook for Systematic Reviews of Interventions, 33 previously used by the team, [34][35][36] and piloted on the first three studies.For the remaining studies, data were extracted by a trained RA and verified by at least one RA or other author.”

• cites [33] Higgins J, Green S. Handbook for systematic reviews of interventions version 5.1. 0 [updated March 2011]. The Cochrane Collaboration. 2011; [cited 2020 September 15]. 5:252-8. Available from: https://training.cochrane.org/handbook/currentNot checked yet

  Not checked in the free run.

• cites [34] Beatty L, Lambert S. A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions. Clinical Psychology Review. 2013;33(4):609–22. sourceNot checked — no full text of the source
• cites [35] Lambert SD, Harrison JD, Smith E, Bonevski B, Carey M, Lawsin C, et al. The unmet needs of partners and caregivers of adults diagnosed with cancer: A systematic review. BMJ Supportive & Palliative Care. 2012;2(3):224-30. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The PRISMA statement was followed.

“The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) was followed, 20”

• cites [20] Moher D, Liberati A, Tetzlaff J, Altman DG, Group. TP. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine. 2009;151(4):264-9. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The methodological quality of the studies was assessed by two trained RAs using a combination of criteria from the Cochrane Collaboration's Risk of Bias tool and CONSORT statement.

“The methodological quality of the studies was assessed by two trained RAs using a combination of criteria from the Cochrane Collaboration's Risk of Bias tool 33 and CONSORT statement, 46”

• cites [33] Higgins J, Green S. Handbook for systematic reviews of interventions version 5.1. 0 [updated March 2011]. The Cochrane Collaboration. 2011; [cited 2020 September 15]. 5:252-8. Available from: https://training.cochrane.org/handbook/currentNot checked yet

  Not checked in the free run.

• cites [46] Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. International Journal of Surgery. 2012;10(1):28-55. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Self-management is a recommended treatment for adults with mild to moderate depressive symptoms and as an adjunct to more intensive treatments for adults experiencing severe depressive symptoms.

“Self-management is a recommended treatment for adults with mild to moderate depressive symptoms and as an adjunct to more intensive treatments for adults experiencing severe depressive symptoms.45”

• cites [45] Patten SB, Kennedy SH, Lam RW, O'Donovan C, Filteau MJ, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. Journal of Affective Disorders. 2009;117 Suppl 1:S5-14. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The review was prospectively registered (PROSPERO registration number: CRD42018100397).

“the review was prospectively registered (PROSPERO registration number: CRD42018100397).”

May combine two claims.

Egger's test and funnel plots did not reveal publication bias at T1 (p = 0.323) or T2 (p = 0.116).

“An Egger's test and funnel plots were computed and did not reveal publication bias at T1 (p = 0.323) or T2 (p = 0.116) (Appendix D).”

Probably not a substantial claim: may not pass S4 (based).

This is the first systematic review to critically appraise the effect of interventions either aimed at reducing caregivers' depression or helping the caregiver manage the care recipient's depression.

“This is the first systematic review to critically appraise the effect of interventions either aimed at reducing caregivers' depression or helping the caregiver manage the care recipient's depression.”

May combine two claims.

The sample size was too small to examine a number of mediators, and much remains unknown about the optimal components of this kind of intervention.

“Unfortunately, the sample size was too small to examine a number of mediators and much remains unknown about the optimal components of this kind of intervention.”

Probably not a substantial claim: may not pass S3 (load-bearing).

We often did not receive responses from authors asking for more information.

“We often did not receive responses from authors asking for more information.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Tolan et al. found that families who received a booster intervention following a family-focused prevention program reported sustained benefits.

“Tolan et al. 72 found that families who received a booster intervention following a family-focused prevention program reported sustained benefits.”

• cites [72] Tolan PH, Gorman-Smith D, Henry D, Schoeny M. The Benefits of Booster Interventions: Evidence from a Family-Focused Prevention Program. Prevention Science. 2009;10(4):287-97. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The inclusion/exclusion of full texts was confirmed by two authors, and discrepancies were discussed at regular team meetings to reach consensus.

“The inclusion/exclusion of full texts was confirmed by two authors, and discrepancies were discussed at regular team meetings to reach consensus.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Limitations of this review include missing details on the study design.

“Limitations of this review include missing details on the study design.”

May combine two claims.

There was significant heterogeneity for the pooled ES of anxiety postintervention, and no further investigation of the specific source was conducted due to the small number of studies.

“Also, there was significant heterogeneity for the pooled ES of anxiety postintervention, and no further investigation of the specific source was conducted due to the small number of studies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Evidence in the physical activity literature supports the use of boosters to achieve sustained behavior outcomes.

“Evidence in the physical activity literature also supports the use of boosters to achieve sustained behavior outcomes.71”

• cites [71] Fjeldsoe B, Neuhaus M, Winkler E, Eakin E. Systematic Review of Maintenance of Behavior Change Following Physical Activity and Dietary Interventions. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2011;30:99-109. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

These findings align with previous studies emphasizing that learning self-management skills enhances self-efficacy, ultimately resulting in changes in health behaviors and health status.

“These findings align with previous studies 40 emphasizing that learning self-management skills enhances self-efficacy, ultimately resulting in changes in health behaviors and health status.”

• cites [40] Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Annals of Behavioral Medicine. 2003;26(1):1-7. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable).

To increase the durability of intervention effects, booster or maintenance sessions might be needed.

“Thus, to increase the durability of intervention effects, booster or maintenance sessions might be needed.”