Clinical effectiveness of the START (STrAtegies for RelaTives) psychological intervention for family carers and the effects on the cost of care for people with dementia: 6-year follow-up of a randomised controlled trial
Open accessAbstract
Background: The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective. Aims: To assess the clinical effectiveness over 6 years and the impact on costs and care home admission. Method: We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission. Results: In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35). Conclusions: START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers. Declarations of interest: G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
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A study in care homes observed that engagement increased during activities in those who attended the groups.
“A study in care homes observed engagement increased during activities in those who attended the groups.228”
From Dementia prevention, intervention, and care: 2020 report of the Lancet Commission (2020) · cites this paper as [228]
The Intervention and delivery section describes individual therapy for family carers, not group activities in care homes. The Primary outcome section reports carers’ anxiety and depressive symptoms; it does not report increased engagement during activities. (LLM, conf=0.86)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredMulticomponent carer interventions reduce family carer depression, burden, or stress and are cost-effective and cost saving.
“They reduce family carer depression, depression, burden, or stress and are cost-effective and cost saving.”
From Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission (2024) · cites this paper as [486]
The Abstract describes START as a multicomponent intervention and reports reduced depressive symptoms and cost-effectiveness for family carers of people with dementia. The Main findings report sustained depression benefits, but say START “might actually be cost-saving”; the cost comparison was underpowered. The source therefore does not establish the unqualified claim that these interventions are cost saving. (LLM, conf=0.89)
Experimental — accuracy not yet measuredThere is evidence that some multicomponent carer interventions are effective in the short and long term; they usually include information about medical and community-based resources, skills training, stress reduction and coping techniques, emotional support, and future planning.
“There is evidence that some multicomponent carer interventions are effective in the short and long-term; and these usually include information about medical and community-based resources, skills training, stress reduction and coping techniques, providing emotional support and future planning. (2, 482-486)”
From Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission (2024) · cites this paper as [486]
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- Authors
- Livingston, G., Manela, M., O'Keeffe, A., Rapaport, P., Cooper, C., Knapp, M., King, D., Romeo, R., Walker, Z., Hoe, J., Mummery, C., & Barber, J.
- Affiliations
- St Pancras Hospital (GB)
- University College London (GB)
- London School of Economics and Political Science (GB)
- UCL Queen Square Institute of Neurology (GB)
- Corresponding author
- Livingston, Gill
- ORCID
- Venue
- The British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2019-07-12
- Volume
- 216
- Issue
- 1
- Pages
- 35-42
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2948477228
- Cited by
- 61
- References
- 37
- Citations by year
- 2026: 7 · 2025: 7 · 2024: 16 · 2023: 6 · 2022: 11 · 2021: 5 · 2020: 7 · 2019: 2
- FWCI
- 4.97
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- City Research Online (City University London) (acceptedVersion)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (acceptedVersion)
- UWL Repository (University of West London) (acceptedVersion)
- London School of Economics and Political Science Theses Online (London School of Economics and Political Science) (acceptedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Research Portal (King's College London) (submittedVersion, cc-by-nc-nd)
- Funders
- London School of Economics and Political Science
- National Institute for Health and Care Research (08/14/06, 08/14/99)
- King's College London
- University College London Hospitals NHS Foundation Trust
- H. Lundbeck A/S
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Social Sciences › Psychology › Clinical Psychology › Family Caregiving in Mental Illness
- Health Sciences › Health Professions › Pharmacy › Nursing care and research
- Keywords
- family caregivers, dementia, caregiver depression, anxiety, coping interventions, cost of care, nursing home admission, cost-effectiveness, home care, follow-up care, Hospital Anxiety and Depression Scale, carer support services, long-term care costs
- MeSH terms
- Psychosocial Intervention, Adaptation, Psychological, Cost-Benefit Analysis, Dementia, Follow-Up Studies, Humans, Time Factors, Treatment Outcome, Caregivers
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