New Approach Cuts Depression, Anxiety in Dementia Caregivers

Deborah Brauser

November 26, 2014

A novel intervention may provide long-term improvement in mood levels in caregivers looking after family members with dementia, new research suggests.

Dr Gill Livingston

A randomized trial of 209 caregivers showed that those who underwent the START (Strategies for Relatives) program had significantly better scores on the Hospital Anxiety and Depression Scale (HADS) compared with those who received treatment as usual (TAU).

In addition, START was found to be cost-effective for both the caregivers and the dementia patients they supported.

"START...improved carers' depression and anxiety symptoms and quality of life not only in the short term, but also up to 24 months later. This is the first trial to show such results," write investigators led by Gill Livingston, MD, MBChB, FRCPsych, from the Division of Psychiatry at University College London in the United Kingdom.

The study was published online November 19 in Lancet Psychiatry.

Heavy Burden

"Two-thirds of people with dementia live at home supported mainly by family carers," write the investigators, adding that approximately 40% of these caregivers have clinical depression or anxiety.

Although past studies have shown that the START program can be effective for treating caregivers, most only looked at short-term outcomes.

The current randomized, parallel-group trial was created to assess long-term clinical results and cost-effectiveness of using START to treat psychological symptoms in caregivers of family members with dementia ― and to examine whether the program was also beneficial to the patients with dementia.

Between November 2009 and June 2011, 260 UK caregivers were recruited from three mental health agencies and one neurologic outpatient clinic. All participants provided patient support at least once per week; 209 were included in the final analysis.

Study participants were randomly assigned to receive either START (n = 140) or TAU (n = 69). START consisted of 8 manual-based sessions conducted during a period of 2 to 4 months and supervised by psychology graduates. The sessions touched on topics such as stress and well-being, behavioral strategies, and communication styles.

The program was developed from the US Coping with Caregiving intervention, and each session ended with a relaxation session featuring a tailored relaxation CD. All sessions were conducted in the participants' homes unless participants cited a preference for an in-office setting.

TAU, on the other hand, "was based on National Institute for Health and Care Excellence (NICE) guidelines, with services based around the person with dementia." Measures for the caregivers included total scores, depression scores, and anxiety scores on the HADS (known as HADS-T, HADS-D, and HADS-A, respectively). Higher scores signified more symptoms. The Health Status Questionnaire (HSQ) was also used to measure quality of life.

Initial results were presented this past summer at the Alzheimer's Association International Conference (AAIC) in Copenhagen, Denmark, and were reported by Medscape Medical News at that time.

At an on-site press conference, Dr Livingston reported that the caregivers who received TAU were seven times more likely to experience depression and anxiety than those receiving START at the end of 2 years.

The START group was "much, much less likely to be depressed than those in the nonintervention group. This was a massive, massive difference," she said.

Although overall caregiver cost for those undergoing START was £170 ($290 USD) higher than for the TAU group, overall patient costs were £571 ($975 USD) lower.

New Results

Additional results from the new journal article showed that the START group had a significantly better adjusted mean score on the HADS-T than the TAU group at the 24-month follow-up (mean difference, -2.58 points; 95% confidence interval [CI], -4.26 to -0.90; P = .003).

"Adjusted models for continuous scores" showed that, compared with TAU, START provided significant beneficial effects during a 24-month period on the HADS-A (mean difference, -1.16) and the HADS-D (mean difference, -1.45).

Scores on the HSQ-Mental Health, which measures quality of life, were also significantly improved in the START group compared with the TAU group (mean difference, 7.47; 95% confidence interval [CI], 2.87 - 12.08).

There were no between-group differences on any of the quality of life–Alzheimer's disease measures used to assess the patients.

However, the investigators note that START was cost-effective for both the caregivers and the patients, with "67% probability of cost-effectiveness at the £20,000 per QALY [quality-adjusted life year] willingness-to-pay threshold, and 70% at the £30,000 threshold."

"The number of people with dementia is rapidly growing, and policy frameworks assume that their families will remain the frontline providers of (unpaid) support," write the researchers.

"This cost-neutral intervention, which substantially improves family-carers' mental health and quality of life, should therefore be widely available."

Enduring Benefit

In an accompanying editorial, Sube Banerjee, MD, FRCPsych, from the Centre for Dementia Studies at Brighton and Sussex Medical School at the University of Sussex in the United Kingdom, writes that these findings were "strong and important" and show enduring benefits.

"This well conducted study addresses an important area for intervention for which the evidence base is sparse. Family carers are a vital resource for the management of people with dementia," writes Dr Banerjee.

"Although many carers derive personal satisfaction from caring, the experience can also be detrimental ― physically, psychologically, and financially."

He notes that any intervention that can decrease negative outcomes should be welcomed and that START "has a strong theoretical basis."

Program benefits cited by Dr Banerjee include its being straightforward and manualized, that it can be given in a residential home by non–clinically trained individuals who are readily available, and that it is relatively low in cost.

"On the basis of these results, the START intervention should be offered as individual therapy to all family carers of people with dementia as part of the support with a timely diagnosis," he writes.

At this summer's AAIC, press conference moderator Ralph Nixon, MD, chair of the Alzheimer's Association Medical and Scientific Advisory Council, noted that the study showcases the importance of caregivers.

By preparing them for what lies ahead and teaching them necessary coping skills, START can help caregivers preserve their own mental health, which will ultimately result in better care for their dementia patients, said Dr Nixon.

Dr Livingston, 10 of the 11 other study authors, and Dr Nixon have reported no relevant financial relationships. The remaining study author reports receiving fees, grants, and other payments from GE Healthcare and grants from Lundbeck. Dr Banerjee reports having received consultancy and speakers' fees, research funding, and education support from pharmaceutical companies that manufacture antidepressants, antidementia medications, and other drugs.

Lancet Psychiatry. Published online November 19, 2014. Article, Editorial

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