Plain English Summary
Background and study aims
Family carers of people with dementia are a group at high risk of mental health problems like depression and anxiety. As they provide most of the care received by people with dementia in this country, and the number of people with dementia is projected to increase substantially, there is an urgent need within society to develop ways to decrease their distress. The UK government has recognised that family dementia carers need dedicated psychological therapies, and that this should be a key component of high quality dementia care, but in practice resources are not available. The only studies that have demonstrated efficacy of a manual based psychological therapy in this group were carried out in the
USA and the therapy was conducted by clinical psychologists. Clinical psychologists are a highly trained and finite resource within the NHS. Researchers in the USA have developed a talking therapy programme to help family or friends of people with memory problems. This has been adapted this for Britain (for example; seeing people individually rather than in groups). The aim of this study is to test whether this programme is effective in friends and relatives of people with memory problems in the UK.
Who can participate?
Family carers who provide emotional or practical support at least weekly and identify themselves as the primary carer of someone with dementia not living in 24 hour care and who are carers of patients referred in the last year.
What does the study involve?
An interviewer conducts an initial interview. This takes about an hour. They ask participants about their relative/friend's memory and behavioural symptoms, difficulties they may have with their daily routine, their and their relative's/friend's health, services that provide assistance to their friend/relative, and the rewards and difficulties of caring including how they have coped with these difficulties over recent times. A researcher (the same person if possible) visits again 4, 8, 12 and 24 months after the initial interview. At these visits, they ask some of the same questions again to see whether things have changed. Participants are randomly allocated to one of two groups after the first interview. The first group do not receive any extra visits apart from the researcher coming back to see how they are getting on. In the second group a psychological therapist conducts eight talking therapy sessions. The first visit is shortly after the first interview, and the meetings are weekly for eight sessions. The meetings are scheduled for a time and place that is convenient, and most people prefer this to be at their home. Each lasts about an hour. The psychological therapist is someone who has received training to deliver this programme. Participants are encouraged to discuss recent problems that have arisen while helping the person with memory problems and what to do. Participants are also given brief exercises to do between sessions, for example, making a note of incidents which cause stress. With consent some of the sessions are tape recorded for later analysis, to ensure that the therapy is being delivered correctly. The study does not involve the person with memory problems, and no specific additional care is offered. Participants are followed up every six months from 2 years until the person with dementia goes into a care home or dies, or for 6 years.
What are the possible benefits and risks of participating?
It cannot be promised that the study will help the participants. It will provide evidence regarding whether the programme is helpful for family and friends of people with memory problems. If it is, then knowing this could help improve the support offered to family and friends of people with memory problems. It is not anticipated that there will be any disadvantages to taking part except for the inconvenience of making time for the interviews and the talking therapy sessions, but it is possible that some topics discussed concerning the stresses of caring may be upsetting.
Where is the study run from?
University College London (UK)
When is the study starting and how long is it expected to run for?
August 2009 to December 2018
Who is funding the study?
Health Technology Assessment Programme (UK)
Who is the main contact?
Prof. Gill Livingston
g.livingston@ucl.ac.uk
Trial website
Contact information
Type
Scientific
Primary contact
Prof Gill Livingston
ORCID ID
Contact details
University College London
Holborn Union Building
Archway Campus
Highgate Hill
London
N19 5NL
United Kingdom
+44 (0)20 7561 4218
g.liivngston@ucl.ac.uk
Additional identifiers
EudraCT number
ClinicalTrials.gov number
Protocol/serial number
HTA 08/14/06
Study information
Scientific title
START (STrAtegies for RelaTives) study: a pragmatic randomised controlled trial to determine the effectiveness of a manual based coping strategy programme in promoting the mental health of carers of people with dementia
Acronym
START
Study hypothesis
That eight sessions of manual based coping strategy therapy, delivered over 8-14 weeks by supervised graduate mental health workers is clinically (in terms of anxiety and depressive symptoms) and cost-effectiveness for family carers, compared to usual care.
Ethics approval
East London and the City Research Ethics Committee 1, 11/08/2009, ref: 09/H0703/84
Approval for substantial amendment on 11/09/2011
Study design
Randomised multi-centre single-blind controlled trial
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Trial setting
Other
Trial type
Quality of life
Patient information sheet
Not available in web format, please use the contact details to request a patient information sheet
Condition
Family carer of patient with dementia
Intervention
An interviewer conducts an initial interview. This takes about an hour. They ask participants about their relative/friend's memory and behavioural symptoms, difficulties they may have with their daily routine, their and their relative's/friend's health, services that provide assistance to their friend/relative, and the rewards and difficulties of caring including how they have coped with these difficulties over recent times. A researcher (the same person if possible) visits again 4, 8, 12 and 24 months after the initial interview. At these visits, they ask some of the same questions again to see whether things have changed. Participants are randomly allocated to one of two groups after the first interview. The first group do not receive any extra visits apart from the researcher coming back to see how they are getting on. In the second group a psychological therapist conducts eight talking therapy sessions. The first visit is shortly after the first interview, and the meetings are weekly for eight sessions. The meetings are scheduled for a time and place that is convenient, and most people prefer this to be at their home. Each lasts about an hour. The psychological therapist is someone who has received training to deliver this programme. Participants are encouraged to discuss recent problems that have arisen while helping the person with memory problems and what to do. Participants are also given brief exercises to do between sessions, for example, making a note of incidents which cause stress. With consent some of the sessions are tape recorded for later analysis, to ensure that the therapy is being delivered correctly. The study does not involve the person with memory problems, and no specific additional care is offered.
Added 24/08/2017:
Participants are followed up every six months from 2 years until the person with dementia goes into a care home or dies, or for 6 years.
Intervention type
Other
Phase
Not Applicable
Drug names
Primary outcome measure
Current primary outcome measures as of 10/05/2013:
1. Carer HADS Total
2. Cost-effectiveness: Cost of care for each group will be measured using the Client Service Receipt Inventory (CSRI). The EQ5D is a generic measure to generate QALYs (quality of life adjusted health years); societal weights will be applied.
At 2 years:
1. Carer HADS Total
2. Cost-effectiveness: Cost of care for each group will be measured using the Client Service Receipt Inventory (CSRI). The EQ5D is a generic measure to generate QALYs (quality of life adjusted health years); societal weights will be applied.
At 7 years:
Time to entry to 24 care
Previous primary outcome measures until 10/05/2013:
1. Carer HADS depression and anxiety scores
2. Cost-effectiveness: Cost of care for each group will be measured using the Client Service Receipt Inventory (CSRI). The EQ5D is a generic measure to generate QALYs (quality of life adjusted health years); societal weights will be applied.
Secondary outcome measures
Current secondary outcome measures as of 10/05/2013:
At 8 months:
1 Depression and anxiety caseness and scores on the HADS
2. Carer (HSQ mental health) and care recipient (QoL-AD) quality of life
3. Modified Conflict Tactics Scale
At 2 years:
1 Time to entry of the person with dementia to 24-hr care
2 Depression and anxiety caseness and scores on the HADS
3 Carer (HSQ mental health) and care recipient (QoL-AD) quality of life
4. Modified Conflict Tactics Scale
Previous secondary outcome measures until 10/05/2013:
1. Time to entry of the person with dementia to 24-hr care
2. Depression and anxiety caseness on the HADS
3. Carer (HSQ) and care recipient (QoL-AD) quality of life
4. Modified Conflict Tactics Scale
Overall trial start date
01/08/2009
Overall trial end date
31/12/2018
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
1. Family carers who provide emotional or practical support at least weekly and identify themselves as the primary carer of someone with dementia not living in 24 hour care referred in the last year
2. Participants must be over 18 years of age and can be of either sex
Participant type
Carer
Age group
Adult
Gender
Both
Target number of participants
258
Participant exclusion criteria
1. Carers who are unable to give informed consent to the trial, for example because they have dementia themselves
2. Carers who are currently taking part in a randomised clinical trial in their capacity as a family carer
3. Carers who live more than 1.5 hours from the researchers' base
Recruitment start date
01/08/2009
Recruitment end date
01/06/2011
Locations
Countries of recruitment
United Kingdom
Trial participating centre
University College London
London
N19 5NL
United Kingdom
Sponsor information
Organisation
University College London (UK)
Sponsor details
c/o Dr O. Avwenagha
Research Governance Co-ordinator
Joint UCLH/UCL Biomedical Research Unit
R&D Directorate (Maple House)
Rosenheim Wing (Ground Floor)
25 Grafton Way
London
WC1E 5DB
United Kingdom
+44 (0)20 7380 9928
o.avwenagha@ucl.ac.uk
Sponsor type
University/education
Website
Funders
Funder type
Government
Funder name
Health Technology Assessment Programme
Alternative name(s)
HTA
Funding Body Type
unknown
Funding Body Subtype
Location
Results and Publications
Publication and dissemination plan
Planned publication in a high-impact peer reviewed journal.
IPD sharing statement
The data sharing plans for the current study are unknown and will be made available at a later date.
Intention to publish date
31/12/2019
Participant level data
To be made available at a later date
Basic results (scientific)
Publication list
2013 clinical effectiveness results in: http://www.ncbi.nlm.nih.gov/pubmed/24162942
2013 cost effectiveness results in: http://www.ncbi.nlm.nih.gov/pubmed/24162943
2014 participants' views in: https://www.ncbi.nlm.nih.gov/pubmed/24898089
2014 coping strategies results in: https://www.ncbi.nlm.nih.gov/pubmed/25083601
2014 HTA report in: http://www.ncbi.nlm.nih.gov/pubmed/25300037
2014 main results in: http://www.ncbi.nlm.nih.gov/pubmed/26361313
2016 reducing abuse results in: https://www.ncbi.nlm.nih.gov/pubmed/26652193
2017 dissemination results in: https://www.ncbi.nlm.nih.gov/pubmed/28827274
Publication citations
-
Clinical effectiveness results
Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, King D, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C, 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., BMJ, 2013, 347, f6276.
-
Cost effectiveness results
Knapp M, King D, Romeo R, Schehl B, Barber J, Griffin M, Rapaport P, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C, Livingston G, Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial., BMJ, 2013, 347, f6342.
-
Results
Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, Romeo R, King D, Livingston D, Lewis-Holmes E, Mummery C, Walker Z, Hoe J, Cooper C, START (STrAtegies for RelaTives) study: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manual-based coping strategy programme in promoting the mental health of carers of people with dementia., Health Technol Assess, 2014, 18, 61, 1-242, doi: 10.3310/hta18610.
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Results
Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, King D, Romeo R, Livingston D, Mummery C, Walker Z, Hoe J, Cooper C, Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomised, controlled trial, Lancet Psychiatry, 2014, 1, 7, 539-548, doi: 10.1016/S2215-0366(14)00073-X.
-
Results
Sommerlad A, Manela M, Cooper C, Rapaport P, Livingston G, START (STrAtegies for RelaTives) coping strategy for family carers of adults with dementia: qualitative study of participants' views about the intervention, BMJ Open, 2014 , 4, 6, e005273, doi: 10.1136/bmjopen-2014-005273.
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Results
Li R, Cooper C, Barber J, Rapaport P, Griffin M, Livingston G, Coping strategies as mediators of the effect of the START (strategies for RelaTives) intervention on psychological morbidity for family carers of people with dementia in a randomised controlled trial, J Affect Disord, 2014 , 168, 298-305, doi: 10.1016/j.jad.2014.07.008.
-
Results
Cooper C, Barber J, Griffin M, Rapaport P, Livingston G, Effectiveness of START psychological intervention in reducing abuse by dementia family carers: randomized controlled trial, Int Psychogeriatr, 2016 , 28, 6, 881-887, doi: 10.1017/S1041610215002033.
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Results
Lord K, Rapaport P, Cooper C, Livingston G, Disseminating START: training clinical psychologists and admiral nurses as trainers in a psychosocial intervention for carers of people with dementia's depressive and anxiety symptoms, BMJ Open, 2017 , 7, 8, e017759, doi: 10.1136/bmjopen-2017-017759.