systematic review of the effect of psychological interventions on family caregivers of people with...

Journal of Affective Disorders 101 (2007) 75–89www.elsevier.com/locate/jad

Research report

Systematic review of the effect of psychological interventions onfamily caregivers of people with dementia☆

A. Selwood a,⁎, K. Johnston a, C. Katona b, C. Lyketsos c, G. Livingston a

a Department of Mental Health Sciences, University College London, Archway Campus, Holborn Union Building,Highgate Hill, London, N19 5NL, UK

b Kent Institute of Medicine and Health Sciences, Canterbury, UKc Division of Geriatric Psychiatry and Neuropsychiatry, Suite 308, 550 North Broadway, Baltimore, Maryland 21205, USA

Received 7 June 2006; received in revised form 19 September 2006; accepted 31 October 2006Available online 14 December 2006

Abstract

Background: Caregivers of people with dementia are at high risk of psychological morbidity and associated breakdown in care.Many psychologically based interventions have been designed to help caregivers of people with dementia. More work is needed toidentify which, if any, are helpful for such caregivers.Method: We conducted a systematic review of the immediate and long term efficacy of different types of psychologicalinterventions for the psychological health of caregivers of people with dementia, using standardized criteria, to assist clinicians inimplementing rational, evidence-based management recommendations. We reviewed studies examining the effects of any therapyderived from a psychological approach that satisfied pre-specified criteria. Using the Oxford Centre for Evidence-Based Medicinecriteria we rated the quality of each study, extracted data and gave overall ratings to different types of intervention.Results: We identified 244 references in our search of which 62 met our inclusion criteria.Limitations: Our findings are limited by lack of good quality evidence, with only ten level 1 studies identified.Conclusions: We found excellent evidence for the efficacy of six or more sessions of individual behavioral management therapycentered on the care recipient's behavior in alleviating caregiver symptoms both immediately and for up to 32 months. Teachingcaregivers coping strategies either individually or in a group also appeared effective in improving caregiver psychological healthboth immediately and for some months afterwards. Group interventions were less effective than individual interventions. Educationabout dementia by itself, group behavioral therapy and supportive therapy were not effective caregiver interventions.© 2006 Elsevier B.V. All rights reserved.

Keywords: Dementia; Caregivers; Psychological interventions; Systematic review

☆ On behalf of the Old Age Taskforce of the World Federation ofBiological Psychiatry. We would like to acknowledge the particularhelp of Henry Brodaty and Carlos Lima. The authors are all clinicians.There is no other conflict of interest.⁎ Corresponding author. Tel.: +44 207 288 5931; fax: +44 207 288 3411.E-mail address: [email protected] (A. Selwood).

0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved.doi:10.1016/j.jad.2006.10.025

1. Introduction

The number of peoplewith dementia is increasingwithsignificant public health implications including the linkedpsychological morbidity of caregivers (CG) in terms ofburden, general psychological distress and depressivesymptomatology (Pinquart and Sorensen, 2003). In onestudy, for example, 47% of those caring for someone with

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76 A. Selwood et al. / Journal of Affective Disorders 101 (2007) 75–89

dementia were depressed compared to only 3% caring forsomeone with physical health problems (Livingston et al.,1996). This morbidity is associated with care breakdownand institutionalisation of the care recipient (CR) (Brodatyet al., 1993). A meta-analysis of psychological interven-tions to help CGs of older people with physical ailmentsor dementia suggested that interventions are lessefficacious when targeted at those looking after peoplewith dementia, and if delivered to groups rather thanindividuals (Sorensen et al., 2002). Thus dementia CGsmay be a particularly difficult group to help, althoughthere is evidence from meta-analysis that interventionscan decrease CG psychological morbidity (Brodaty et al.,2003; Schulz et al., 2002) and that only multicomponentinterventions reduce CG burden (Acton and Kang, 2001).Further good quality studies of the individual compo-nents of these interventions is needed to identify whichpsychologically based interventions, if any, are helpfulfor CGs of people with dementia (Cooke et al., 2001;Pusey and Richards, 2001; Brodaty et al., 2003). This isthe first systematic review to categorise interventions,rate the study quality, evaluate all studies of such ap-proaches on the psychological health of CGs for dementiaand assess the level of confidence in the results, in orderto compare the efficacy of different types of interventionsusing standardised criteria. This is in order to assistclinicians in the implementation of rational, evidence-based management and mirrors the approach we followedin a systematic review examining the benefits of psycho-logical treatments for the neuropsychiatric symptoms ofpatients with dementia (Livingston et al., 2005).

2. Methods

2.1. Search strategy

We searched electronic databases until July 2003,reference lists from articles, the Cochrane Library andhand-searched four journals. We asked experts aboutadditional studies (even if post-July 2003). We usedsearch terms encompassing caregivers/carers, individualdementias and interventions. We included primaryresearch studies with quantitative outcome measuresof CG psychological health but did not include out-comes regarding the person with dementia. If a scalemeasured a mixture of anxiety and depression we calledthis “psychological distress” as in the terminology of theGeneral Health Questionnaire (GHQ)(Goldberg andWilliams, 1988). We excluded studies including CGsof people without dementia and interventions eitherinvolving medication or not based on an explicitly psy-chological model, e.g. aromatherapy.

2.2. Data extraction strategy

We used a tool adapted from a review of checklists(Moher et al., 1995) and assigned a level of evidence(LOE) grade to studies according to the Oxford Centre forEvidence Based Medicine (CEBM) guidelines (http://www.cebm.net/levels_of_evidence.asp#levels). LOEgrades range from 1–5 with lower numbers indicatinghigher quality e.g. randomised controlled trials (RCT)with narrow confidence intervals and 80% or moreparticipant follow-up are level 1 studies and single casereports level 5. Two raters (GL and AS) assignedindependent LOE grades to each study and discussedreasons behind disagreements until a consensus wasreached. We divided the interventions into six categoriesbased on their general approach in linewith those in earlierreviews (Acton and Kang, 2001; Pusey and Richards,2001; Sorensen et al., 2002): education; dementia specifictherapy (DST); CG coping strategies (CS) divided intogroup (gCS) and individual (iCS); behavioral manage-ment techniques (BMT) divided into group (gBMT) andindividual (iBMT); and supportive therapy. By individualtherapy we mean focussing on the individual CG orfamily. We also divided the BMT into those using b6 or≥6 sessions, as six sessions is often regarded as thetherapeuticminimum (Pilling et al., 2002). Descriptions ofthe interventions in each category are provided in theresults section. Each category of intervention was thengiven an overall grade of recommendation (GR) rangingfrom A to D according to the CEBM criteria indicatingthe confidence with which we can draw a conclusionthat an intervention is effective or ineffective. The bestlevel of evidence is indicated by a GR of A; the lowestlevel by a GR of D. A GR of A represents, for example,consistent level 1 studies but a GR of D represents level 5or troublingly inconsistent or inconclusive studies. Thetwo raters assigned independent GR to each study andagain came to a consensus by discussion.

3. Results

We identified 244 references in our search, of which62 met the inclusion criteria. References were excludedas: 74 were not primary research; 36 had qualitativeoutcomes; 35 reported no psychological intervention; 32had no family CG outcome fitting the inclusion criteriaand in 5 some CRs did not have dementia.

3.1. Educational interventions

We identified 16 papers describing educational inter-ventions involved solely in providing information about

http://www.cebm.net/levels_of_evidence.asp#levels

http://www.cebm.net/levels_of_evidence.asp#levels

77A. Selwood et al. / Journal of Affective Disorders 101 (2007) 75–89

dementia. Six were randomised controlled trials (RCT),although none was level 1, and all were consistentlynegative. The first found that taped telephone lectures didnot improve CG psychological health or decrease burdenimmediately after the intervention (Goodman andPynoos, 1990). A small RCT of education found no dif-ference in the Relative Stress Scale (RSS) when comparedto controls 5 months after intervention (Burgener et al.,1998). Similarly group sessions did not decrease CGstress on the RSS in comparison to controls 6 weeks later(Done and Thomas, 2001). A smaller RCT comparededucation to gCS and found no significant differencein stress (Gendron et al., 1996). Nurse education at amemory clinic did not result in any difference betweengroups in terms of either psychological health or burden(Logiudice et al., 1999). In the final RCT, individualsessions had no effect on CG mood at 1, 6 or 12 weeksafter the intervention (Sutcliffe and Larner, 1988). Anecological study found no effect on CG depression im-mediately or at 9 months (Kuhn and de Leon, 2001).Counter-intuitively, a group education programme led to asignificant increase in CG burden (Coen et al., 1999). Theother studies were all level 4 and 5 and all but threeshowed negative results either immediately or somemonths later (Belmin et al., 1999; Cummings et al., 1998;Magni et al., 1995; Morris et al., 1992; Russell et al.,1989; Toner, 1987; Wilkins et al., 1999; Zanetti et al.,1998). The GR for education as an intervention for CGdistress, depression and burden is B. The evidence showsno evidence of benefit and suggests that education byitself is not an effective intervention either immediatelyor some months later for CG depression, burden or dis-tress (Table 1).

3.2. Dementia specific therapies targeted at the patient(DST)

We found 5 papers describing the outcome ofdementia specific therapies targeted at the patient,only one of which was an RCT (Spector et al., 2001).The RCT was a very small unmasked study assessingthe effect on CGs of Cognitive Stimulation Therapy(CST) for the patient compared to usual treatment. CSTis derived from reality orientation (RO) but usesinformation processing rather than factual knowledge.After 1 week, CG psychological symptoms as measuredby the General Health Questionnaire (GHQ) weresignificantly better in the intervention group. The otherpapers (Haight et al., 2003; Quayhagen et al., 2000;Quayhagen and Quayhagen, 1989; Thorgrimsen et al.,2002) described small level 4 studies, three of whichused CST or reminiscence therapy. Outcomes were

negative, although all had small numbers. In the fourththe intervention group, which participated in group lifereview (creating and discussing a chronology ofsignificant life events), did significantly better interms of CG burden compared to the control group(Haight et al., 2003). The GR for Dementia SpecificTherapies is D as the evidence is troublingly inconsis-tent. At this point there is no evidence to support thevalue of patient-targeted DST as a way of helping CGs(Table 2).

3.3. Group CG coping strategies (gCS)

Many interventions were designed to help CGs copewith stress and involved teaching coping strategies, stressmanagement, problem appraisal and problem solvingoften together with education about dementia. All RCTswere six or more sessions in length. We divided these CGcoping strategies into those using group (gCS) and thoseusing individual (iCS) approaches.

We identified one level 1 study involving gCS. Theintervention consisted of a 14 hour training programmebased on stress and coping theory (Hepburn et al.,2001). Three months after the study ended, those in theintervention group were significantly less depressedand experienced lower CG burden than those in thecontrol group. There were four level 2 RCTs (Coonet al., 2003; Gallagher-Thompson et al., 2001; Gendronet al., 1996; Steffen, 2000). In one, depression im-proved in carers immediately and at 3 months follow-ing groups of anger or depression management (Coonet al., 2003). A similar study found improvement indepression but not in burden at 1 month (Gallagher-Thompson et al., 2001). The other RCTs were smallerand did not show significant differences in outcome. Asmall RCTwith 17 subjects receiving education and 18gCS found no difference between groups in eitherdepression, anxiety or burden (Gendron et al., 1996).Similarly, an 8 week CS group focussing on anger andfrustration found no significant difference compared tocontrols (Steffen, 2000). A large study of 10 weeksgCS reported improvement in the intervention group interms of depressive symptoms after 2 weeks but did notcompare groups with each other (Gallagher-Thompsonand Coon, 2003). There are also three level 4 and 5studies, none of which showed a significant change(Dellasega, 1990; McCurry et al., 1996; Quayhagenet al., 2000). The GR for gCS for depression is B, withevidence from one level 1 study and the larger level 2studies that it is effective immediately and for up to3 months after intervention. The GR for gCS for bur-den is D as the evidence is inconsistent (Table 3a).

Table 1Characteristics, outcome and level of evidence of education

Author/year IG No ControlNo

Therapeutic regimen Time to follow up Outcome LOE

Goodmanand Pynoos(1990)⁎

35(Ed)

31(support)

12 weekly telephone accessedtaped lectures or 12 week peertelephone network of 4–5 caregivers

Immediately No effect on psychologicalhealth or burden in eithergroup or between groups

2b

Burgener etal. (1998)⁎

Gp1=11,Gp 2=12,Gp 3=12

12 1×90 minute home educational andbehavior intervention programusing a booklet. 3 groups:1 = both interventions;2 = education only;3 = behavioral only

Approx5 months postintervention

No sig difference in stress 2b

Done andThomas(2001)⁎

30 15 Two×1 hour group short trainingworkshop in communication

6 weeks No sig difference incarer stress

2b

Gendron et al.(1996)⁎

17 (Ed) 18(gBMT)

8×weekly 90 minute groupeducational sessions comparedwith gBMT

Immediately,3 and6 months

No sig difference indepression, anxietyor burden

2b

Logiudice etal. (1999)⁎

25 25 Nurse led family conference inmemory clinic to discussdiagnosis/ questions

6 and12 months postintervention

No difference betweengroups in burdenand GHQ

2b

Sutcliffe andLarner(1988)⁎

4 Ed,6 iCS

5 6 weekly×45 minuteindividual Ed or iCSsessions at home

1, 6 and12 weeks

No differencein mood foreducation group

2b

Coen et al.(1999)

32 Owncontrol

2 hour group educationsessions for 8 weeks

6–7 monthspost

Sig. ↑ in carer burden 2c

Kuhn andde Leon(2001)

58 0 5×didactic 2 hour weeklyeducation sessions aboutdementia and caregiving

Immediatelyand 9 months

No significantdifference, trendto become moredepressed

2c immediately,4 at 9/12

Belmin et al.(1999)

19 Owncontrol

Three×3 hour groupproviding informationabout dementia

2 weeks Sig. ↓ in burden 4

Cummings etal. (1998)

13 0 8 weeks of separate educationgroups for people withdementia and their caregivers

Immediately ↓ in perceived strain,increase incoping

4

Morris et al.(1992)

Ed=18 gBMT=13 5×75 minute meetings — seminarformat with invited speakerscompared with gBMT

Immediatelyand approximately3 months

No sig difference indepressionand strain

4

Russell et al.(1989)

6 Owncontrol

Six week closed educationalsupport group for relatives

Between 1 and8 weeks

No sig difference indepression,GHQ or strain

4

Toner (1987) 12 12 5 visits in both groups. Carers inEd group given educational bookletto read and discuss

Immediately Intervention groupsig better onGHQ

4

Wilkins et al.(1999)

11 0 8 week structured group Edintervention plus weeklyphone calls

Immediately and30 days

No sig difference 4

Zanetti et al.(1998)

12 11 6×one hour sessions ofdidactic presentations followedby group discussion

Immediately and3 months

No effect ondepression. Burdenassoc. with behavioraldisturbanceimproved only at 3/12

4

Magni et al.(1995)

22 0 8×2 hourly weeklyeducational sessions

Immediately No sig difference 5

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5 withlower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer quality gradations, with arange from “a” (higher quality) to “c” (lower quality)];⁎ = randomised controlled trial; IG = intervention group; No = number; DST = dementia specifictherapy; gBMT = group behavioral management techniques; iBMT = individual behavioral management techniques; gp = group; sig = significant; diff =difference; Ed = education; GHQ = general health questionnaire (psychological symptoms of anxiety and depression).


Table 2Characteristics, outcome and level of evidence of dementia specific therapy (DST)


Therapeutic regimen Time tofollow up

Outcome LOE

Spector et al.(2001)⁎

10 (total — number inpatient and controlgroups unclear)

Cognitive stimulationtherapy — 15×45 minutetwice weekly sessions.

1 week postintervention

GHQ sig. better intreatment group

2b

Haight et al.(2003)

22 (total — number inpatient and controlgroups unclear)

Life review — 8×1 weeklyvisits for patient or patientand caregiver

Immediately Both life review groupshad sig. reducedburden comparedto control group

4

Quayhagenand Quayhagen(1989)

10 6 Cognitive stimulation therapy —monthly sessions training thecaregiver to provide 6 hoursof CST a week

4 and8 months postintervention

Increase in burden anddepressive symptoms innon-treatment group.Treatment group showedno change

4

Quayhagen et al.(2000)

DST=21iBMT=29 gBMT=22Support=16

15 Cognitive stimulation therapy —8×weekly 1.5 hour home-basedsessions training the caregiverto provide 5 hours of CST a week

Immediately CST group ↓ indepression. No analysisof diff. between groups

4

Thorgrimsen et al.(2002)

7 4 Reminiscence therapy — RYCT(remembering yesterday, caring today).18 weekly manualised sessions, 11for caregivers only and others for dyad

Immediately No significant difference inGHQ and relative stress

4

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-BasedMedicine guidelines and ranged from 1 to 5with lower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer qualitygradations, with a range from “a” (higher quality) to “c” (lower quality); No = number; IG = intervention group; DST = dementia specific therapy;CST = cognitive stimulation therapy; iBMT = individual behavioral management techniques; gBMT = group behavioral management techniques;sig = significant; diff = difference; GHQ = general health questionnaire (psychological symptoms of anxiety and depression); ⁎ = randomisedcontrolled trial.


3.4. Individual coping strategies (iCS)

There were 4 RCTs of iCS, all of which lasted at least6 sessions. The only level 1 study reported improve-ment in CG psychological distress and depression bothimmediately and at 3 months (Marriott et al., 2000).There were three level 2 RCTs. The largest showed nodifference in CG burden either immediately or at6 months (Roberts et al., 1999). The others both showedan improvement in depression in the intervention group(Steffen, 2000) although burden did not improve eitherimmediately or up to 12 weeks (Sutcliffe and Larner,1988). A cohort study of iCS found significant im-provement in depression and psychological symptomsimmediately (Romero and Wenz, 2001). There weretwo level 4 studies showing mixed results (Quayhagenet al., 2000; Moniz-Cook et al., 1998). The GR for iCSfor depression is B as there is one level 1 study andconsistent level 2 studies indicating that it worksimmediately to reduce CG distress and depression andthe benefit appears to last up to 3 months post inter-vention. The GR for iCS for burden is D as there are notenough studies to be conclusive (Table 3b).

3.5. Group behavioral management techniques (gBMT)

Eleven studies, all ofwhichwere of at least six sessions,taught groups of CGs about behavioral managementtheory and how to manage problem behaviors in the CR,often combined with CG coping strategies. We found onelevel 1 study of gBMT, incorporating a multi-facetedapproach including coping strategies, problem solving andeducation for the CG as well as BMT regarding the personwith dementia (Brodaty and Gresham, 1989). It reportedthat GHQ scores of CGs were reduced after theintervention programme but were only significantlylower than controls after 12 months. This programmewas unusual in that it involved a ten day inpatientadmission for both the CG and CR. There were six level 2RCTs (Haley et al., 1987; Hebert et al., 1994, 2003;McCurry et al., 1998; Robinson and Yates, 1994; Zaritet al., 1987).A largeRCTbased on stress appraisal, copingskills and behavioral management of the person withdementia did not change depression, anxiety or burden inthe intervention group compared to the controls immedi-ately (Hebert et al., 2003). Another largeRCT inwhich theintervention group had group counselling, problem

Table 3aCharacteristics, outcome and level of evidence for group caregiver coping strategies (gCS)


Therapeutic regimen Time to followup

Outcome LOE

Hepburn et al.(2001)⁎

72 45 7×2 hour weekly grouptraining sessions in copingand stress management

3 months Sig better indepression, burden

1b

Coon et al.(2003)⁎

53 anger, 64depression

52 2 groups-8×2 hour weekly then2 monthly sessions in copingwith depression or anger

Immediatelyand 3/12

Sig improvement inanger and depressionin IG

2b

Gallagher-Thompsonet al. (2001)⁎

43 27 8×2 hour weekly interventionon coping with frustrationand anger

1 month Sig. improvement indepression. No changein burden

2b

Gallagher-Thompson andCoon (2003)⁎

105 108 10×weekly group called“Coping with caregiving” —learning relaxation,communication etc.

2 weeks Depressive symptomsimproved in IG. Nobetween groups comparison

2c

Gendron et al.(1996)⁎

18 (gCS) 17 (Ed) 8 weekly 90 minute groupsessions of problem solving andcognitive restructuring comparedwith Ed group

Immediately3 and 6months

No difference indepression, anxietyor burden

2b

Steffen(2000)⁎

12 (home-based)iCS+9(class-based) gCS

12 8 weeks of CS to manage angerand frustration. Two groups:home based video viewing+weeklyphone sessions; class based viewing

Post intervention(non-specific)

No difference indepression betweengCS and control

2b

Dellasega(1990)

39 36 “Coping with Caregiving”program- 2 sessions: education,coping then communicationand relaxation

Immediately No difference in burden 4

Quayhagen et al.(2000)

DST=21iCS=29 gCS=22Support=16

15 8×1.5 hour group sessions of problemsolving and education. First half,caregiver and person withdementia separately,then dyad together

Immediately No change in anxiety,depression or wellbeing.No analysis of diff.between groups

4

McCurry et al.(1996)

4 0 6×90 minute sessions for treatmentof caregiver insomnia using groupeducation, behavioral strategies,relaxation, discussion

3 months One person sig.improved in mood

5

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5with lower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer qualitygradations, with a range from “a” (higher quality) to “c” (lower quality); No = number; IG = intervention group; w/l = waiting list; gCS = groupcoping strategies; iCS = individual coping strategies; sig = significant; diff = difference; Ed = education; GHQ = general health questionnaire(psychological symptoms of anxiety and depression); ⁎ = randomised controlled trial.


solving and behavioral management training found nosignificant difference in burden and depression eitherimmediately or at 1 year (Zarit et al., 1987). A level 4 re-analysis of these results with a within group analysis of theparticipants divided according to symptom severity againshowed no difference (Whitlatch et al., 1991). Similarly asmaller study found no improvement in depression orburden either immediately or up to 8 months postintervention (Hebert et al., 1994). A behavioral and stressmanagement group did not improve depression immedi-ately (Haley et al., 1987), and a behavioral managementprogramme showed no significant difference in terms ofburden or GHQ score 1 month after intervention

(Robinson and Yates, 1994). Another RCT focussing onpatient behavioral problems, CG sleep and stress man-agement techniques found no difference either immedi-ately or 3 months post intervention in mood or burden inthe intervention group (McCurry et al., 1998). A cohortstudy, which was an outpatient version of the level 1 studydiscussed above, consisted of training sessions ineducation, stress management and problem behaviormanagement. It found no difference in GHQ and burden6 months after the intervention (Brodaty et al., 1994). Theauthors concluded that interventions should be tailored tothe specific problems of individual CGs (Brodaty andGresham, 1989; Brodaty et al., 1994). Another non-

Table 3bCharacteristics, outcome and level of evidence for individual caregiver coping strategies (iCS)

Author/year IG No Control No Therapeutic regimen Time to follow up Outcome LOE

Marriott et al.(2000)⁎

14 28 14×fortnightly CS sessionsincluding carer education,stress managementand coping skills

Immediatelyand 3months

Improvement inpsychologicaldistress anddepression

1b

Roberts et al.(1999)⁎

38 39 Average of 8 sessions over 6months — manualisedproblem-solving counsellingby nurses at homeor by phone

Immediatelyand 6months

No sig differencein burden

2b

Romero andWenz (2001)

43 0 Residential intervention-8hours of individual and familysessions plus respite care

Immediately Sig. improvementin depression andpsychological symptomspre and post intervention

2c

Steffen (2000)⁎ 12 (home-based) iCS, 9(class-based) gCS

12 8 weeks of CS and cognitivechange strategies to manage angerand frustration. Two groups: homebased video viewing+weeklyphone sessions; class based viewing

Postintervention(non-specific)

Both treatment groupssig. better in depression

2b

Sutcliffe andLarner (1988)⁎

6 iCS, 4 Ed 5 control 6×weekly 45 minute individualhome visits offering either iCSconsisting of a carer-focussedapproach concentrating onfeelings or Ed

1, 6 and12 weeks

Improvement indepression at 12 weeksin CS. No difference inburden or psychologicalsymptoms

2b

Moniz-Cooket al. (1998)

15 15 6–12 hours over 4–14 weeks at home-information, counselling, coping skills,crisis prevention, memory management

6 and12 months

significant improvementin depression and GHQ

4

Quayhagenet al. (2000)

DST=21iCS=29 gCS=22Support=16

15 8×1.5 hour individual home basedsessions of problem solving andstress reduction, anger management,communication enhancementand conflict resolution

Immediately No change in anxiety,depression or wellbeing.No analysis ofdiff. between groups

4

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5with lower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer qualitygradations, with a range from “a” (higher quality) to “c” (lower quality); No = number; IG = intervention group; sig = significant; CBT = cognitivebehavioral therapy; iBMT = individual behavioral management techniques; gBMT = group behavioral management techniques; imm = immediately;mths = months; gp = group; wks = weeks; GHQ = general health questionnaire; Ed = education; ⁎ = randomised controlled trial.


randomised smaller study showed no significant differ-ence in depression or burden (Kahan et al., 1985). Therewas also a level 4 study which showed no significantdifference in depression or strain either immediately or atabout 3months after intervention (Morris et al., 1992). TheGR for gBMT for depression, burden and distress is B asthere is one level 1 study and several level 2 studies, whichindicate that it is not effective either immediately or at upto 8 months (Table 4).

3.6. Individual behavioral management techniques(iBMT) of fewer than 6 sessions

Five RCTs reported an intervention of fewer than sixsessions (Buckwalter et al., 1999; Burgener et al., 1998;Schmidt et al., 1988; Stolley et al., 2002; Wright et al.,

2001). The only level 1 study found no significantdifference in depression either immediately or at 6monthsafter two home visits teaching BMT for the individualbehavioral problems of the CR compared to the controlgroup (Buckwalter et al., 1999). A small study found that4 sessions of two different types of iBMT, centred on theCR's individual problem behavior, showed no significantdifference between groups immediately after the inter-vention in burden or depression and anxiety (Schmidtet al., 1988). Another, larger level 2 RCT looked at theeffects of Progressively Lowered Stress Threshold(PLST), an individual BMT targeting CR behaviorwhich most troubles the CG (Stolley et al., 2002). Thisstudy, which only followed up 46% of participants,showed no significant benefit in burden at 3 and 6 monthfollow up, although they were significantly better

Table 4Characteristics, outcome and level of evidence for group behavioral management techniques (gBMT) all more than 6 sessions

Author/year IG No Control No Therapeutic regimen Time tofollow up

Outcome LOE

Brodatyand Gresham(1989)⁎

33+32delayedintervention

32 w/l+ 31respite

10 days of inpatient gBMT.Then 12 months of groupconference calls.

3,6 and12 months

Approachessignificance for GHQ↓ in IG at 6/12 vs. control;sig better at 12 months

1b

Brodaty et al.(1994)

33 22/26 6×3 hour training sessions(over 4 months)-education,stress and problem behaviormanagement

6 months No diff in GHQ or burden. 2b

Haley et al.(1987)⁎

21“support”+22“support/skills”

11 10 sessions — managementof behavioral problems andcoping skills. “Supportive”used Ed and problem solvingand “support/skills” was the sameplus stress management skills

Immediately No sig difference indepression

2b

Hebert et al.(1994)⁎

23 18 8×2 hour weekly groupsessions stress appraisal,coping and behavioral management

Immediately8/52, 8/12

No sig diff in burdenor depression

2b

Hebert et al.(2003)⁎

79 79 15×2 hour weekly sessionson stress appraisal, coping andbehavioral management

Immediately No sig differencein burden, depressionor anxiety

2b

McCurry et al.(1998)⁎

7(gBMT plus CS)and14 (iBMT plus CS)

15 6 weeks group/4 weeks individual.Sleep hygiene and stressmanagement, techniques

Immediatelyand 3 monthspost intervention

No sig difference inmood or burden

2b

Robinson andYates (1994)⁎

10 social skills,11 gBMT

12 Six×90 minute fortnightlysessions of either a gBMTmanagement program or asocial skills program

1 month postintervention

No sig difference InGHQ or burdenbetween groups

2b

Zarit et al.(1987)⁎

44 (gBMT),36 (iBMT)

39 8 sessions of either groupor individual/familycounselling, problem solvingand behavior management

Immediatelyand 1 year

No sig differencebetween gBMT andcontrol in depressionand burden

2b

Kahan et al.(1985)

22 18 8 weekly 2 hour groupmeetings of education, stressmanagement and behaviormanagement

Immediately No between groupdifference indepression and burden

3b

Morris et al.(1992)

gBMT=13 Ed=18 5×75 minute meetings —“Ways of coping” groupincluding problem solving,behaviormanagement and homeworkcompared with Ed group

Immediately andapproximately3 months

No sig differencein depressionand strain

4

Whitlatch et al.(1991)

113 total (numberin patient and controlgroups unclear)

Re-analysis of Zarit paper(see above)

Immediately and1 year

No sig difference betweengBMT and control indepression and burden

4

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5 withlower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer quality gradations, with arange from “a” (higher quality) to “c” (lower quality); No = number; IG = intervention group; w/l = waiting list; CBT = cognitive behavioral therapy;gBMT = group behavioral management techniques; iBMT = individual behavioral management techniques; sig = significant; diff = difference; Ed =education; GHQ = general health questionnaire (psychological symptoms of anxiety and depression); wks = weeks; mths = months; ⁎ = randomisedcontrolled trial.


compared to the control group at 12 months. Theremaining RCTs showed no significant difference instress and depression (Burgener et al., 1998; Wright et al.,2001). TheGR for fewer than six sessions of iBMTis B as

there are consistent level 2 studies and extrapolation fromlevel 1 studies indicating that this is not an effectiveintervention for improvement of CG depression, distressor burden either immediately or for up to 6 months. Over

Table 5aCharacteristics, outcome and level of evidence for individual behavioral management techniques fewer than 6 sessions (iBMT)



Outcome LOE

Buckwalteret al. (1999)⁎

132 BMT 108 Two home visits by nurse thenbi-weekly phone calls for 6 months

Immediatelyand 6 months

No sig differencein depression

1b

Burgeneret al. (1998)⁎

Gp 1=11,Gp 2=12,Gp 3=12BMT

12 1×90 minute home educational andbehavior intervention program. 3 groups:1=both interventions; 2=education only;3=behavioral intervention only

Approximately5 months postintervention

No sig differencein caregiver stress

2b

Schmidtet al. (1988)⁎

10 (EE+PS)BMT

10(PS)

4×1 hr individual psychotherapysessions- one problem solving (PS) andone emotional expression plus problemsolving (EE+PS)

Immediately No difference betweentreatments in burden,depression, anxiety

2b

Stolleyet al. (2002)⁎

133BMT

108 Progressively Lowered Stress Threshold(PLST) — 4 hours of in home training inprevention and management of behaviorproblems and behavioral techniques followedby phone support for 6 months

3, 6 and12 monthsfrom start ofintervention

Intervention group sigbetter at 12 months for burden.Earlier results not sig

2b

Wrightet al. (2001)⁎

68 BMT+CS

25 Three iBMT home visits in 6 months followedby phone calls for support and counselling

Immediately No sig difference betweengroups in stress and depression

2b

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5with lower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer qualitygradations, with a range from “a” (higher quality) to “c” (lower quality); No = number; IG = intervention group; sig = significant; CBT = cognitivebehavioral therapy; iBMT = individual behavioral management techniques; gBMT = group behavioral management techniques; imm = immediately;mths = months; gp = group; wks = weeks; GHQ = general health questionnaire; Ed = education; ⁎ = randomised controlled trial.


the longer term (12 months) the evidence is inconclusiveand the GR is therefore D (Table 5a).

3.7. iBMT of 6 or more sessions

There were three level 1 studies using iBMT lasting forsix sessions or more (Mittelman and Roth, 2004;Mittelman et al., 1995; Teri et al., 1997). Two level 1studies reported the same intervention but the second onehad twice as many participants in it (all those in the firststudy plus 200 more participants). The intervention wasmulti-component and involved six individual and familysessions consisting of BMT (role play and educationabout preventing behavior) about specific behaviorswhich the CR showed as well as stress managementfollowed by ad hoc telephone consultations available at alltimes. Controls received treatment as usual and telephoneadvice. The second paper extended the cohort and time offollow up (Mittelman and Roth, 2004; Mittelman et al.,1995). It found that the intervention group was signifi-cantly less depressed at 4, 8 and 32months. The final level1 study had nine sessions of iBMT with one groupreceiving behavioral strategies centred on improvingpleasant events for the patient (iBMT-general therapy)while the other received strategies for problem solving(BMT tailored to individual CR behavior) compared totreatment as usual or waiting list (Teri et al., 1997). The

results showed that depression was significantly better inthe CG intervention groups immediately post interventioncompared to the control groups. This was particularlyevident for individualised BMT. The 6 month followup did not have a control group but the interventiongroups showed significant improvement in depression(Table 5b).

There were six level 2 studies, the first of which usediBMT for both comparison groups, either BMTfocussing on the problems which the individual CRhad (Burns et al., 2003) or enhanced care which wasBMT plus CS. There was no significant differencebetween the two groups in terms of depression, perhapsnot surprisingly and both groups had more depressivesymptoms over time. The follow up rate was particularlylow in this study as less than 50% of participants wereincluded in the final analysis. Other level 2 RCTs werevery small and generally showed no significantdifference in stress and depression after BMT and CScentred on individual patient behavior either immedi-ately or at up to 12 months (Garand et al., 2002;McCurry et al., 1998; Mohide et al., 1990) and on CGburden either immediately or at up to 1 year (McCurryet al., 1998; Zarit et al., 1987). Similarly, a small level 2RCTwas conducted with homebound CGs using a videointervention and there was no face to face contact. Itfound no significant difference between the groups in

Table 5bCharacteristics, outcome and level of evidence for individual behavioral management techniques more than 6 sessions (iBMT)


Therapeutic regimen Time to follow up Outcome LOE

Mittelman et al.(1995)⁎

103 BMT+CS

103 6×individual and family sessions of advice respecific behaviors over 4/12 then caregiver supportgroup+ad-hoc telephone consultation available 24/7

Every 4 months duringfirst year then every 6 monthstill patient died

At 4 months intervention groupsignificantly less depressed

1b

Mittelman andRoth (2004)⁎

203 BMT+CS

203 6×individual and family sessionswithin 4/12—advice on specific behaviorsthen caregiver support group+ad-hoc telephoneconsultation available 24/7

Every 4 months duringfirst year then every 6 monthstill 2 years after patient died

Intervention group sig. lessdepressed at 8 and 32 months

1b

Teri et al.(1997)⁎

PE=23PS=19 BMT

TAU=10WL=20

2 intervention groups — 9×1 weekly iBMT.Strategies for increasing Pleasant Events (PE)and for Problem Solving (PS). 2 controlgroups-treatment as usual (TAU) and waiting list (WL)

Immediately and 6 monthspost follow up

Sig. improvement in depression butnot burden in both treatment groupscompared to controls

1b immediately,2b at 6 months

Burns et al.(2003)⁎

82-EC BMT+CS

85-BConly BMT

Behavior Care (BC)=management ofbehavioral problems in care recipient.Enhanced Care (EC)=caregiver stress-copingconcerns+Behavior Care (BC). 4 office visits a yearfor 2 years+phone calls 1–2 ×a month

immediately No difference in depression orwellbeing between groups orimprovement over time

2b

Chang (1999)⁎ 34 31 8 week video assisted modellingprogramme with cognitive reframing andproblem solving in weekly phone calls

During, immediately and4 weeks post intervention

Depression worse in non-interventiongroup. No statistical test —we calculated no sig diff

2b

Garand et al.(2002)⁎

39 total(unclear how many ineach gp)BMT

Behavioral techniques about problem behaviors. 2 home visits then phone BMT fortnightly for 6 months

Immediately No significant difference in mood 2b

McCurry et al.(1998)⁎

7 gBMT;14 iBMT

15 6 weeks group/4 weeks individual sleep hygiene,stress management, techniques to reducepatient’s disruptive behavior

Immediately and 3 months No sig difference in mood or burden 2b

Mohide et al.(1990)⁎

30 BMT+ CS 30 Trained Caregiver Support Nurse (CSN) made home visits,mean no=22 — caregiver education, BMT plus 4 hoursweekly respite, on-demand respite and monthly 2 hourcaregiver self help group

Immediately and 12 months No significant difference betweengroups in depression, anxietyand quality of life

2b

Zarit et al.(1987)⁎

44 (gBMT),36 (iBMT)

39 8 sessions of either group or individual/ familycounselling, problem solving

Immediately and 1 year No sig difference between groups inburden

2b

Whitlatch et al.(1991)

113 total(no. in patient and controlgroups unclear)

Re-analysis of Zarit paper (see below) Immediately and 1 year iBMT effective in some subgroups 4

Gendron et al.(1986)

8 4 8 weekly individual sessions of “Supporter EnduranceTraining” including relaxation training, assertiontraining and role playing.

Monthly during and6 months post intervention

GHQ+depression unchanged. Anxietyimproved in 4/8 vs. 1/4 in control gp

5

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-Based Medicine guidelines and ranged from 1 to 5 with lower numbers indicating higher quality.Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer quality gradations, with a range from “a” (higher quality) to “c” (lower quality); No = number; IG = interventiongroup; sig = significant; CBT = cognitive behavioral therapy; iBMT = individual behavioral management techniques; gBMT = group behavioral management techniques; imm = immediately; mths =months; gp = group; wks = weeks; GHQ = general health questionnaire; Ed = education.

84A.Selw

oodet

al./Journal

ofAffective

Disorders

101(2007)

75–89

Table 6Characteristics, outcome and level of evidence of supportive therapy



Outcome LOE

Brennanet al. (1995)⁎

51 51 Computer based programmewith educational materials,programme with informationabout practical resources andsupport from other caregivers.Nurse also contributed to forumand answered questions over 1 year.

Immediately No sig differencein burden or depression

1b

Castroet al. (2002)⁎

51 49 30–40 minute exercise session perweek for 12 months+15 supportivetelephone contacts during the 12 months

Immediately No significant differencein depression, anxiety,burden between groups

1b

Drummondet al. (1991)⁎

30 30 4 hours respite, educationand 6 months×2 hours weeklyself-help group

Immediately No sig difference in depression,anxiety, quality of life

2b

Goodman andPynoos (1990)⁎

31-support 35-Ed 12 weekly telephone accessedtaped lectures or 12 week peertelephone network of 4–5 caregivers

Immediately No effect on psychologicalhealth or burden eitherbetween or within groups

2b

Woodset al. (2003)

43 61 Admiral nurse support 8 monthsfrom startof intervention

No sig difference inpsychological distress

2b

Lazaruset al. (1981)

4 3 10×weekly hour long discussion group Immediately No significant differencein depression or anxiety

4

Quayhagenet al. (2000)

DST=21iBMT=29gBMT=22Support=16

15 8 weeks of 4 hours/week respitecare with 2×monthly support groupfor caregivers

Immediately No change in depression, anxietyor wellbeing. No analysis ofdifference between groups

4

Strawnet al. (1998)

14 0 Weekly supportive phone calls bytrained psychologist for 12 weeks

Immediatelyand 2 weeks

Psychological health andburden decreased significantly

4

Winogrondet al. (1987)

18 0 Weekly support group for 6 months Immediately No sig change in burdenor life satisfaction

4

LOE = level of evidence [levels of evidence were rated according to Oxford Centre for Evidence-BasedMedicine guidelines and ranged from 1 to 5 withlower numbers indicating higher quality. Lower case letters (“a”, “b”, “c”) used to designate level 1, 2 and 3 studies, indicate finer quality gradations, with arange from “a” (higher quality) to “c” (lower quality); No = number; IG= intervention group; sig = significant; iBMT= individual behavioral managementtherapy; gBMT = group behavioral management therapy; DST = dementia specific therapy; Ed = education; ⁎ = randomised controlled trial.


depression during, immediately and 4 weeks after theintervention (Chang, 1999). Two papers reported on onestudy. The first reported it as an RCT (see above) andshowed no significant difference in burden immediatelyor at 1 year, but subgroup analysis revealed that8 sessions of iBMT were effective in some subgroups(Whitlatch et al., 1991; Zarit et al., 1987). Finally onelevel 5 study looking at iBMT found that psychologicalsymptoms and depression were unchanged at 6 monthscompared to controls (Gendron et al., 1986). The GR formore than 6 sessions of iBMT for depression is A asthere are consistent level 1 studies indicating that this isan effective intervention for immediate improvement ofCG depression and up till 32 months. Although the level2 studies are not as positive, they are all either very smallor both groups have iBMT. The GR for burden is C asthere are extrapolations from level 2 studies that iBMTis not effective in reducing CG burden (Table 5b).

3.8. Supportive therapy

We identified nine studies describing a supportivetherapy intervention of which four were RCTs. The firstwas a level 1 RCT of a computer based programmewhich the CGs could access daily. A nurse acted asgroup facilitator and clinical expert. Information aboutdementia was provided and discussion of resources wasavailable to help with any difficulties e.g. home careservices and health care. The intervention involved anaverage of two encounters a week for a year and foundno significant difference in either burden or depressionimmediately after the intervention (Brennan et al.,1995). The next level 1 RCT consisted of telephonesupport plus exercise for a year. No significant dif-ference was found in depression, anxiety or burdenimmediately after the intervention when compared tothe control group (Castro et al., 2002). There were two


other RCTs. A “support program” versus communitynursing treatment as usual found no difference indepression, anxiety or quality of life immediately afterthe intervention (Drummond et al., 1991). A level 2study of 12 weeks of a peer telephone network of 4–5CGs found there was no immediate effect on psycho-logical health or burden (Goodman and Pynoos, 1990).The intervention comprised a 2 hours a week self-helpgroup, 4 hours a week of respite care and respite ondemand. It is unclear how much help those in the TAUgroup received. A large level 2 controlled cohort studyconsidered the effects of support by specialist dementianurses (Admiral nurses focussing exclusively on CGs)and found no significant difference in psychologicalsymptoms compared to treatment as usual at 8 monthsafter entering the study (Woods et al., 2003). This timepoint is equivalent to immediately after the interventionas the intervention continued beyond the study. Theother four studies were level 4 and three had negativeresults (Lazarus et al., 1981; Quayhagen and Quayha-gen, 1989; Quayhagen et al., 2000; Strawn et al., 1998;Winogrond et al., 1987). The GR for more than 6sessions of supportive therapy is B as there are con-sistent level 2 studies and extrapolation from a level 1study indicating that this is not an effective interventionfor immediate improvement of CG depression, anxietyor burden (Table 6).

4. Discussion

The most important result from our study is that thereis consistent, excellent evidence that iBMT for six ormore sessions is efficacious both immediately and in thelonger term in alleviating CG depression. There is alsogood evidence that iCS and gCS are effective in alle-viating depression and distress immediately and forsome months. These findings fit well with the results ofour group's previous systematic review which foundthat BMT centred on changing the behavior of indi-vidual patients was effective in reducing neuropsychi-atric symptoms in people with dementia (Livingstonet al., 2005). It also fits with the evidence for the efficacyof BMT in treating depression (Casacalenda et al., 2002;Gloaguen et al., 1998). Our review finds however thatgBMT is not effective which also fits in with our pre-vious review which found that teaching principles ratherthan what to do with specific behaviors was ineffectivein changing neuropsychiatric symptoms. gBMT in a tenday inpatient admission of both the patient and CG wasefficacious after a year, but it is difficult to make anygeneralisations from this unique intervention (Brodatyand Gresham, 1989). In summary gBMT differs fun-

damentally from iBMT in that gBMT usually teachesprinciples of managing behavior rather than how tomanage the specific behavior with which the CG isfaced. Another difference may be that the most suc-cessful interventions often include the wider family aspart of the intervention (Marriott et al., 2000; Mittelmanand Roth, 2004; Mittelman et al., 1995). This is clearlymore practical in individual interventions.

We were surprised to find that education alone isinefficacious. This does however accord with our earliersystematic review showing that teaching principles ofdementia care does not seem to be efficacious in re-ducing the neuropsychiatric symptoms of dementia(Livingston et al., 2005). We do not recommend thatclinicians stop using education but rather suggest thatthey should explicitly link education to the person thatthe CG is looking after and the practicalities of lookingafter them, as a reason for the failure may be thatsometimes CGs do not understand that informationprovided applies to the person they are caring for andattribute the problem behaviors to other causes (Patonet al., 2004).

Supportive therapy also appears ineffective inhelping CGs in terms of the outcomes we analyzed,perhaps because the therapy is not informed by anymethods of engendering change since it instead aims tomaintain. It may therefore be unsurprising that it leads tolittle change. We have little evidence about dementiaspecific therapies but again they do not aim to improveCG psychological outcomes.

Like previous overviews, we have identified that it isoften unclear what intervention is being delivered inany study and whether it is consistently implemented(Bourgeois et al., 1996; Cooke et al., 2001). We foundthat it was frequently difficult to classify interventionsand some, although placed in one category, had elementsfrom others. We therefore had to make decisions aboutthe most appropriate category and we have made this astransparent as possible by including details of eachintervention. It is not possible to assess the quality ofinterventions in this review other than by looking at thenumber of sessions provided in each intervention. Wewould therefore recommend that future researchers fullydescribe, or ideally manualize or provide a trainingpackage for interventions so that others are able toreproduce effective treatments.

Our findings are limited by lack of good qualityevidence with only ten level 1 studies. We did notinclude studies in which medication was used andtherefore cannot comment on the effect of psychologicalapproaches combined with medication, used in everyday practice. We also cannot comment on other


outcomes, such as subjective well being and increasedknowledge, as we did not consider them.

In conclusion, providing individual treatment on awide scale for CGs has resource implications although itmay be less expensive than institutionalisation. It mayalso be possible to provide individual therapy withineconomic restraints by manualising the individual inter-ventions so that they can be provided by a variety ofhealth care workers with little training. Further researchin this area would be useful for both clinicians and policymakers. There is clear evidence that CG psychologicalhealth can be improved by six or more sessions of eitherindividual BMT focussing on the CR's behavior or byteaching CGs coping strategies either individually or ina group.

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systematic review of the effect of psychological interventions on family caregivers of people with...

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