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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


Knapp, M., King, D., Romeo, R., Schehl, B., Barber, J., Griffin, M., Rapaport, P., Livingston, D., Mummery, C., Walker, Z., Hoe, J., Sampson, E. L., Cooper, C., Livingston, G.


BMJ (Clinical Research Ed.), Volume: 347, Pages.: f6342-f6342

Year of Publication



Objective: To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone.; Design: Cost effectiveness analysis nested within a pragmatic randomised controlled trial.; Setting: Three mental health and one neurological outpatient dementia service in London and Essex, UK.; Participants: Family carers of people with dementia.; Intervention: Eight session, manual based, coping intervention delivered by supervised psychology graduates to family carers of people with dementia added to usual treatment, compared with usual treatment alone.; Primary Outcome Measures: Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score (HADS-T) of affective symptoms and quality adjusted life years (QALYs) in cost effectiveness analyses over eight months from baseline.; Results: Of the 260 participants recruited to the study, 173 were randomised to the START intervention, and 87 to usual treatment alone. Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period (mean difference -1.79 (95% CI -3.32 to -0.33)), indicating better outcomes associated with the START intervention. There was a small improvement in health related quality of life as measured by QALYs (0.03 (-0.01 to 0.08)). Costs were no different between the intervention and usual treatment groups (£252 (-28 to 565) higher for START group). The cost effectiveness calculations suggested that START had a greater than 99% chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £30,000 per QALY gained, and a high probability of cost effectiveness on the HADS-T measure.; Conclusions: The manual based coping intervention START, when added to treatment as usual, was cost effective compared with treatment as usual alone by reference to both outcome measures (affective symptoms for family carers, and carer based QALYs).; Trial Registration: ISCTRN 70017938.;

Bibtex Citation

@article{Knapp_2013, doi = {10.1136/bmj.f6342}, url = {}, year = 2013, month = {oct}, publisher = {{BMJ}}, volume = {347}, number = {oct25 2}, pages = {f6342--f6342}, author = {M. Knapp and D. King and R. Romeo and B. Schehl and J. Barber and M. Griffin and P. Rapaport and D. Livingston and C. Mummery and Z. Walker and J. Hoe and E. L. Sampson and C. Cooper and G. Livingston}, title = {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}, journal = {{BMJ}} }


adaptation psychological, adult, aged, aged, 80 and over, anxiety, caregivers, dementia, depression, diagnosis, economics, education, etiology, female, great britain, health care costs, humans, intention to treat analysis, linear models, male, manuals as topic, methods, middle aged, prevention & control, psychological tests, psychology, psychotherapy, quality of life, questionnaires, statistics & numerical data, treatment outcome

Countries of Study


Types of Dementia

Dementia (general / unspecified)

Types of Study

Economic evaluation, Randomised Controlled Trial

Type of Outcomes

Carers’ Mental Health, Quality of Life of Carer

Type of Interventions

Intervention for Carers

Carer Focussed Interventions

Training programmes / workshops including behavioural training