Strategies for Relatives (START) intervention

Topic Status Complete

Strategies for Relatives (START) intervention to improve the mental health of carers of people with dementia

Outcome of the appraisal


The evidence supports the routine adoption of the Strategies for Relatives (START) intervention for carers of people with dementia.


The use of START leads to a reduction in symptoms of depression and an improvement in quality of life of the carer as compared to usual care. Benefits are evident in the short term but are also maintained over a longer time period.


Health economic modelling suggests that START is cost effective compared to usual care with an incremental cost effectiveness ratio (ICER) of £12,400 per QALY and may lead to cost-savings when benefits and cost for the recipients of care are also considered.

Why was this topic appraised?


The vast majority of people with dementia are cared for at home and it is estimated that 700,000 people in the UK act as unpaid informal carers. Dementia is characterised by difficulties with cognition, communication, motor performance, and everyday functioning. The nature and extent of these difficulties can vary according to the stage of progression and dementia sub-type. Due to these difficulties, people with dementia may need support from close relatives or friends.


Caregiving presents serious challenges and can be a highly stressful experience that places strain on relationships and wellbeing. Recent estimates suggest that the prevalence of anxiety and depression is over 30% in carers and the COVID-19 pandemic may have exacerbated this situation. Addressing this issue is of high importance to ensure the health and wellbeing of carers who take on an essential role within society and to prevent the breakdown of care that could lead to need for residential care. Welsh Government has highlighted that effective psychological interventions play an important role in supporting carers but availability is currently limited in Wales.


HTW considered this topic after it was proposed by Social Care Wales and Carers Trust Wales

Plain language summary


Dementia describes a set of symptoms that can include impaired ability to remember, think, or make decisions and changes in mood or behaviour. Dementia is caused when the brain is damaged by a disease and there are different types of dementia depending on the disease and type of damage. Alzheimer’s dementia is the most common form in the UK. Though dementia mostly affects older adults, it is not a part of normal aging. People with dementia may experience loss of memory, language skills, visual perception, problem solving, self-management, and the ability to focus and pay attention, which can interfere with their ability to perform tasks. The majority of people with dementia in the UK live at home and many rely on family members and friends to help them with daily tasks they cannot undertake themselves.


Providing care at home can involve practical, personal and emotional care. There are many positive aspects associated with caring for a family member or friend at home, however caring can present serious challenges and can be a highly stressful experience. Carers can have high rates of mental health problems compared to the general population and the demands of caring appear to play a driving role in this. It is therefore important that carers are offered support to help them manage their wellbeing. This support can take the form of mental health care, including psychological interventions, which are actions or activities performed to bring about change in a person’s behaviour, emotional state or feelings.


HTW looked at the evidence base for the Strategies for Relative programme aimed at improving the mental wellbeing of unpaid caregivers.  The evidence supports the routine adoption of the Strategies for Relatives (START) intervention for carers of people with dementia.

Topic Exploration Report

TER230 02.2021

Evidence Appraisal Review

EAR031 09.2021


GUI031 10.2021


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