Effective interventions for depressive symptoms among caregivers of people with dementia: A systematic review and meta-analysis

Abstract

Background

Caring for a family member with dementia puts caregivers at risk for depressive symptoms. Yet, interventions with promising effects on caregiver depressive symptoms are not well documented.

Aims

This review aimed to examine the quality and effectiveness of interventions to reduce depressive symptoms reported by caregivers of people with dementia.

Design

A systematic review and meta-analysis of nonpharmacological intervention trials was conducted.

Methods

The electronic databases searched included MEDLINE, CINAHL, and PsycINFO to find randomized controlled trials published between 2007 and 2017. A total of 31 randomized controlled trials were included in the meta-analysis.

Results

Cognitive-behavioral therapy (838 participants) showed a large, significant effect (standardized mean difference = −0.905; 95% CI = (−1.622, −0.187); p = 0.013) and mindfulness interventions (186 participants) showed moderate, significant effects (standardized mean difference = −0.578; 95% CI = (−0.881, −0.275); p < 0.001) on decreasing caregiver depressive symptoms, while psychoeducational interventions demonstrated small but significant effects (standardized mean difference = −0.244; 95% CI = (−0.395, −0.092); p = 0.002). Emotional support, cognitive rehabilitation, and multicomponent interventions showed less than small or nonsignificant effects related to depressive symptoms among caregivers.

Conclusion

Cognitive-behavioral therapy interventions, which focus on diminishing negative thoughts and increasing positive activities, can effectively decrease depressive symptoms for caregivers of individuals with dementia. Future research is recommended to assess the long-term effectiveness of cognitive-behavioral therapy in this population.

Keywords

caregivers dementia depression meta-analysis systematic review

Introduction

Dementia, including Alzheimer’s disease, is the sixth leading cause of the death in the U.S. and one of the top 10 causes of death worldwide regardless of race, sex, or age (Alzheimer’s Association, 2018). About 46.5 million people are living with dementia worldwide and the number is predicted to double approximately every 20 years, exceeding 74.7 million by 2030 and 131.5 million by 2050 (The Global Voice on Dementia, n.d.). Caregivers, usually family and friends, provide unpaid care to home-dwelling older adults with dementia. Caregivers meet essential and necessary needs of their care recipients, including helping with activities of daily living (e.g., bathing, eating, and moving), administering medications and treatments, and coordinating with physicians for the person’s care (Lwi, Ford, Casey, Miller, & Levenson, 2017). Family and friend caregivers will continue to become an even more critical resource given the rapidly increasing rate of dementia and the rising costs associated with dementia care (Vernooij‐Dassen, Draskovic, McCleery, & Downs, 2011).

Caregivers and depressive symptoms

Caregivers of people with dementia are particularly vulnerable to developing depressive symptoms. According to a recent systematic review that investigated the impact of caregiving, rates of depression are higher among those who provide care for people with dementia than among caregivers of people with other chronic illnesses (Schoenmakers, Buntinx, & Delepeleire, 2010). In addition, reported prevalence of depression among caregivers of people with dementia ranges from 30 to 80% (Schoenmakers et al., 2010). Furthermore, when caregiving became more demanding (increased weekly hours of caregiving), caregivers were six times more likely to experience depressive symptoms than noncaregivers (Cannuscio et al., 2002).

Interventions for caregivers of people with dementia have included cognitive-behavioral therapy (CBT), psychoeducational programs, emotional support, cognitive rehabilitation therapy, and multicomponent interventions (Waller, Dilworth, Mansfield, & Sanson-Fisher, 2017). However, it remains unclear which type or types of interventions are most effective in reducing caregivers’ depressive symptoms. Most published systematic reviews incorporating meta-analyses typically report the effectiveness of interventions based on mode of delivery, such as group-, individual-, or technology-based, rather than the content or approach of the intervention (Boots, Vugt, Knippenberg, Kempen, & Verhey, 2014; Olazarán et al., 2010; Thompson et al., 2007; Waller et al., 2017). Although two meta-analyses have reported effectiveness based on content (Pinquart & Sörensen, 2006; Sörensen, Pinquart, & Duberstein, 2002), those studies were conducted more than 10 years ago and, therefore, do not reflect the findings of more recent interventions. Also, these two reports included randomized as well as nonrandomized trials, affecting the generalizability of the findings (Pinquart & Sörensen, 2006; Sörensen et al., 2002).

Objectives

Over the past 10 years, a number of experimental studies for caregivers of people with dementia have been conducted worldwide, demonstrating some favorable outcomes for caregivers (Waller et al., 2017). Among experimental studies, randomized controlled trials (RCTs) are considered the “gold standard” for examining the effectiveness of interventions and provide a stronger basis for translating research results into clinical practice (Spieth et al., 2016). For that reason, to find high quality, evidence-based interventions for depressive symptoms experienced by caregivers of people with dementia, the current study synthesized the most recent 10 years of RCT data.

The aims of this systematic review incorporating meta-analyses are (1) to compare the effectiveness of different types of RCT interventions targeting depressive symptoms among caregivers of people with dementia and (2) to describe the nature and quality of current studies using methodological quality appraisal.

Methods

Search strategy and eligibility criteria

This systematic review incorporating meta-analysis is exempt from IRB approval as in this study investigators collected and synthesized data from former RCTs that the clinical trial researchers obtained the ethics approvals and participants already agreed on the informed consent. Trials were searched using major health care research databases including MEDLINE (Ovid), CINAHL, and PsycINFO. Four key terms “Dementia” or “Alzheimer’s disease” AND “Caregiver*” AND “depression” AND “intervention” were combined using a Boolean technique to intensify the search of the relevant literature. The search was limited to literature published from 2007 to 2017 and written in English. The initial search yielded 289 citations from MEDLINE, 373 from CINAHL, and 339 from PsycINFO. Using Refworks®, duplicate citations (n = 537) were removed, resulting in a total of 464 citations.

The titles and abstracts of the 464 citations were screened using the following inclusion criteria: (i) participants were unpaid caregivers such as a spouse, child, other family member, or friend; (ii) care recipients were diagnosed with dementia, Alzheimer’s disease, or mild cognitive impairment; (iii) the care recipient and caregiver resided in a community setting; (iv) depressive symptoms were measured as an outcome; (v) the study used a RCT design; and (vi) the findings were published in a journal article. Studies were excluded if (i) they were review articles, concept analyses, case reports, or expert opinion articles; (ii) were poster or paper presentations; (iii) the sample size was fewer than 10; and (iv) the report did not identify the type of intervention or did not provide enough information to identify which type of intervention was conducted (e.g. only described as psychosocial intervention).

After applying the inclusion and exclusion criteria, 41 studies remained for full-text screening. Authors were contacted for additional information if the studies did not report sufficient statistical data (means, standard deviations, or p- or t-values) to measure effect size. Because 10 studies did not provide additional information, these were excluded. A final sample of 31 studies remained. The search strategy is depicted in Figure 1 using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (Moher et., 2015).

Figure 1.

PRISMA flow chart of search studies. RCT: randomized controlled trial.

Major study details were extracted from each article. These included characteristics of the caregiver participants (country, age, gender) and study methods (sample size, intervention content, intervention period, duration of one session, facilitators, types of control group, outcome measures of depressive symptoms).

Assessment of methodological quality

Applying the risk of bias tool from the Cochrane Effective Practice and Organization of Care (EPOC, 2017) group, we assessed the methodological quality of included studies. The risk of bias tool evaluates nine criteria: random sequence generation, allocation concealment, similarity of baseline outcome measurement and baseline characteristics, incomplete outcome data, allocation blinding, contamination, selective reporting, and other bias.

The Cochrane EPOC risk of bias tool guides reviewers in how to make a judgment for a low, unclear, or high risk of bias. First, if a random method in the sequence generation process is reported (e.g. computerized random number generator), the study is rated as having a low risk of bias in random sequence generation. If there is an evident report of bias in random sequence generation (e.g. randomization based on admission date), the study is rated as having a high risk of bias. If the study did not mention a specific criterion, it was evaluated as “unclear.” Additional information for making judgments for each criterion is explained in the suggested risk of bias criteria (EPOC, 2017).

Types of interventions

We categorized all interventions into five types based on descriptions by Pinquart and Sörensen (2006): (a) CBT, (b) psychoeducational intervention, (c) emotional support intervention, (d) cognitive rehabilitation for care recipients, and (e) multicomponent interventions. CBT focuses on identifying and modifying maladaptive thoughts, developing a new behavioral pattern, and increasing pleasant leisure activities. Psychoeducational interventions provide information regarding dementia and caregiving-related issues and practice applying new knowledge to individual caregiving situations. Emotional support interventions provide the opportunity to express personal feelings and to reduce social isolation. Cognitive rehabilitation for care recipients was designed to improve or maintain the competence of the care recipients using strategies designed to strengthen cognition because their severity of cognitive decline is highly correlated with depression among their caregivers (Pinquart & Sörensen, 2006). Lastly, multicomponent interventions combine more than one type of interventions such as education, skill building, social support, and/or cognitive strategies (Belle et al., 2006).

In addition, we added a mindfulness-based intervention category given its frequent appearance in the literature. Mindfulness interventions involve a particular type of attention such as increased awareness of the present moment, mind and body movement, and openness and curiosity (Whitebird et al., 2013).

Measures of depressive symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders, depression can be diagnosed when a person has more than two depressive symptoms such as loss of interest, sleep disturbance, or suicidal ideation that exists longer than two weeks (Spector & Tampi, 2005). In this study, we use the term depressive symptoms instead of depression because the vast majority of caregivers self-reported their level of depressive symptoms, rather than having a diagnostic clinical interview for depressive disorders by a health care professional. When a study measured levels of depressive symptoms using self-report scales, such as the Center for Epidemiologic Studies-Depression Scale, the Geriatric Depression Scale, Beck Depression Inventory, Hospital Anxiety and Depression Scale-Depression Score, Montgomery and Asberg Depression Rating Scale, or Cornell Scale for Depression in Dementia as a study outcome, these data were included in the meta-analysis.

Meta-analysis

A standardized mean difference (SMD) and 95% confidence intervals were calculated based on means, standard deviations, p- or t-values, and group sample size (Borenstein, Hedges, Higgins, & Rothstein, 2011). A random effects model was selected to account for different sources of variation among studies besides sampling differences (Deeks, Higgins, & Altman, 2008). Cohen’s d was used for interpreting the magnitude of effect sizes: 0.2–0.49 = small effect, 0.5–0.79 = moderate effect, and ≥0.8 = large effect (Cohen, 1988). Q and I² statistics were calculated to assess the heterogeneity of the studies. A Q statistic with a p-value ≤ 0.05 was taken as an indication of heterogeneity, and I² statistics of 0, 25, 50, and 75% were considered as no, low, moderate, or high heterogeneity (Higgins & Green, 2011).

Orwin’s fail-safe N analysis and funnel plot analysis were used to test publication bias. Orwin’s fail-safe N analysis indicates the number of studies required to nullify the results of a meta-analysis (Deeks et al., 2008). Funnel plot analysis shows publication bias if the inverted funnel shape is asymmetrical (Deeks et al., 2008). Statistical analyses were conducted using Comprehensive Meta-Analysis software version 3.0 (Borenstein, Hedges, Higgins, & Rothstein, 2014).

Results

Characteristics of trials, participants, and interventions

The combined sample from the 31 RCTs was 4039 participants, with individual study samples ranging from 16 to 487. The majority of the studies were conducted in the United States (n = 14), followed by the United Kingdom (n = 5), Hong Kong (n = 3), Denmark (n = 2), Italy (n = 2), Spain (n = 2), France (n = 1), the Netherlands (n = 1), and one study conducted in three European countries (Denmark, Poland, and Spain). The mean age of caregivers across studies was 62.2 years (range: 50.5–71.1; SD = 5.2), and most caregivers were women (78.2%, range: 62.5%–100%). Detailed information regarding each study intervention is reported in Table 1.

Table 1.

Summary of intervention studies on caregivers’ depressive symptoms.

Author/Year	Country	Analyzed Sample size	Mean age/Percent of female	Intervention contents	Intervention sessions and period	Duration of each session	Intervention facilitators	Control group	Outcome measure	F/U
Cognitive-behavioral therapy
Steffen and Gant (2016)	U.S.	74	Age: 60.3Female: 100.0%	A telehealth behavioral coaching that using video instructional materials, workbook, and telephone coaching in behavioral management, pleasant events, scheduling, and relaxation.	14 sessions/ 10 weekly calls and 2 biweekly calls	30–50 minutes	One licensed, doctoral-level clinical psychologist and five masters-trained clinicians	A basic education guide and support	Beck Depression Inventory II	Baseline, 14 weeks, 6 months
Au et al. (2015)	Hong Kong	59	Age: 56.6Female: 83.1%	Pleasant event scheduling and improving communications include activity monitoring, activity scheduling, reinforcing or modifying the pleasant event and communication, and activity rescheduling/revision using telephone.	12 sessions/ 4 weekly calls and 8 biweekly calls (20 weeks)	15–30 minutes	Trained senior citizens	Education	CES-D	Baseline, 4 weeks, 20 weeks
Au et al. (2014)	Hong Kong	60	Age: 56.6Female: 76.7%	Information on behavioral activation and administration of pleasant event schedule; discussion on concepts of adaptive coping.	8–10 sessions/ 6 subsequent telephone calls (at least weekly) and additional support 2–4 weeks (8–10 weeks)	20 minutes	NR	Usual care	CES-D	Baseline, 4 weeks
Livingston et al. (2014)	U.K.	259	Age: 60.0Female: 68.7%	Identifying individual difficulties and implementing strategies including relaxation, behavioral management, communication strategies, identification and changing of unhelpful thoughts, positive reframing, accessing of emotional support, future planning, and increasing occurrence of pleasant events.	8-14 sessions/ at least once per week over 8–14 weeks	NR	Supervised psychology graduate students	Usual care	Hospital Anxiety and Depression Scale Depression Score	Baseline, 4 months, 8 months, 12 months, 24 months
Moore et al. (2013)	U.S.	100	Age: 71.1Female: 74.0%	Education on how to monitor use of time; identification of leisure activities; development of an activity hierarchy for prioritizing their activities; scheduling/participating in selected leisure activities and tracking of moods.	6 sessions/ 4 in home therapy session and 2 weekly phone session (6 weeks)	Home session lasted 1 hour, Phone session lasted 15–60 minutes	Two Master’s level clinicians	Information support	CES-D	Baseline, 6 weeks, 1 year
Losada, Márquez‐González, and Romero‐Moreno ⁽2011)	Spain	167	Age: 60.0Female: 83.0%	Training caregivers in techniques and skills to acknowledge, analyze, and change maladaptive thoughts.	12 sessions/ 12 weekly group sessions (maximum 8 people in group)	Mean duration of each group session was 90–120 minutes	Psychologists and occupational therapists	Usual care	CES-D	Baseline, 12 weeks
Gallagher-Thompson et al. (2007)	U.S.	45	Age: 59.3Female: NR	Teaching caregivers to observe and record troublesome behaviors in the home, identifying recurrent unhelpful thinking patterns; focusing on assertiveness training; discussing advance directives; identifying potentially pleasant activities.	8 sessions/ 4 months in-home session	90 minutes	NR	Telephone support	CES-D	Baseline, 12 weeks
Marquez-Gonzalez, Losada, Izal, Perez-Rojo, and Montorio (2007)	Spain	74	Age: 56.6Female: 79.7%	CBT group intervention focused on management of dysfunctional thoughts and training behavioral skills.	8 sessions/ 8 weekly group sessions (maximum 8 people in group)	120 minutes	Two trained psychologists	Wait-list control	CES-D	Baseline, 8 weeks
Psychoeducational intervention
Nunez-Naveira et al. (2016)	Denmark, Poland, and Spain	61	Age: NRFemale: 63.9%	Education on cognitive declines (attention, memory, orientation), daily tasks (bathing, incontinence, massage), behavioral changes (anxiety, depressive mood, manic symptoms), social activities (communication, apathy), and caregiver (coping with own stress); social network where the caregivers can interact with other participants and exchange information and opinions.	Number of sessions is not applicable/ for 3 months	NR	E-learning platform (mobile application)	NR	CES-D	Baseline, 3 months, 12 months
Sepe-Monti, Vanacore, Bartorelli, Tognetti, and Giubilei ⁽2016)	Italy	164	Age: 58.7Female: 65.9%	Savvy Caregiver ProgramProviding clinical and pharmacological information about the disease; managing self-care and emotional situations; involving patients in activities of their residual abilities; managing the patients’ daily behavior; introducing a decision-making model; highlighting the importance of the family as a source of support.	6 weekly sessions	2 hours	A local psychologist group leader	A two-session group program mainly providing medical information	CES-D	Baseline, 8 weeks, 6 months
Waldorff et al. (2012)	Denmark	330	Age: 66.0Female: 66.7%	Expressing his or her life story and what is of personal importance and of great value; writing notes with the aim of improving coping strategies and empowering the participants to focus on the positive factors; education on Alzheimer’s disease.	11–14 sessions/ at least 4 counseling session, 2 education session, and 5–8 telephone counseling for 12 months	NR	Nurses, counselor, and study coordinator	Two brief counseling for 12 months	Geriatric Depression Scale	Baseline, 6 months, 12 months
de Rotrou et al. (2011)	France	157	Age: 65.0Female: 68.0%	Focusing on education, problem-solving techniques, emotion-centered coping strategies, management of patients’ behavior, communication skills, crisis management, resource information and practical advice.	12 weekly group sessions	2 hours	Psychologist and geriatricians	Usual care	Montgomery and Asberg Depression Rating Scale (MADRS)	Baseline, 3 months, 12 months
Finkel et al. (2007)	U.S.	36	Age: 64.6Female: 67.6%	Provision of information about the disease and community resources and strategies to enhance safety, communication, self-care, social support, and management of problem behaviors using computer–telephone integration system.	14 sessions/ 8 individual educational/skill building sessions and 6 support group sessions over 6 months	NR	Certified clinical social workers	Receiving basic educational materials and two brief telephone check-in calls	CES-D	Baseline, 6 months
Support intervention
Charlesworth et al. (2008)	U.K.	236	Age: 68.0Female: 64%	Befriending as offering emotional, informational, and practical support.	Daily or weekly contact at least 6 months	NR	Trained volunteers	Usual care	Hospital Anxiety and Depression Scale-Depression Score	Baseline, 6 months, 15 months, 24 months
Winter and Gitlin (2007)	U.S.	103	Age; 66.6Female: 100.0%	Providing emotional support and validation.	24 sessions/ weekly group telephone-based support (5 in group) over 6 months (number of people in group not specified)	NR	Social workers	NR	CES-D	Baseline, 6 months
Cognitive rehabilitation for care recipients
Woods et al. (2016)	U.K.	487	Age: 69.6Female: 84.8%	Reminiscence for carers and care recipients which each session blended work in large and small groups, and a range of activities including art, cooking, physical reenactment of memories, singing, and oral reminiscence.	19 sessions/ 12 weekly and 7 monthly group sessions	2 hours	Trained facilitators	Usual care	Cornell Scale for Depression in Dementia	Baseline, 3 months, 10 months
Orgeta et al. (2015)	U.K.	356	Age: 65.7Female: 73.0%	Home-based individual cognitive stimulation therapy that having a total of 75 activity sessions, focusing on different themes, such as being creative, word games, and current affairs.	25–75 sessions/ up to 3 times weekly session over 25 weeks	30 minutes	Trained family caregivers	Usual care	Hospital Anxiety and Depression Scale Depression Score	Baseline, 13 weeks, 26 weeks
Schmitter-Edgecombe and Dyck (2014)	U.S.	46	Age: 65.9Female: 69.6%	Memory strategies training but covered topics such as stress and coping, healthy lifestyles, and planning for the future.	32 sessions/ 2 individual sessions, half day work shop, and 20 group sessions over 3 months plus monthly maintenance session for 9 months	Group meeting session lasted 2 hours	Two trained clinicians	Usual care	Geriatric Depression Scale	Baseline, 12 months
Clare et al. (2010)	U.K.	28	Age: 69.9Female: NR	Care recipients set up personally meaningful goals by providing practical aids and strategies, techniques for learning new information and by practicing in maintaining attention and concentration, and techniques for stress management.	8 weekly sessions	1 hour	An experienced occupational therapist	Relaxation therapy or no treatment	Hospital Anxiety and Depression Scale Depression Score	Baseline, 8 weeks, 6 months
Onor et al. (2007)	Italy	16	Age: 59.0Female: 62.5%	Care recipients received 24 reality orientation therapy and 12 sessions of activities stimulating both implicit memory and the memory of events.	36 sessions/ during 4 months	1 hour	Trained psychologist	No form of intervention	Geriatric Depression Scale	Baseline, 2 months, 4 months
Mindfulness intervention
Brown, Coogle, and Wegelin ⁽2016)	U.S.	38	Age: 61.1Female: 84.2%	Learning skills aimed at increasing awareness of experiences and sensations related to physical symptoms, emotions, thoughts, and behaviors during interactions with care recipients.	8 weekly group sessions (10–20 participants in a group)	1.5–2 hours	Two master’s degree-level trained facilitators with over 10 years of experience	Social support	Profile of Mood States - Depression	Baseline, 8 weeks, 3 months
Lavretsky et al. (2013)	U.S.	39	Age: 60.5Female: 94.9%	Meditation involved repetitive finger movements or mudras and deep breathing relaxation at the beginning and the final.	Daily sessions/ 12 minutes per day for 8 weeks	12 minutes	By themselves using CD	Relaxation	Hamilton Rating Scale for Depression	Baseline, 8 weeks
Whitebird et al. (2013)	U.S.	78	Age: 56.8Female: 88.5%	Participants received instruction on sitting and walking meditation, body scan meditation, and gentle Hatha yoga and stretching exercises.	8 weekly group sessions	2.5 hours	Trained instructor	Combination of education and support	CES-D	Baseline, 8 weeks, 6 months
Oken et al. (2010)	U.S.	31	Age: 64.5Female: 80.6%	Didactic instruction and discussion concerning stress, relaxation, meditation, and mind–body interaction; instruction and practice in meditation and other mindfulness exercises; group discussion and problem-solving regarding exercises.	7 weekly sessions	90 minutes	A clinical psychologist	Either education or respite-only group service	CES-D	Baseline, 7 weeks
Multicomponent intervention
Blom, Zarit, Groot Zwaaftink, Cuijpers, and Pot ⁽2015)	Netherlands	245	Age: 61.2Female: 69.4%	An internet course titled “Mastery over Dementia” had the element of the course were coping with behavioral problems, relaxation, arranging help from others, cognitive restructuring, and communication with others.	9 sessions/ 8 lessons plus 1 booster session (a month after participants finish the 8 sessions)	NR	Internet course	Receiving minimal information by e-mail (e-bulletins) every three weeks over six months	CES-D	Baseline, 5 to 6 months
Gaugler, Reese, and Mittelman (2015)	U.S.	107	Age: 50.5Female: 94.3%	Education and psychosocial support that individualized to meet the needs of each caregiver; caregivers were also encouraged to build and utilize social support from family and friends, improve interactions with other family members, and communicate their needs.	6 sessions/ 6 individual and family sessions	NR	Master’s-level psychotherapists	Check in calls every four months	Geriatric Depression Scale	Baseline, every 4 months during the 1st year, every 6 months thereafter for 2 years.
Tremont et al. (2015) Tremont et al. (2015)	U.S.	250	Age: NRFemale: 78.0%	Dementia education, emotional support, directing caregivers to appropriate resources, teaching coping strategies.	16 sessions/ 16 telephone calls over 6 months	Each call lasted 15–30 minutes except initial call lasted 60 minutes	Trained therapists with master’s level	Telephone support	CES-D	Baseline, 6 months
Martindale-Adams, Nichols, Burns, Graney, and Zuber (2013)	U.S.	154	Age: 65.6Female: 84.0%	Information about dementia, financial and legal issues, safety, caregiver health and well-being; group leaders presentation on behavioral, stress, and coping; relaxation exercise; discussion and practice on behavioral, stress, and coping.	14 sessions/ 14 telephone group sessions over 1 year (biweekly for 2 months and monthly thereafter for 1 year) (5–6 caregivers in a group)	45 minutes	Trained family caregivers	Receiving information materials and participating one workshop	CES-D	Baseline, 6 months, 12 months
Joling et al. (2012)	Denmark	192	Age: 69.5Female: 70.3%	Teaching problem-solving techniques; mobilizing the existing family networks of the patient and primary caregiver in order to improve emotional and instrumental support; issues such as management of patient behavior problems were identified and the family formed ideas to help the caregiver.	6 sessions/ 6 face-to-face individual and family sessions every 2–3 months over 12 months	NR	Counselors who had an advanced degree in nursing, social work, psychology, or an allied profession	Usual care	CES-D	Baseline, 12 months
Au et al. (2010)	Hong Kong	27	Age: 54.2Female: 100.0%	Employing a skill-building, psychoeducational approach for reducing caregivers’ psychological distress through learning and practicing specific cognitive and behavioral skills.	13 sessions/ 13 weekly group session (5–8 people in group)	2 hours	Clinical psychologists-in-training	Wait-list control	CES-D	Baseline, 13 weeks
Glueckauf et al. (2007)	U.S.	20	Age: 60.5Female: 71.4%	Sessions cover following topics: Overview of the basic characteristics of dementia; relaxation training; effective thinking about caregiving challenges; building in pleasant daily activities; assertiveness in caregiving situations and with family members; developing problem-solving skills; having a social support network and further refining of problem-solving skills.	12 sessions/ 7 group and 5 individual weekly sessions	45–60 minutes	A trained doctoral or master’s-level counselor	Written educational materials	CES-D	Baseline, 13 weeks

CBT: cognitive-behavioral therapy; CES-D: Center for Epidemiologic Studies Depression Scale; NR: not reported.

Intervention effect sizes on caregiver depressive symptoms

Effect sizes according to intervention types are presented in forest plots in Figures 2 to 7.

Figure 2.

The effects of CBT on improving depressive symptoms of caregivers of people with dementia.

Figure 3.

The effects of psychoeducation on improving depressive symptoms of caregivers of people with dementia.

Figure 4.

The effects of emotional support on improving depressive symptoms of caregivers of people with dementia.

Figure 5.

The effects of cognitive rehabilitation for care recipients on improving depressive symptoms of caregivers of people with dementia.

Figure 6.

The effects of mindfulness intervention on improving depressive symptoms of caregivers of people with dementia.

Figure 7.

The effects of multicomponent intervention on improving depressive symptoms of caregivers of people with dementia.

CBT

Eight RCTs used CBT interventions. The average number of sessions was 10 (range: 6–14) and the average intervention period was 12 weeks (range: 6–20). Intervention facilitators were trained psychologists, clinicians, psychology graduate students, or senior citizens. Half of the studies were focused on behavioral activation that encouraged caregivers to develop and increase pleasant events. The remaining four studies targeted acknowledging unhelpful thoughts, changing thoughts, and positive reframing.

Meta-analysis of the eight CBT studies (838 participants) strongly suggested that CBT interventions have a large and statistically significant effect (SMD = −0.905; 95% CI = (−1.622, −0.187); p = 0.013) on reducing caregivers’ depressive symptoms. The Q statistic for the test of heterogeneity indicated statistical significance (Q = 133.98; p < 0.001) and the amount of heterogeneity was high (I² = 94.78%), which indicates variation in the studies in terms of intervention design and study samples. To mitigate the effects of heterogeneity, we applied a random effects model and, to be consistent, used a random effects model when assessing the other interventions.

Psychoeducational intervention

Five RCTs applied a psychoeducational intervention. The average number of sessions was 11 (range: 6–14) and the average intervention period was 20 weeks (range: 6–48). Various health care workers including social workers, counselors, nurses, psychologists, and geriatricians facilitated the interventions. The content included disease progression of dementia, management of care recipients’ behavioral problems, problem-solving skills, and self-care for caregivers. Face-to-face delivery, telephone calls, a web-based course, and an application for mobile devices were used as modes of delivery.

Meta-analysis of these five studies (748 participants) indicated that psychoeducational interventions have a small but very significant effect (SMD = −0.244; 95% CI = (−0.395, −0.092); p = 0.002) on reducing caregivers’ depressive symptoms. The Q statistic for the test of heterogeneity indicated nonstatistical significance (Q = 2.30; p = 0.681) and the amount of heterogeneity was none (I² = 0%).

Emotional support intervention

Two RCTs used emotional support interventions. One study used telephone calls and the other used face-to-face meetings. At least 24 sessions (daily or weekly contact) were delivered over a six-month period. Trained volunteers or social workers provided emotional support, which involved listening to and validating the caregivers’ emotions.

Meta-analysis of these two studies (339 participants) indicated that emotional support interventions do not demonstrate significant effects (SMD = −0.123; 95% CI = (−0.344, 0.097); p = 0.272) on reducing caregivers’ depressive symptoms. The Q statistic for the test of heterogeneity indicated nonsignificance (Q = 0.93; p = 0.336) and the amount of heterogeneity was none (I² = 0%).

Cognitive rehabilitation for care recipients

Five RCTs used cognitive rehabilitation for the care recipients. An average of 29 sessions (range: 8–50 sessions) was provided and the average intervention period was 27 weeks (range: 8–48). The facilitators of the intervention were psychologists, occupational therapists, and trained family caregivers. Cognitive rehabilitation was comprised of diverse activities intended to stimulate memories and maintain attention, such as word games, art, and singing.

Meta-analysis of these five studies (933 participants) indicated that cognitive rehabilitation interventions do not demonstrate significant effects (SMD = −0.104; 95% CI = (−0.240, 0.031); p = 0.130) on reducing caregivers’ depressive symptoms. The Q statistic for the test of heterogeneity indicated nonsignificance (Q = 2.75; p = 0.600) and the amount of heterogeneity was none (I² = 0%).

Mindfulness intervention

Four RCTs applied mindfulness interventions. Three studies delivered 7–8 weekly sessions and one study delivered a daily intervention for eight weeks. Three studies used clinical psychologists or trained instructors to facilitate the intervention while one study used a recorded CD-ROM. Three studies integrated meditative components into the core elements of the mindfulness intervention, such as attention to the present moment and nonjudgmental awareness, while the fourth did not.

Meta-analysis of these four studies (186 participants) indicated that mindfulness interventions have a moderate, significant effect (SMD = −0.578; 95% CI = (−0.881, −0.275); p < 0.001) on reducing caregivers’ depressive symptoms. The Q statistic for the test of heterogeneity indicated nonstatistical significance (Q = 1.17; p = 0.761) and the amount of heterogeneity was none (I² = 0%).

Multicomponent interventions

Seven RCTs used multicomponent interventions. An average of 11 sessions (range: 6–16) were provided and the average intervention period was 26 weeks (range: 12–48). Psychotherapists, trained therapists, counselors, psychologists, and trained family caregivers facilitated these interventions. Six studies used face-to-face delivery of the intervention and the last one used the internet as a venue for the intervention (Blom et al., 2015). The multicomponent interventions included a broad spectrum of content such as coping strategies, relaxation techniques, cognitive/behavioral skills, communication, psychosocial support, education on dementia, and caregiver well-being.

Meta-analysis of these seven studies (995 participants) indicated that the effects of multicomponent interventions were not significant (SMD = −0.123; 95% CI = (−0.249, 0.003); p = 0.055) in reducing caregivers’ depressive symptoms. The Q statistic from the test of heterogeneity indicated no statistical significance (Q = 2.27; p = 0.894) and the amount of heterogeneity was none (I² = 0%).

Methodological quality appraisal

Methodological evaluation of each study is presented in Table 2. More than half of the trials examined (64.5%, 20 out of 31 studies) reported specific methods of random sequence generation, for example using a computer-generated algorithm, permuted-block randomization, or dynamic randomization. Allocation concealment was maintained by 35.5% of studies (11 out of 31 studies) using either centralized randomization methods, an on-site computer system, or by blinding an independent statistician. Almost half of the studies (48.4%, 15 out of 31 studies) showed baseline outcome measurements and characteristics were similar across groups by comparing the level of depressive symptoms of treatment and control groups at the baseline, by age and gender, or by controlling for any differences in predepressive levels. Outcomes were assessed blindly in 48.4% (15 out of 31 studies) of included trials. Incomplete outcome data were addressed adequately in most trials (87.1%, 27 out of 31 studies) by testing the difference between completers and noncompleters, stating detailed reasons for dropouts, or showing similar dropout rates of treatment and control groups. Approximately 61.3% of studies (19 out of 31 studies) protected against contamination by delivering the intervention at individual homes, by having random allocation stratified by center, or by delivering the intervention through telephone, Internet, or mobile device. All studies were free of selective outcome reporting bias by presenting all measurements listed in the “Methods” section and in the “Results” section.

Table 2.

Quality appraisal of included studies based on Cochrane effective practice and organization of care risk of bias tool.

Author/Year	Random sequence generation	Allocation concealment	Baseline outcome measurements similar	Baseline characteristics similar	Incomplete outcome data	Knowledge of the allocated interventions adequately prevented	Protection against contamination	Selective outcome reporting	Other risks of bias
Cognitive-behavioral therapy
Steffen and Gant (2016)	Low	Low	Low	Low	Low	Unclear	Low	Low	Low
Au et al. (2015)	Unclear	Unclear	Unclear	Low	Low	Unclear	Low	Low	Low
Au et al. (2014)	Unclear	Unclear	Low	Low	Low	Low	Low	Low	Low
Livingston et al. (2014)	Low	Low	Low	Low	Low	Low	Low	Low	Low
Moore et al. (2013)	Low	Low	Unclear	Low	Low	Low	Low	Low	Low
Losada et al. (2011)	Low	Unclear	Low	Low	Low	Low	Unclear	Low	Low
Gallagher-Thompson et al. (2007)	Unclear	Unclear	Low	Low	Low	Unclear	Low	Low	Low
Marquez-Gonzalez et al. (2007)	Low	Unclear	Low	Low	Low	Unclear	Unclear	Low	Low
Psychoeducational intervention
Nunez-Naveira et al. (2016)	Low	Unclear	Unclear	High	Low	High	Unclear	Low	Low
Sepe-Monti et al. (2016)	Low	Low	Low	High	Low	Low	Unclear	Low	Low
Waldorff et al. (2012)	Low	Low	Low	Low	Low	Low	Low	Low	Low
de Rotrou et al. (2011)	Low	Low	Low	Low	Low	Low	Low	Low	Low
Finkel et al. (2007)	Unclear	Unclear	Unclear	Low	Low	Unclear	Low	Low	Low
Emotional support
Charlesworth et al. (2008)	Low	Low	High	High	Low	High	Unclear	Low	Low
Winter and Gitlin (2007)	Unclear	Unclear	Low	High	Unclear	Unclear	Low	Low	Low
Cognitive rehabilitation therapy for care recipients
Woods et at. (2016)	Low	Unclear	Low	Low	Low	Low	Low	Low	Low
Orgeta et al. (2015)	Low	Low	Unclear	Unclear	Low	Low	Low	Low	Low
Schmitter-Edgecombe and Dyck (2014)	High	High	Low	Low	Low	Unclear	Low	Low	Low
Clare et al. (2010)	Low	Low	Unclear	Low	Low	Low	Low	Low	Low
Onor et al. (2007)	Unclear	Unclear	Low	Unclear	Low	High	Unclear	Low	Low
Mindfulness
Brown et al. (2016)	Unclear	Unclear	Low	High	Low	Unclear	Unclear	Low	Low
Lavretsky et al. (2013)	Low	Unclear	Low	Low	Low	Unclear	Unclear	Low	Low
Whitebird et al. (2013)	Low	Unclear	Low	Low	Low	Unclear	Unclear	Low	Low
Oken et al. (2010)	Low	Low	Low	Unclear	Low	Low	Unclear	Low	Low
Multicomponent intervention
Blom et al. (2015)	Low	Unclear	Low	Low	High	Low	Low	Low	Low
Gaugler et al. (2015)	Low	Unclear	Low	Low	Unclear	Low	Unclear	Low	Low
Tremont et al. (2015)	Low	Unclear	Low	Unclear	Low	Low	Low	Low	Low
Martindale-Adams et al. (2013)	Unclear	Unclear	Unclear	Low	Low	Unclear	Low	Low	Low
Joling et al. (2012)	Low	Low	Low	High	Low	Low	Low	Low	Low
Au et al. (2010)	Unclear	Unclear	Low	Low	Low	Unclear	Unclear	Low	Low
Glueckauf et al. (2007)	Unclear	Unclear	Low	High	High	Unclear	Low	Low	Low

Publication bias

To test for publication bias of the meta-analysis, a classic fail-safe N was examined. This meta-analysis combined data from 31 studies, with a z-value of −9.11 and the corresponding two-tailed p-value of <0.001. The fail-safe N was 639, meaning 639 “null” studies would be needed to exceed a two-tailed p-value of 0.05. Additionally, studies included in the meta-analysis were positioned at the top of the funnel plot, indicating high precision and large sample sizes (Figure 8). The mean effect size of this meta-analysis (Figure 8, open diamond) was very similar to the modified effect size (closed diamond) that incorporated published studies as well as possible unpublished studies. Therefore, the meta-analysis indicated no publication bias.

Figure 8.

Funnel plot of standard error by standardized difference in means.

Discussion

This present systematic review and meta-analysis investigated 31 RCTs and examined the effectiveness of various types of interventions on depressive symptoms for caregivers of people with dementia. CBT interventions showed the largest and most significant effect on decreasing caregivers’ depressive symptoms. This result supports previous meta-analyses by Pinquart and Sörensen (2006) and Vernooij-Dassen et al. (2011). It is important to mention that three out of the eight RCTs that achieved a significant reduction in depressive symptoms uniformly implemented behavioral activation as a stand-alone intervention. Behavioral activation, which is a component of CBT, comprises a process of identifying leisure activities, scheduling activities, and reinforcing or modifying activities (Au et al., 2015; Moore et al., 2013; Steffen & Gant, 2016). As a result, behavioral activation can increase positive reinforcement, achieve task-oriented goals, and decrease avoidance and negative reinforcement, each of which can counteract depressive symptoms (Chartier & Provencher, 2013). Behavioral activation is easy to tailor to individual preferences and requires minimal time investment from a specialized therapist. For these reasons, the intervention can easily expand the accessibility and dissemination to a larger community (Au et al., 2015; Steffen & Gant, 2016).

Psychoeducational interventions showed a small but significant effect on caregivers’ depressive symptoms, which corresponds with previous meta-analyses (Jensen, Agbata, Canavan, & McCarthy, 2015; Pinquart & Sörensen, 2006). Psychoeducational interventions can be effective in reducing caregivers’ depressive symptoms through the attainment of caregiving skills, ways of self-adjustment, and facilitating a supportive network (Jensen et al., 2015). The effects of psychoeducational interventions on depressive symptoms can be enhanced by increased active participation of the caregivers, such as applying the learned knowledge and skills at home rather than merely providing information (Pinquart & Sörensen, 2006).

Emotional support interventions showed nonsignificant effects. Our results contradict those of Chien et al. (2011), who observed a moderate effect (0.40) of these support interventions. However, Chien et al. (2011) defined support groups more broadly than the present meta-analysis, such as those including educational psychology/training groups as support groups. Future research is needed to test the effectiveness of support interventions with a more consistent definition of the intervention.

Cognitive rehabilitation interventions for care recipients showed a nonsignificant effect. Our results have both similarity and dissimilarity with a previous meta-analysis by Leung, Orgeta, and Orrell (2017), which combined seven cognitive rehabilitation studies and showed a significant effect on caregivers’ depressive symptoms. The authors not only included stand-alone cognitive rehabilitation studies but also included a combination of cognitive rehabilitation and CBT interventions. The discrepancy in statistical significance of cognitive rehabilitation interventions between our results and the previous meta-analysis may be driven by the different classification criteria regarding interventions, although the extent of effect size from both studies was similar.

Mindfulness interventions showed a moderate, significant effect, which is supported by previous studies (Kor, Chien, Liu, & Lai, 2017). Caregivers of people with dementia usually undergo stressful tasks and high degrees of uncertainties related to caregiving. Mindfulness may help caregivers accept their thoughts and feelings without judgment and be more relaxed within the stressful caregiving environment (Kor et al., 2017). However, mindfulness interventions should be used with caution. Mindfulness is a relatively new intervention for caregivers of people with dementia given that the earliest study included in this meta-analysis was conducted in 2010. Additionally, studies have involved comparatively small sample sizes, although this meta-analysis has a larger sample size than the previous one in Kor et al. (2017). Lastly, three RCTs out of four were preliminary or pilot RCTs conducted in the U.S. To confirm the effectiveness of mindfulness interventions, larger sample sizes and various geographical regions should be studied in future research.

Multicomponent interventions showed a no significant effect (p = 0.055) on caregivers’ depressive symptoms, which is supported by previous reports from Olazarán et al. (2010) and Pinquart and Sörensen (2006). The included multicomponent intervention studies discussed the possible reasons for the lack of effect on depressive symptoms such as not targeting individuals’ specific needs (Martindale-Adams et al., 2013) and studying samples having relatively low depressive symptoms (Glueckauf et al., 2007). The most frequently identified reason was the nonadherence and comparatively high dropout rates of participants in the treatment group (Blom et al., 2015; Gaugler et al., 2015; Joling et al., 2012). Multicomponent interventions usually have a long and time-intensive character given that these interventions involve different elements such as education, skills building, and emotional support (Blom et al., 2015). Caregivers may experience more stress or more family conflict by participating in lengthy and time-intensive interventions as these take time away from caregiving responsibilities and add another role of attending intervention sessions (Northouse, Katapodi, Song, Zhang, & Mood, 2010). Future research is needed, focusing on designing a method for caregivers to more easily implement different components of a multicomponent intervention.

In the current meta-analysis, the overall risk of bias decreased over time. In a previous meta-analysis, Thompson et al. (2007) investigated the effectiveness of social support interventions for caregivers of people with dementia and found that only 6.8% of included trials reported methods of randomization and concealment of allocation. However, in this meta-analysis, 64.5% of included studies reported specific methods of randomization and 33.5% reported allocation concealment. In addition, the previous meta-analysis by Thompson et al. (2007) found that 27.3% of included trials maintained blinding while the current study observed 48.4% of included studies assessed outcomes blindly.

Limitations

The limitations of the present study should be considered when interpreting the results. First, the CBT intervention studies had high heterogeneity. Contributors to high heterogeneity can be different geographical regions, a range of the number of intervention sessions, various intervention facilitators, diverse control groups, and different outcome measurements among the studies. Second, the long-term effects of the interventions were not examined. Because of the wide range of follow-up periods across studies, the meta-analysis examined only the immediate effects of interventions. Third, given that the majority of the caregiver participants were women, as in most caregiving research, this study results may not be generalizable to men. Fourth, complete information on intervention fidelity was not reported. Intervention content and delivery modes were examined in this study, but other essential intervention fidelity features such as training of providers, understanding of the intervention, and enactment of skills gained from the intervention were not evaluated because of inconsistent or rare reports from the studies.

Conclusion

As the roles of caregivers of individuals with dementia become ever more critical, maintaining the well-being of caregivers must be priority in public health. This systematic review and meta-analysis incorporating the most recent RCTs confirms that CBT interventions have the largest and most significant effect on reducing caregivers’ depressive symptoms. Increasing activities that caregivers enjoy, which is a part of CBT, can be effective in reducing depressive symptoms. Health care professionals should consider CBT or encourage leisure activities for caregivers of people with dementia. Future research investigating the long-term effectiveness and standardization of CBT procedures is warranted. Although mindfulness interventions showed a moderate effect on caregivers’ depressive symptoms, future large-scale studies are needed to verify these effects.

Improving nonpharmacological interventions to include CBT and mindfulness strategies may contribute to the health of older adults with dementia, their caregivers, and the overall health of the family. Particularly, improved caregiver mental health may play a positive role for allowing care recipients to reside in the community instead of being institutionalized in long-term care facilities. In return, health care costs related to dementia care as well as personal, financial, and organizational resources will be minimized.

Footnotes

Authors’ contributions

ML has contributed to study design, data analysis/interpretation, and writing the manuscript. JHR has contributed to data analysis/interpretation and writing the manuscript. MC has contributed to data analysis. JGA has been involved in conception of the study and critically revising the manuscript. KR has been involved in conception of the study and critically revising the manuscript. ICW has been involved in study conception, design, and revising manuscript substantially.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study supported by University of Virginia, School of Nursing, Lancaster Award.

Mijung Lee, RN, MSN, is a PhD candidate at the School of Nursing, University of Virginia, Charlottesville, VA, USA. Her research focuses on family caregivers of individuals of cognitively impaired middle-aged and older adults residing in the community, with particular emphasis on depression, quality of life, and caregiver burden.

Ji Hoon Ryoo, PhD, is an associate professor at Keck School of Medicine of the University of Southern California. His current research interests include analysis of longitudinal and multilevel data analysis, structural equation modeling, psychometrics, propensity score analysis, and meta-analysis. As a biostatistician, his fields of research include medicine, nursing, and psychology.

Mihee Chung, RN, MSN, is a PhD candidate at the School of Nursing, University of Virginia, Charlottesville, VA, USA. Her research includes the quality of life of the family caregivers of Korean American older adults, focuses on the perceptions of caregiving and their challenges.

Joel G Anderson, PhD, CHTP, FGSA, is an associate professor in the College of Nursing at the University of Tennessee-Knoxville. His research focuses on nonpharmacological strategies for symptom management and caregiver support in Alzheimer’s disease and related dementias. This includes exploring the caregiving experience and understanding the ways in which social media are used by family caregivers and persons with dementia.

Karen Rose, PhD, RN, FGSA, FAAN, is the McMahan-McKinley professor of Gerontology at the University of Tennessee-Knoxville College of Nursing. Her current research focuses on quality of life and technology solutions for persons with dementia and their family and friend caregivers.

Ishan C Williams, PhD, FGSA, is an associate professor at the University of Virginia, School of Nursing. Her current research focuses on quality of life among older adults with dementia and their family caregivers, chronic disease management for older adults with Type 2 diabetes, and culturally appropriate community-based interventions among underrepresented older adults.

References

Alzheimer’s Association. (2018). Alzheimer’s Disease Facts and Figures. Retrieved from https://www.alz.org/media/HomeOffice/Facts%20and%20Figures/facts-and-figures.pdf

Gallagher-Thompson

Wong

Leung

Chan

C. C. &

Chan

(2015). Behavioral activation for dementia caregivers: Scheduling pleasant events and enhancing communications. Clinical Interventions in Aging, 10, 611–619. DOI: 10.2147/CIA.S72348.

Lee

Leung

Pan

Thompson

Gallagher-Thompson

(2010). The coping with caregiving group program for Chinese caregivers of patients with Alzheimer’s disease in Hong Kong. Patient Education and Counseling, 78(2), 256–260.

Wong

M. K.

Leung

L. M.

Leung

Wong

(2014). Telephone-assisted pleasant-event scheduling to enhance well-being of caregivers of people with dementia: A randomized controlled trial. Hong Kong Medical Journal, 20(3), 30–33.

Belle

S. H.

Burgio

Burns

Coon

Czaja

S. J.

Gallagher-Thompson

D. &

Martindale-Adams

(2006). Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized, controlled trial. Annals of Internal Medicine, 145(10), 727–738.

Blom

M. M.

Zarit

S. H.

Groot Zwaaftink

R. B. M.

Cuijpers

Pot

A. M.

(2015). Effectiveness of an internet intervention for family caregivers of people with dementia: Results of a randomized controlled trial. PLoS ONE, 10(2), e0116622. DOI: 10.1371/journal.pone.0116622.

Boots

L. M. M.

De Vugt

M. E.

Van Knippenberg

R. J. M.

Kempen

G. I. J. M.

Verhey

F. R. J.

(2014). A systematic review of internet‐based supportive interventions for caregivers of patients with dementia. International Journal of Geriatric Psychiatry, 29(4), 331–344.

Borenstein

Hedges

L. V.

Higgins

J. P.

Rothstein

H. R.

(2011). Introduction to Meta-Analysis. West Sussex, UK: John Wiley & Sons.

Borenstein

Hedges

Higgins

Rothstein

(2014). Comprehensive Meta-Analysis (Version 3) [Computer software]. Englewood, NJ: Biostat.

10.

Brown

K. W.

Coogle

C. L.

Wegelin

(2016). A pilot randomized controlled trial of mindfulness-based stress reduction for caregivers of family members with dementia. Aging & Mental Health,20(11), 1157–1166.

11.

Cannuscio

C. C.

Jones

Kawachi

Colditz

G. A.

Berkman

Rimm

(2002). Reverberations of family illness: A longitudinal assessment of informal caregiving and mental health status in the Nurses’ Health Study. American Journal of Public Health, 92(8), 1305–1311.

12.

Charlesworth

Shepstone

Wilson

Thalanany

Mugford

Poland

(2008). Does befriending by trained lay workers improve psychological well-being and quality of life for carers of people with dementia, and at what cost? A randomized controlled trial. Health Technology Assessment, 12(4), iii.

13.

Chartier

I. S.

Provencher

M. D.

(2013). Behavioural activation for depression: Efficacy, effectiveness and dissemination. Journal of Affective Disorders, 145(3), 292–299.

14.

Chien

L. Y.

Chu

Guo

J. L.

Liao

Y. M.

Chang

L. I.

Chen

C. H.

Chou

K. R.

(2011). Caregiver support groups in patients with dementia: A meta‐analysis. International Journal of Geriatric Psychiatry, 26(10), 1089–1098.

15.

Clare

Linden

D. E.

Woods

R. T.

Whitaker

Evans

S. J.

Parkinson

C. H. &

Yuen

K. S.

(2010). Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer disease: A single-blind randomized controlled trial of clinical efficacy. The American Journal of Geriatric Psychiatry, 18(10), 928–939.

16.

Cochrane Effective Practice and Organization of Care (EPOC). (2017). Suggested Risk of Bias Criteria for EPOC Reviews. EPOC Resources for review authors. Retrieved from http://epoc.cochrane.org/resources/epoc-resources-review-authors

17.

Cohen

(1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.

18.

de Rotrou

Cantegreil

Faucounau

Wenisch

Chausson

Jegou

D. &

Rigaud

(2011). Do patients diagnosed with Alzheimer’s disease benefit from a psycho‐educational programme for family caregivers? A randomised controlled study. International Journal of Geriatric Psychiatry,26(8), 833–842. DOI: 10.1002/gps.2611.

19.

Deeks

J. J.

Higgins

J. P.

Altman

D. G.

(2008). Analyzing Data and Undertaking Meta-Analyses. In Higgins

J. P.

Green

(Eds.), Cochrane handbook for systematic reviews of interventions: Cochrane book series. Chichester, UK: John Wiley & Sons, Ltd. DOI: 10.1002/9780470712184.ch934.

20.

Finkel, S., Czaja, S. J., Martinovich, Z., Harris, C., Pezzuto, D., & Schulz, R. (2007). E-care: a telecommunications technology intervention for family caregivers of dementia patients. The American Journal of Geriatric Psychiatry, 15(5), 443–448.

21.

Gallagher-Thompson

Gray

H. L.

Tang

P. C. Y.

C. Y.

Leung

L. Y. L.

Wang

P. &

Thompson

L. W.

(2007). Impact of in-home behavioral management versus telephone support to reduce depressive symptoms and perceived stress in Chinese caregivers: Results of a pilot study. The American Journal of Geriatric Psychiatry, 15(5), 425–434. DOI: 10.1097/JGP.0b013e3180312028.

22.

Gaugler

J. E.

Reese

Mittelman

M. S.

(2015). Effects of the Minnesota adaptation of the NYU caregiver intervention on depressive symptoms and quality of life for adult child caregivers of persons with dementia. The American Journal of Geriatric Psychiatry, 23(11), 1179–1192.

23.

The Global Voice on Dementia. (n.d). Dementia Statistics. Retrieved from https://www.alz.co.uk/research/statistics

24.

Glueckauf

R. L.

Sharma

Davis

W. S.

Byrd

Stine

Jeffers

S. B. &

Martin

(2007). Telephone-based cognitive-behavioral intervention for distressed rural dementia caregivers: Initial findings. Clinical Gerontologist: The Journal of Aging and Mental Health, 31(1), 21–41. DOI: 10.1300/J018v31n01_03.

25.

Higgins

J. P. T.

Green

(2011). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. Retrieved from www.cochrane-handbook.org

26.

Jensen

Agbata

I. N.

Canavan

McCarthy

(2015). Effectiveness of educational interventions for informal caregivers of individuals with dementia residing in the community: Systematic review and meta‐analysis of randomised controlled trials. International Journal of Geriatric Psychiatry, 30(2), 130–143.

27.

Joling

K. J.

Van Marwijk

H. W.

Van der Horst

H. E.

Scheltens

Van de Ven

P. M.

Appels

B. A.

Van Hout

H. P.

(2012). Effectiveness of family meetings for family caregivers on delaying time to nursing home placement of dementia patients: A randomized trial. PLoS One, 7(8), e42145.

28.

Kor

P. P.

Chien

W. T.

Liu

J. Y.

Lai

C. K.

(2017). Mindfulness-based intervention for stress reduction of family caregivers of people with dementia: A systematic review and meta-analysis. Mindfulness, 1, 16.

29.

Lavretsky

Epel

E. S.

Siddarth

Nazarian

Cyr

N. S.

Khalsa

D. S. &

Irwin

M. R.

(2013). A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: Effects on mental health, cognition, and telomerase activity. International Journal of Geriatric Psychiatry, 28(1), 57–65. DOI: 10.1002/gps.3790.

30.

Leung

Orgeta

Orrell

(2017). The effects on carer well‐being of carer involvement in cognition‐based interventions for people with dementia: A systematic review and meta‐analysis. International Journal of Geriatric Psychiatry,32(4), 372–385.

31.

Livingston

Barber

Rapaport

Knapp

Griffin

Romeo

R. &

Mummery

(2014). 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 Technology Assessment, 18(61), 1–242.

32.

Losada

Márquez‐González

Romero‐Moreno

(2011). Mechanisms of action of a psychological intervention for dementia caregivers: Effects of behavioral activation and modification of dysfunctional thoughts. International Journal of Geriatric Psychiatry, 26(11), 1119–1127.

33.

Lwi

S. J.

Ford

B. Q.

Casey

J. J.

Miller

B. L.

Levenson

R. W.

(2017). Poor caregiver mental health predicts mortality of patients with neurodegenerative disease. Proceedings of the National Academy of Sciences USA, 114(28), 7319–7324.

34.

Marquez-Gonzalez

Losada

Izal

Perez-Rojo

Montorio

(2007). Modification of dysfunctional thoughts about caregiving in dementia family caregivers: Description and outcomes of an intervention programme. Aging & Mental Health, 11(6), 616–625. DOI: 10.1080/13607860701368455.

35.

Martindale-Adams

Nichols

L. O.

Burns

Graney

M. J.

Zuber

(2013). A trial of dementia caregiver telephone support. Canadian Journal of Nursing Research, 45(4), 30–48.

36.

Moher

Shamseer

Clarke

Ghersi

Liberati

Petticrew

M., &

Stewart

L. A.

(2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), 1.

37.

Moore

R. C.

Chattillion

E. A.

Ceglowski

von Känel

Mills

P. J., &

Mausbach

B. T.

(2013). A randomized clinical trial of behavioral activation (BA) therapy for improving psychological and physical health in dementia caregivers: Results of the pleasant events program (PEP). Behaviour Research and Therapy, 51(10), 623–632.

38.

Northouse

L. L.

Katapodi

M. C.

Song

Zhang

Mood

D. W.

(2010). Interventions with family caregivers of cancer patients: Meta‐analysis of randomized trials. CA: A Cancer Journal for Clinicians, 60(5), 317–339.

39.

Nunez-Naveira

Alonso-Bua

de Labra

Gregersen

Maibom

Mojs

, … Millan-Calenti

J. C.

(2016). UnderstAID, an ICT platform to help informal caregivers of people with dementia: A pilot randomized controlled study. BioMed Research International 2016, 5726465. DOI: 10.1155/2016/5726465.

40.

Oken

B. S.

Fonareva

Haas

Wahbeh

Lane

J. B.

Zajdel

Amen

(2010). Pilot controlled trial of mindfulness meditation and education for dementia caregivers. Journal of Alternative & Complementary Medicine, 16(10), 1031–1038. DOI: 10.1089/acm.2009.0733.

41.

Olazarán

Reisberg

Clare

Cruz

Peña-Casanova

Del Ser

, … Spector

(2010). Nonpharmacological therapies in Alzheimer’s disease: A systematic review of efficacy. Dementia and Geriatric Cognitive Disorders, 30(2), 161–178.

42.

Onor

M. L.

Trevisiol

Negro

Alessandra

Saina

Aguglia

(2007). Impact of a multimodal rehabilitative intervention on demented patients and their caregivers. American Journal of Alzheimer’s Disease & Other Dementias, 22(4), 261–272.

43.

Orgeta

Leung

Yates

Kang

Hoare

Henderson

C., &

Orrell

(2015). Individual cognitive stimulation therapy for dementia: A clinical effectiveness and cost-effectiveness pragmatic, multicentre, randomised controlled trial. Health Technology Assessment, 19(64), 1–108. DOI: 10.3310/hta19640.

44.

Pinquart

Sörensen

(2006). Helping caregivers of persons with dementia: Which interventions work and how large are their effects? International Psychogeriatrics, 18(4), 577–595.

45.

Schmitter-Edgecombe

Dyck

D. G.

(2014). Cognitive rehabilitation multi-family group intervention for individuals with mild cognitive impairment and their care-partners. Journal of the International Neuropsychological Society, 20(9), 897–908.

46.

Schoenmakers

Buntinx

Delepeleire

(2010). Factors determining the impact of care-giving on caregivers of elderly patients with dementia. A systematic literature review. Maturitas, 66(2), 191–200.

47.

Sepe-Monti

Vanacore

Bartorelli

Tognetti

Giubilei

(2016). The savvy caregiver program: A probe multicenter randomized controlled pilot trial in caregivers of patients affected by Alzheimer’s disease. Journal of Alzheimer’s Disease, 54(3), 1235–1246. DOI: 10.3233/JAD-160235.

48.

Sörensen

Pinquart

Duberstein

(2002). How effective are interventions with caregivers? An updated meta-analysis. Gerontologist, 42(3), 356–372.

49.

Spector

Tampi

(2005). Caregiver depression. Annals of Long Term Care, 13(4), 34.

50.

Spieth

P. M.

Kubasch

A. S.

Penzlin

A. I.

Illigens

B. M. W.

Barlinn

Siepmann

(2016). Randomized controlled trials – A matter of design. Neuropsychiatric Disease and Treatment, 12, 1341.

51.

Steffen

A. M.

Gant

J. R.

(2016). A telehealth behavioral coaching intervention for neurocognitive disorder family carers. International Journal of Geriatric Psychiatry, 31(2), 195–203. DOI: 10.1002/gps.4312.

52.

Thompson

C. A.

Spilsbury

Hall

Birks

Barnes

Adamson

(2007). Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatrics, 7(1), 18.

53.

Tremont, G., Davis, J. D., Papandonatos, G. D., Ott, B. R., Fortinsky, R. H., Gozalo, P., ... & Bishop, D. S. (2015). Psychosocial telephone intervention for dementia caregivers: A randomized, controlled trial. Alzheimer's & Dementia, 11(5), 541–548.

54.

Vernooij‐Dassen

Draskovic

McCleery

Downs

(2011). Cognitive reframing for carers of people with dementia. The Cochrane Database of Systematic Reviews, (11), CD005318.

55.

Waldorff

F. B.

Buss

D. V.

Eckermann

Rasmussen

M. L. H.

Keiding

Rishøj

S., &

Waldemar

(2012). Efficacy of psychosocial intervention in patients with mild Alzheimer’s disease: The multicentre, rater blinded, randomised Danish Alzheimer Intervention Study (DAISY). British Medical Journal, 345, e4693.

56.

Waller

Dilworth

Mansfield

Sanson-Fisher

(2017). Computer and telephone delivered interventions to support caregivers of people with dementia: A systematic review of research output and quality. BMC Geriatrics, 17(1), 265.

57.

Whitebird

R. R.

Kreitzer

M. J.

Crain

A. L.

Lewis

B. A.

Hanson

L. R.

Enstad

C. J.

(2013). Mindfulness-based stress reduction for family caregivers: A randomized controlled trial. The Gerontologist, 53(4), 676–686. DOI: 10.1093/geront/gns126.

58.

Winter

Gitlin

L. N.

(2007). Evaluation of a telephone-based support group intervention for female caregivers of community-dwelling individuals with dementia. American Journal of Alzheimer’s Disease and Other Dementias, 21(6), 391–397. DOI: 10.1177/1533317506291371.

59.

Woods

R. T.

Orrell

Bruce

Edwards

R. T.

Hoare

Hounsome

B., &

Russell

(2016). REMCARE: Pragmatic multi-centre randomised trial of reminiscence groups for people with dementia and their family carers: Effectiveness and economic analysis. PLoS One, 11(4), e0152843.