New Beginnings with START: Experiences of piloting a manualised intervention for carers in a secondary care mental health service Dr Rachel Wenman Bedfordshire and Luton Mental Health and Wellbeing Service. Provided by ELFT.

STrAtegies for RelaTives (START) Coping with caring intervention Developed by Livingston et al (2013) 8 sessions using a leaflet/manual Individual sessions (not group) Based on Cognitive Behavioural approach

www. ucl.ac.uk/psychiatry/start

Evidence base RCT 2:1 intervention vs Treatment as usual 260 carers 8 sessions with graduate trained by research team. Outcome end of therapy lower HADS, better QoL 2 years – 7x less likely to be depressed Cost effectiveness

Key issues/Questions How does START fit? Who can deliver START? What resources do we have? Who can deliver START? Tailoring training to needs Who is eligible? When? How to measure outcome? Ethical issues Motivating the system

IAPT – primary care talking therapy Service context 4 CMHTS – severe and enduring mental health problems. Complex needs, difficulties engaging with services 4 Memory Clinics – MDT diagnostic process + signposting and support Prescription clinic 3rd sector: carer support, information, cognitive stimulation groups, activity groups (music, singing, walking football etc) CST programme IAPT – primary care talking therapy

IAPT – primary care talking therapy Where to offer START? 4 CMHTS Memory Clinics IAPT – primary care talking therapy Prescription clinic

Who can deliver START? Low intensity therapy Delivered by non-clinicians/therapists Specialist training and supervision Pre-requisites Experience with people with dementia/PSI Core skills – listening, person-centred, empathic Interested

Training 2 day training + self directed Dementia Understanding challenging behaviour Stress – models and coping **Therapeutic interactions differences and boundaries, Delivering interventions – role plays, practice, discussion Ethical and risk issues

Training 5 CMHT staff (OT, nursing, CSWs) 3 Assistant psychologists 3 Trainee Clinical Psychologists more self-directed learning

Treatment Preventative Criteria To All Who and When? Pilot 1-2 referrals per psychology staff CMHT – offer within existing caseload

Measuring outcomes PHQ-9, GAD-7 for anxiety and depression Relative stress scale Self ratings: Understanding of dementia Level of stress Ability to cope with behaviour Satisfaction with coping strategies Ending – feedback open questions and ratings: How helpful (what was and wasn’t helpful, improvements), how well it fits with CMHT input, timing of intervention being offered.

Ethical issues Case and activity recording Confidentiality Risk issues

Status 1st wave of training Pilot of psychologists and 1 CMHT delivering intervention 13 referrals and 9 appropriate 1 non-psychologist begun intervention Unintended outcomes

Moving Forward Review Pilot Staff support Training 3rd Sector partner Drivers

Key issues/Questions How does START fit? Who can deliver START? What resources do we have? Who can deliver START? Tailoring training Who is eligible? When? How to measure outcome? Ethical issues Motivating the system

References Greene et al (1982) Measuring Behavioural Disturbance of Elderly Demented Patients in the Community and its Effects on Relatives. Age and Ageing, 11: 121-126 Knapp et al (2013) Cost effectiveness of a manual based coping strategy programme. BMJ 347: f6342 Livingston et al (2013) Clinical Effectiveness of a manual based coping strategy programme. BMJ 347: f6276 Livingston et al (2014) Long term clinical and cost effectiveness of psychological intervention for family carers of people with dementia. The Lancet: 1: 539-48 Somerland (2014) START… Qualitative Study of participants views about the intervention. BMJ; 4e005273. Ulstein et al (2007) The Relative Stress Scale, a useful instrument to identify various aspects of carer burden in dementia. International Journal of Geriatric Psychiatry. 22: 61-67