title: Efficacy and experiences of telephone counselling for informal carers of people with dementia.
abstract: BACKGROUND
  Informal carers of people with dementia can suffer from depressive symptoms, emotional distress and other physiological, social and financial consequences.
  
  
  OBJECTIVE
  This review focuses on three main objectives:To:1) produce a quantitative review of the efficacy of telephone counselling for informal carers of people with dementia;2) synthesize qualitative studies to explore carers' experiences of receiving telephone counselling and counsellors' experiences of conducting telephone counselling; and3) integrate 1) and 2) to identify aspects of the intervention that are valued and work well, and those interventional components that should be improved or redesigned.
  
  
  METHODS
  The Cochrane Dementia and Cognitive Improvement Group's Specialized Register, The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, PSYNDEX, PsycINFO, Web of Science, DIMDI databases, Springer database, Science direct and trial registers were searched on 3 May 2011 and updated on 25 February 2013. A Forward Citation search was conducted for included studies in Web of Science and Google Scholar. We used the Related Articles service of PubMed for included studies, contacted experts and hand-searched abstracts of five congresses.
  
  
  METHODS
  Randomised controlled trials (RCTs) or cross-over trials that compared telephone counselling for informal carers of people with dementia against no treatment, usual care or friendly calls for chatting were included evaluation of efficacy. Qualitative studies with qualitative methods of data collection and analysis were also included to address experiences with telephone counselling.
  
  
  METHODS
  Two authors independently screened articles for inclusion criteria, extracted data and assessed the quantitative trials with the Cochrane 'Risk of bias' tool and the qualitative studies with the Critical Appraisal Skills Program (CASP) tool. The authors conducted meta-analyses, but reported some results in narrative form due to clinical heterogeneity. The authors synthesised the qualitative data and integrated quantitative RCT data with the qualitative data.
  
  
  RESULTS
  Nine RCTs and two qualitative studies were included. Six studies investigated telephone counselling without additional intervention, one study combined telephone counselling with video sessions, and two studies combined it with video sessions and a workbook. All quantitative studies had a high risk of bias in terms of blinding of participants and outcome assessment. Most studies provided no information about random sequence generation and allocation concealment. The quality of the qualitative studies ('thin descriptions') was assessed as moderate. Meta-analyses indicated a reduction of depressive symptoms for telephone counselling without additional intervention (three trials, 163 participants: standardised mean different (SMD) 0.32, 95% confidence interval (CI) 0.01 to 0.63, P value 0.04; moderate quality evidence). The estimated effects on other outcomes (burden, distress, anxiety, quality of life, self-efficacy, satisfaction and social support) were uncertain and differences could not be excluded (burden: four trials, 165 participants: SMD 0.45, 95% CI -0.01 to 0.90, P value 0.05; moderate quality evidence; support: two trials, 67 participants: SMD 0.25, 95% CI -0.24 to 0.73, P value 0.32; low quality evidence). None of the quantitative studies included reported adverse effects or harm due to telephone counselling. Three analytical themes (barriers and facilitators for successful implementation of telephone counselling, counsellor's emotional attitude and content of telephone counselling) and 16 descriptive themes that present the carers' needs for telephone counselling were identified in the thematic synthesis. Integration of quantitative and qualitative data shows potential for improvement. For example, no RCT reported that the counsellor provided 24-hour availability or that there was debriefing of the counsellor. Also, the qualitative studies covered a limited range of ways of performing telephone counselling.
  
  
  CONCLUSIONS
  There is evidence that telephone counselling can reduce depressive symptoms for carers of people with dementia and that telephone counselling meets important needs of the carer. This result needs to be confirmed in future studies that evaluate efficacy through robust RCTs and the experience aspect through qualitative studies with rich data.
authors.affiliation: German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Berliner Allee 29, Freiburg, Germany, 79110.
authors.forename: Sabine
authors.initials: S
authors.lastname: Lins
authors.forename: Daniela
authors.initials: D
authors.lastname: Hayder-Beichel
authors.forename: Gerta
authors.initials: G
authors.lastname: Rücker
authors.forename: Edith
authors.initials: E
authors.lastname: Motschall
authors.forename: Gerd
authors.initials: G
authors.lastname: Antes
authors.forename: Gabriele
authors.initials: G
authors.lastname: Meyer
authors.forename: Gero
authors.initials: G
authors.lastname: Langer
mesh_terms: D000368:Aged; D017028:Caregivers / Q000523:psychology*; D003376:Counseling / Q000379:methods / Q000592:standards*; D003704:Dementia / Q000451:nursing*; D003863:Depression / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D010549:Personal Satisfaction; D036301:Qualitative Research; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D020377:Self Efficacy; D012944:Social Support; D013689:Telephone