Do we need both cognitive and behavioural components in interventions for depressed mood in people with mild intellectual disability?

bs_bs_banner

Journal of Intellectual Disability Research 105

doi: 10.1111/jir.12110

volume 59 part 2 pp 105–115 february 2015

Do we need both cognitive and behavioural components in interventions for depressed mood in people with mild intellectual disability? J. A. McGillivray & M. Kershaw School of Psychology, Deakin University, Burwood, Vic., Australia

Abstract Background A growing literature suggests that people with mild intellectual disability (ID) who have depressed mood may benefit from cognitive– behavioural interventions. There has been some speculation regarding the relative merit of the components of this approach. The aim of this study was to compare (i) cognitive strategies; (ii) behavioural strategies; and (iii) combined cognitive–behavioural (CB) strategies on depressed mood among a sample of 70 individuals with mild ID. Methods Staff from three participating agencies received training in how to screen individuals with mild ID for depressive symptoms and risk factors for depression. Depressive symptoms and negative automatic thoughts were assessed prior to and at the conclusion of the intervention, and at 6-month follow-up. The interventions were run in groups by the same therapist. Results A post-intervention reduction in depression scores was evident in participants of all three interCorrespondence: Dr Jane Anne McGillivray, School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Vic. 3125, Australia (e-mail: [email protected]).

ventions, with no significant difference between groups. A significant reduction in negative automatic thoughts post-intervention was evident in the CB combination group and was maintained at follow-up. Examination of clinical effectiveness suggests some advantage of the CB combination in terms of improvement and highlights the possible short term impact of behavioural strategies in comparison with the longer-term potential of cognitive strategies. Conclusions The findings support the use of group cognitive–behavioural interventions for addressing symptoms of depression among people with ID. Further research is necessary to determine the effectiveness of components. Keywords cognitive–behavioural treatment, component analysis, depression, intellectual disability The vulnerability of people with intellectual disability (ID) to mental health disorders is now widely accepted (Lowry 1998; Moss 2001; Gibbs et al. 2008; Morin et al. 2010). In particular, people with ID experience the same and perhaps elevated levels of depression than are evident within the general

© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd

Journal of Intellectual Disability Research

volume 59 part 2 february 2015

106 J. A. McGillivray & M. Kershaw • Analysis of interventions for depression in people with ID

population (Smiley & Cooper 2003). Prevalence estimates among people with ID range from 2.2% to 8.9% (Davis et al. 1997; Deb et al. 2001; White et al. 2005; Cooper et al. 2007), with a high likelihood that these figures may be an underestimate on the basis of difficulties associated with detection and diagnosis in this population (McBrien 2003; Antonacci & Attiah 2008; Perez-Achiaga et al. 2009). Cognitive–behavioural (CB) therapy is recognised as an evidence-based approach for the treatment of depression and is recommended as the treatment of choice in numerous formalised clinical guidelines (e.g. American Psychiatric Association 2000; National Institute for Clinical Excellence 2004). Although there has been comparatively less research concerning the efficacy of CB strategies for depression among people with ID than in the general population (Hatton 2002; Beail 2003; Willner 2005), there is now a significant body of research indicating that people with ID experiencing depression may also benefit from the use of CB strategies (Lindsay et al. 1993; Dagnan & Chadwick 1997; Rose et al. 2000; Ghafoori et al. 2010). Our own research has demonstrated a reduction in depressive symptoms in this population following participation in CB group programmes and with indications that benefits were sustained over time (McCabe et al. 2006; McGillivray & McCabe 2007; McGillivray et al. 2008). More recently, Ghafoori et al. (2010) also found that group-based CB strategies significantly decreased depression symptoms among individuals with mild-borderline ID and depression. However, the improvements in this study were not shown to be sustained over time. Despite the widespread acceptance of the approach, there has been some debate as to the relative effectiveness of the behavioural and the cognitive components of CB programmes in treating depression (Jacobson et al. 1996; Gortner et al. 1998; Dimidjian et al. 2006). Most of this literature pertains to the use of these strategies with the general population. For example, behavioural activation therapy alone has been shown to be effective in reducing symptoms of depression in adults (Lejuez et al. 2001, 2011; Manos et al. 2011). In addition, a component analysis of a cognitive therapy approach has demonstrated that the behavioural components alone resulted in the same out-

comes as the full cognitive therapy package both at the end of acute treatment and at 2-year follow-up for participants experiencing major depression (Jacobson et al. 1996; Gortner et al. 1998). A metaanalysis undertaken by Cuijpers et al. (2007) led to the conclusion that behavioural activation strategies alone are effective in reducing depression symptoms in adults, while subsequent randomised controlled trials have supported the finding that behavioural activation produces outcomes equivalent to those of a combination behavioural and cognitive approach (Cuijpers et al. 2008; Ekers et al. 2008). There are indications, furthermore, that behavioural strategies alone may be as effective as pharmacological treatments. For example, in a randomised trial, behavioural activation performed as well as paroxetine and better than cognitive strategies in the treatment of moderate to severe depression (Dimidjian et al. 2006; Coffman et al. 2007). Relatively little research has been conducted into the comparative efficacy of cognitive versus behavioural strategies among people with mild ID. There has been some speculation, however, that people with ID may be more likely to benefit from behavioural interventions (Sturmey 2004, 2006; Lindsay 2006). Behavioural activation has been viewed as more suited to those individuals who have poor verbal skills and who may not be ‘psychologically minded’ suggesting, in particular, its relevance to individuals with ID (Sturmey 2009). However, on the basis of findings that depression and anxiety are associated with negative cognitive styles, low self-esteem and an awareness of the negative social consequences of having a disability (Nezu et al. 1995; Dagnan & Sandhu 1999; Glenn et al. 2003), it may be that cognitive strategies are an important component in addressing these concerns. As most studies of the effectiveness of CB programmes in the treatment of depression in people with ID have utilised a combination of behavioural and cognitive strategies, the relative effectiveness of each component on its own and together remains unknown (Sturmey 2004). The aim of the current study was to examine the effects of three alternative group interventions for symptoms of depression in people with mild ID: (i) cognitive strategies only; (ii) behavioural strategies only; and (iii) CB strategies, in the short term and at 6-month follow-up.




J. A. McGillivray & M. Kershaw • Analysis of interventions for depression in people with ID

Method Participants The initial participants were 73 adults who attended one of three vocational support services for people with disabilities in Victoria, Australia. All participants were registered as eligible for support service on the basis of satisfying the criteria for ID as defined under the Disability Act 2006 (Vic). Specifically, concurrent existence of significant sub-average intellectual functioning as assessed with a standardised test of intelligence (i.e. not higher than two standard deviations below the average population as assessed with a standardised test of intelligence) and significant sub-average deficits in adaptive behaviours (i.e. a score at or below the second percentile of people of the same age and cultural background), which manifested during the developmental period. Access to individual assessment records was not possible. The participants were recruited into the study on the basis of identification through a staff administered screening protocol as being at risk of depression and having the necessary language and comprehension skills required to undertake the group intervention programme (indicative of mild range of ID). One individual subsequently withdrew from the study and two others left the organisation prior to the commencement of the group interventions. Thus a total of 70 adults with ID (42 men, 28 women) with a mean age of 36 years (SD = 11.82 years) remained in the study.

Materials Depression screening checklist This informant checklist was used to assist staff members to detect depressive symptoms/risk factors in people with mild ID. It comprises 22 items across the areas of mood, activities, sleeping and eating and physical signs, concentration and decision-making. Informants are asked to indicate the presence of each item, as observed during the past 2 weeks in the person they are assessing. This checklist has been previously trialled with staff members in agencies providing services to people with ID (McGillivray & Kershaw 2013). In consultation with these staff and in order to promote early

identification of individuals at risk, a minimum criteria of four checked items, including at least one mood item and/or one activities item, was set for inclusion in the study.

Assessment schedule Demographic information Participants were asked to provide information on their gender, age, their current and past state of physical health, and whether they were taking antidepressant medication. They were also asked about their current living situation, the frequency of family and social contact, and the frequency with which they engaged in social and recreational activities.

Beck Depression Inventory (BDI-II) (Beck 1996) The BDI-II is a 21-item self-report scale designed to assess severity of depression symptoms corresponding to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (American Psychiatric Association 1994). Each item consists of four statements from which the respondent is asked to select the item that best represents his/her current mood over the last 2 weeks. Answers are scored from 0 to 3, with higher scores indicating more severe depressive symptoms. This scale has been shown to have adequate sensitivity and specificity to be used as a screening tool to identify individuals with ID who required a referral for treatment (Ailey 2009). In the current study, Cronbach’s alpha for the BDI-II was 0.86.

Automatic Thoughts Questionnaire (ATQ-R) (Hollon & Kendall 1980) The ATQ-R consists of 40 items that measure the frequency of automatic negative statements about the self. Ten of the most relevant items were used in this study. For ease of responding, each item was reduced to a three-point Likert scale where 1 = ‘not at all’, 2 = ‘sometimes’ and 3 = ‘frequently’. Cronbach’s alpha for the modified ATQ-R in the present study was 0.82.





Group treatment programmes Cognitive and behavioural strategies The ‘Think happy, Feel happy, Be happy’ programme comprises a combination of cognitive and behavioural strategies and is designed to be conducted over a 12-week period in 1.5-h weekly group sessions. Materials used in the creation of the programme were originally adapted from various sources (Lindsay et al. 1993; Stenfert Kroese et al. 1997; Infrapsych CBT program for depression 1999; Moodgym Training Program 2004), with other materials developed specifically for use in this programme for individuals with mild ID. Adapted exercises and handouts were conceptually simplified and presented in plain English format. An ongoing general aim of the group is to provide participants with a comfortable environment in which they feel safe enough to discuss personal issues and practice techniques. Participants are encouraged to develop and practice skills in the group setting, as well as in their everyday lives. The programme comprises three modules. The first module focuses on feelings and aims to assist participants to identify their feelings and to understand how behaviour impacts on feelings, and how to improve their ability to cope with stress. Module two focuses on thoughts. The aim of this module is to introduce the CB concept; to provide participants with the opportunity to practice identifying maladaptive thoughts; and to teach them how to reduce and replace these thoughts with more adaptive ones. Module three focuses on enhancing the quantity and quality of social interactions, and includes the use of role-play to improve social skills (e.g. making and maintaining friends); enhance communication skills (e.g. recognising different styles of communication, appropriate use of body language); and communicate assertively. Cognitive focused strategies only The cognitive strategies taught in the Cognitive group sessions were an expanded version of those contained in the ‘Think happy, Feel happy, Be happy’ intervention programme. These strategies included teaching participants that thoughts, feelings and behaviours are linked and that changing the way we think can lead to changes in the way we feel and behave. Participants practised identifying maladap-

tive thoughts and changing negative thinking to more adaptive thinking both within the group and in their daily lives. Sessions were conducted over a 12-week period with each weekly session taking approximately 1.5 h. Behavioural focused strategies only The behavioural strategies taught in the Behavioural group sessions were an expanded version of those contained in the ‘Think happy, Feel happy, Be happy’ intervention programme. These strategies included techniques to enhance communication and social skills; establish and maintain friendships; and interact with others assertively. Role play was used to develop and practice new skills. Participants were encouraged to practice in real life situations both within the group and in their daily lives and the group provided the opportunity for review and problem-solving. Sessions were conducted over a 12-week period with each weekly session taking approximately 1.5 h.

Procedure Through an informed consent process, staff members recruited participants from three comparable agencies providing vocational services to individuals with mild ID. Prospective participants were screened for symptoms of depression by trained staff using the Depression Screening Checklist. In addition to depressive symptoms or risk factors for depression, staff confirmed that these individuals had the necessary language and comprehension skills required for participation in the group programme. Participants were allocated to receive the programme in groups of seven or eight individuals within their vocational training setting. To minimise confounding of intervention protocols, participants from each agency received a common group intervention. Agency 1 was the Behavioural focused strategies group (n = 24); Agency 2 was the Cognitive focused strategies group (n = 23), and Agency 3 was the CB strategies group (n = 23). In order to maximise fidelity of administration, the intervention programme for all three interventions and across all groups was delivered by a single therapist who was experienced in the delivery of CB programmes to groups and in particular to individuals with ID and





who had undertaken extensive training with standardised manuals for the respective interventions. The lead author provided ongoing supervision to ensure adherence to protocol and consistency of programme delivery. Participants completed the self-report measures of depressive symptoms and automatic negative thoughts prior to the intervention (pre-test), at the conclusion of the intervention (post-test) and 6 months later (follow-up). Varying levels of assistance was provided in this task, with participants ranging from fully independent to requiring the questions read to them. Where this was the case, the assistance was provided by the therapist for all intervention groups.

Results Demographics The majority of participants (n = 31) reported that they lived with their parents or family (44%). Twenty-four participants (34%) lived in supported accommodation and 15 people (12%) lived independently. Thirty-six participants (52%) said they had regular contact with family members, 24 people (34%) had some contact with family members and 10 people (14%) said they had no family contact. Weekly participation in one or two recreational activities was reported by 47% of participants (n = 33), with eight (11%) reporting that they were involved in three or more recreational activities per week. Twenty-nine participants (42%) reported that they did not take part in any recreational activities. Sixteen participants (26%) reported taking antidepressant medication at pre-test (four people in the

CB strategies group, six people in the Behavioural strategies group and eight people in the Cognitive strategies group).

Range of depressive symptoms at pre-test Based on the BDI-II recommended cut-off scores for depressive symptoms in the normal population (Beck et al. 1996), 24 participants (34%) were in the minimally depressed range (0–13); 28 participants (40%) were in the mildly depressed range (14–19); 13 participants (19%) were in the moderately depressed range (20–28); and 5 participants (7%) were in the severely depressed range (29–63).

Reliability of depression screening checklist Coefficient alpha and corrected item-scale correlations were calculated for the 22 items comprising the depression screening checklist. Three items did not appear to be contributing to the internal consistency of the overall scale (item 15 ‘less hungry than usual, needs encouragement to eat’, item 20 ‘cannot concentrate’ and item 21 ‘difficulty making everyday decisions’). Internal consistency of the scale was assessed using Cronbach’s alpha and showed that the scale had moderate reliability (r = 0.73).

Efficacy of the three intervention protocols Examination of differences between groups at pre-test, post-test and follow-up Mean scores and standard deviations were calculated for the three intervention groups at pre-test, post-test and follow-up. These figures are presented in Table 1.

Table 1 Group mean scores and standard deviations for Beck Depression Inventory (BDI-II) and Automatic Thoughts Questionnaire (ATQ)

BDI-II

ATQ

Group

n

Pre-test M (SD)

Post-test M (SD)

Follow-up M (SD)

Pre-test M (SD)

Post-test M (SD)

Follow-up M (SD)

Cognitive–behavioural strategies Cognitive focused strategies Behavioural focused strategies

23 23 24

17.00 (9.12) 15.17 (8.33) 15.79 (8.12)

10.21 (8.14) 9.96 (6.31) 10.21 (5.79)

9.61 (7.29) 10.91 (8.55) 11.17 (10.08)

11.56 (5.07) 11.52 (5.19) 9.12 (4.31)

7.00 (4.69) 11.39 (3.90) 9.00 (5.27)

7.61 (5.24) 10.30 (6.12) 8.96 (4.93)





Examination of the data trends indicate that all three groups showed a reduction in BDI-II scores from pre- to post-test. The CB strategies group demonstrated the greatest reduction in the mean symptoms of depression scores from pre-test to post-test (−6.79) and continued to demonstrate a reduction at follow-up (−0.6). The reduction in mean depression scores from pre-test to post-test in the Behavioural strategies group and the Cognitive strategies group were less pronounced (−5.58 and −5.21 respectively) and both groups demonstrated a slight increase in mean depression symptoms (+0.96 and +0.95 respectively) between post-test and follow-up. The CB strategies group also showed a greater reduction in mean negative automatic thoughts scores from pre-test to post-test (−4.56) when compared with the other groups. However, the CB group was the only group to demonstrate an increase in negative automatic thoughts from posttest to follow-up (+0.61). The Cognitive group showed little reduction in negative automatic thoughts from pre-test to post-test (−0.13) but demonstrated a further reduction in negative automatic thoughts at follow-up (−1.09). The group receiving only behavioural strategies showed minimal change in frequency of negative automatic thoughts from pre-test to post-test (−0.12) through to follow-up (−0.04). A repeated measures anova was conducted to examine differences between the cognitive, behavioural and CB interventions on the BDI-II scores at the three different time points. The main effect of time was significant: F2,134 = 29.731, P = 0.000, partial η2 = 0.31. The main effect of group was not significant: F2,67 = 0.018, P = 0.982, partial η2 = 0.001. The interaction effect was not significant: F4,134 = 0.678, P = 0.608. This indicated that the effect of time on depression scores did not differ between the three intervention groups. Similarly, a repeated measures anova was conducted to examine differences between the cognitive, behavioural and CB interventions on the ATQ scores at the three time points. The main effect of time was significant: F2,134 = 0.6.348, P = 0.002, partial η2 = 0.087. The main effect of group was not significant: F2,67 = 0.2.098, P = 0.131, partial η2 = 0.059. The interaction effect was significant: F4,134 = 4.05, P = 0.004. This indicated that the

effect of time on frequency of negative automatic thoughts differed between the three intervention groups. In order to explore the simple main effects, separate paired-samples t-tests were performed for each group. In the CB intervention group there was a statistically significant decrease in frequency of negative automatic thoughts from pre-test (M = 11.57, SD = 5.07) to post-test (M = 7, SD = 4.69), t (22) = 6.37, P = 0.000. There was no statistically significant difference in frequency of negative automatic thoughts from post-test (M = 7, SD = 4.69) to follow-up (M = 7.61, SD = 5.24). In the Behavioural group there was no statistically significant difference in frequency of negative automatic thoughts from pre-test (M = 9.13, SD = 4.30) to post-test (M = 9, SD = 5.28), t (23) = 0.127, P = 0.900. There was also no statistically significant difference in frequency of negative automatic thoughts from post-test (M = 9, SD = 5.28) to follow-up (M = 8.96, SD = 4.94), t (23) = 0.058, P = 0.955. In the Cognitive group there was no statistically significant difference in frequency of negative automatic thoughts from pre-test (M = 11.52, SD = 5.2) to post-test (M = 11.39, SD = 3.91), t (23) = 0.117, P = 0.908. There was also no statistically significant difference in frequency of negative automatic thoughts from post-test (M = 11.39, SD = 3.91) to follow-up (M = 10.30, SD = 6.12), t (23) = 1.36, P = 0.188.

Clinical significance of change in individual scores on the BDI-II at pre-test, post-test and follow-up To determine clinically meaningful change in scores on the BDI-II, individual scores for symptoms of depression were examined from pre- to post-test for those participants who met the criteria for mild, moderate or severe range of depression (score of >13) as recommended by Beck et al. (1996). The results for each intervention group are presented in Table 2. CB group At pre-test, 14 (61%) of the 23 participants in this group scored >13 on the BDI-II (mild to severe depression). At post-test and again at follow-up, all of these individuals indicated improvement through





Table 2 Clinical effectiveness of three interventions

Post-test

Group

n

Improved (reduced BDI-II score)

Cognitive–behavioural strategies Cognitive focused strategies Behavioural focused strategies

14 15 17

14 (100%) 11 (73%) 14 (82%)

Follow-up

Recovered (score 13 or less on BDI-II)

Improved (reduced BDI-II score)

Recovered (score 13 or less on BDI-II)

8 (53%) 7 (47%) 12 (71%)

14 (100%) 10 (67%) 8 (47%)

8 (53%) 8 (53%) 8 (47%)

n = number of participants scoring >13 on Beck Depression Inventory (BDI-II) at pre-test.

demonstration of a reduction in scores. Furthermore, eight participants (53% of those indicating depression at pre-test) received a score of 13 or less at post-test, indicating recovery (no or minimal depression). This proportion of recovered individuals was maintained at follow-up. Cognitive group At pre-test, 15 (65%) of the 23 participants in this group scored >13 on the BDI-II. At post-test, 73% (n = 11) of these had improved in terms of any reduction of depression scores, with 10 (67%) maintaining improvement at follow-up. A score of 13 or less (recovery) was obtained by seven participants (47%) at post-test and eight participants (53%) at follow-up. Behavioural group At pre-test, 17 participants (71% of the 24 in this group) scored >13 on the BDI-II. Fourteen or 82% of these had improved at post-test, although only eight (47%) maintained these gains at post-test. A score of 13 or less (recovery) was obtained at posttest by 12 (71%), but this status was maintained at follow-up by only eight (47%) of the group.

Discussion The aim of this study was to compare the impact of a combination CB approach with behaviour focused strategies and cognitive focused strategies on symptoms of depression and negative automatic thoughts among a community-based sample of adults with

mild ID. While much research has been conducted into the use of behavioural only or cognitive only strategies to treat depression among the general population (Jacobson et al. 1996; Gortner et al. 1998; Dimidjian et al. 2006), comparatively fewer research studies have been conducted with ID populations (Sturmey 2004, 2006; Lindsay 2006). Our study provides a useful contribution to this under-researched area. Examination of the data showed a postintervention reduction in the mean depression scores of participants in all three interventions. There was, however, no significant difference between groups on this measure. This may signal the overall value of the respective strategies or may indicate the possibility that aspects of attention and group dynamics are important variables in efficacy. In contrast to the Cognitive strategy group and the Behavioural strategy group, individuals in the CB combination group did show a significant reduction in negative automatic thoughts at post-test that was maintained at follow-up. Furthermore, although not significant, there was a small trend for a greater reduction in negative thoughts across time in the Cognitive strategies group than in the Behavioural strategies group. With regard to the overall impact of the interventions, it is important to note the inclusion in the main analysis of the 34% of total participants who were found to be minimally depressed immediately prior to the commencement of the intervention programmes. This status obviously reduces any potential for a post-intervention reduction in symptomatology. Nonetheless, these individuals had been identified at risk by staff and were included in the





study on the basis of our agreement with the partner agencies, and the possibility that participation in the group programmes may deliver a preventative impact. It is also important to consider the clinical significance in any comparison between intervention groups. Most participants with mild to severe depression at the outset showed some improvement in depression scores immediately following participation, irrespective of which group they had attended. However, the proportion who demonstrated improvement in depression scores was larger in the CB group than in the Behavioural and particularly the Cognitive group. At the 6-month follow-up, a greater distinction between groups in the proportion who demonstrated improvement was apparent. Specifically, more of those in the CB group maintained their improvement, while there were relatively fewer in the Behavioural group who showed improvement over time. Examination of recovery rates in those with mild to severe depression at the outset revealed a different pattern across the intervention groups. A greater proportion of the individuals who undertook the Behaviour focused strategies than the Cognitive focused or the combined CB approach appeared to show recovery at post-test. However, this distinction between groups was not evident at the 6-month follow-up, where irrespective of group, approximately half of the participants indicated recovery. In the short term, there thus appears to be some clinical advantage derived from behaviourally focused content, delivered either on its own or in combination with cognitive strategies. Over the longer term, however, any clinical advantage from the behavioural approach does not appear to be maintained. Overall, the findings of this study support the growing body of research indicating that people with mild ID and depressed mood may benefit from the use of CB strategies (Lindsay et al. 1993; Dagnan & Chadwick 1997; Rose et al. 2000; Ghafoori et al. 2010). The findings are also consistent with our previous research demonstrating a sustained reduction in depression symptoms among people with mild ID following participation in group CB treatment programmes (McCabe et al. 2006; McGillivray & McCabe 2007; McGillivray et al. 2008). However, although the combined CB

group appeared to have some clinical advantage in terms of reduced depression scores, as well as a significant reduction in automatic negative thoughts, the relative importance of the cognitive and the behavioural components on depression remains unclear. Despite this, the results of this study confirm the value of behavioural components, particularly in terms of short term clinical effectiveness. There remains a need for replication and for further investigation into the apparent drop in effectiveness of the behavioural strategies over time. It may be that booster sessions in behavioural strategies may promote greater maintenance of the short term gains. It is also possible that the cognitive strategies may exert greater long-term clinical benefit than the behavioural strategies and that a combined CB approach is optimal to maximise long-term outcomes. It is important to exercise caution when interpreting the results of this study. As an evaluation of a naturalistic, community-based intervention, the ability to control factors such as participant characteristics, differences across settings and level of support or other interventions provided to participants was limited. For example, one major limitation of the study is that 26% of the sample reported taking antidepressant medication at pre-test. It is not known how long these participants had been taking antidepressant medications, nor the impact of these on their mood. Of interest, a large number of participants (41%) reported taking other types of medication and the impact of these is not known. It was also not possible to control for other interventions or events that may have occurred in the lives of individuals across the course of the study. As such, we cannot attribute positive changes in depression symptoms exclusively to the effects of participation in the group interventions. A further acknowledged limitation is that the assessments were administered by the therapist who delivered the intervention programmes. However, this was consistent across all groups and for all assessments. Where assistance in completing the instruments was provided, it involved facilitation through reading of the self-report assessment items. Our reliance on the recommendation of staff members as to whether an individual had sufficient cognitive and verbal capacity to participate in the





group interventions is another possible limitation. It has been suggested that prior to undertaking cognitive strategies for the treatment of depression or other mental illness, people with ID should be screened for their readiness to participate and/or be provided with preparatory training as a precursor to participation in cognitive therapy (Willner 2005). Of particular importance are good verbal skills and an ability to differentiate between thoughts, feelings and behaviours (Dagnan et al. 2000; Sams et al. 2006). While we undertook no such formal assessment in our study, reduced symptoms of depression did occur in the participants who undertook the cognitive strategies only and combined CB strategies interventions. Our sample was comprised of individuals who were relatively high functioning and verbally competent and who may thus be most likely to benefit from CB strategies. Further research is required in order to investigate whether comprehension of the cognitive model increases the likelihood of the success of these interventions with this population. This research contributes to a largely underresearched area. Previous studies examining the use of CB strategies with ID populations have utilised multi-component packages consisting of a combination of cognitive and behavioural strategies such as relaxation techniques, social training and cognitive therapy techniques (Sturmey 2004). There remains a need for further investigation of the mechanisms responsible for change. Although conclusions are limited by methodological constraints, our study provides a step towards establishing efficacy while attempting to untangle the particular components that may be responsible for addressing symptoms of depression among people with ID. Further research is clearly necessary before practice recommendations can be made.

References Ailey S. H. (2009) The sensitivity and specificity of depression screening tools among adults with intellectual disabilities. Journal of Mental Health Research in Intellectual Disabilities 2, 45–64. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Association, Washington, DC.

American Psychiatric Association (2000) Practice guidelines for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry 157 (Suppl. ), 1–45. Antonacci D. J. & Attiah N. (2008) Diagnosis and treatment of mood disorders in adults with developmental disabilities. Psychiatric Quarterly 79, 171–92. Beail N. (2003) What works for people with mental retardation? Critical commentary on cognitive–behavioural and psychodynamic psychotherapy research. Mental Retardation 41, 468–72. Beck A. T. (1996) Beck Depression Inventory-II (BDI-II). The Psychological Corporation Harcourt Brace and Company, San Anotonio. Beck A. T., Steer R. A. & Brown M. J. (1996) Manual for the Beck Depression Inventory-II (BDI-II). The Psychological Corporation Harcourt Brace and Company, San Antonio. Coffman S. J., Martell C. R., Dimidjian S., Gallop R. & Hollon S. D. (2007) Extreme nonresponse in cognitive therapy: can behavioral activation succeed where cognitive therapy fails? Journal of Consulting and Clinical Psychology 75, 531–41. Cooper S. A., Smiley E., Morrison J., Williamson A. & Allan L. (2007) Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. British Journal of Psychiatry 190, 27–35. Cuijpers P., van Straten A. & Warmerdam L. (2007) Behavioral activation treatments of depression: a metaanalysis. Clinical Psychology Review 27, 318–26. Cuijpers P., van Straten A., Andersson G. & van Oppen P. (2008) Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology 76, 909–22. Dagnan D. & Chadwick P. (1997) Cognitive therapy with people with learning disabilities: toward a new synthesis. British Journal of Clinical Psychology 36, 485–503. Dagnan D. & Sandhu S. (1999) Social comparison, selfesteem and depression in people with intellectual disability. Journal of Intellectual Disability Research 43, 372–9. Dagnan D., Chadwick P. & Proudlove J. (2000) Toward an assessment of suitability of people with mental retardation for cognitive therapy. Cognitive Therapy and Research 24, 627–36. Davis J. P., Judd F. K. & Herrman H. (1997) Depression in adults with intellectual disability. Part 1: A review. Australian and New Zealand Journal of Psychiatry 31, 232–42. Deb S., Thomas M. & Bright C. (2001) Mental disorder in adults with intellectual disability. 1: Prevalence of functional psychiatric illness among a community-based population aged between 16 and 64 years. Journal of Intellectual Disability Research 45, 495–505.





Dimidjian S., Hollon S. D., Dobson K. S., Schmaling K. B., Kohlenberg R. J., Addis M. E. et al. (2006) Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology 74, 658–70.

Lindsay W. R., Howells L. & Pitcaithly D. (1993) Cognitive therapy for depression with individuals with intellectual disabilities. British Journal of Medical Psychology 66, 135–41.

Disability Act 2006 (Vic). Act No. 23/2006, Victorian Government Printers, Victoria.

Lowry M. A. (1998) Assessment and treatment of mood disorders in persons with developmental disabilities. Journal of Developmental and Physical Disabilities 10, 387–406.

Ekers D., Richards D. & Gilbody S. (2008) A metaanalysis of randomized trials of behavioural treatment of depression. Psychological Medicine 38, 611–23.

McBrien J. A. (2003) Assessment and diagnosis of depression in people with intellectual disability. Journal of Intellectual Disability Research 47, 1–13.

Ghafoori B., Ratanasiripong P. & Holladay C. (2010) Cognitive behavioral group therapy for mood management in individuals with intellectual disabilities: a pilot study. Journal of Mental Health Research in Intellectual Disabilities 3, 1–15. Gibbs S. M., Brown M. J. & Muir W. J. (2008) The experience of adults with intellectual disabilities and their carers in general hospitals: a focus group study. Journal of Intellectual Disability Research 52, 1061–77. Glenn E., Bihm E. M. & Lammer W. J. (2003) Depression, anxiety and relevant cognitions in persons with mental retardation. Journal of Autism and Developmental Disorders 33, 69–76. Gortner E. T., Gollan J. K., Dobson K. S. & Jacobson N. S. (1998) Cognitive–behavioral treatment for depression: relapse prevention. Journal of Consulting and Clinical Psychology 66, 377–84. Hatton C. (2002) Psychosocial interventions for adults with intellectual disabilities and mental health problems. Journal of Mental Health 11, 357–73. Hollon S. D. & Kendall P. C. (1980) Cognitive selfstatements in depression: development of an automatic thoughts questionnaire. Cognitive Therapy and Research 4, 383–95. Infrapsych CBT program for depression (1999) Available at: http://www.infrapsych.com/root/1033/Depression/ Depression_CBTMain.htm (retrieved 11 October 2003). Jacobson N. S., Dobson K. S., Truax P. A., Addis M. E., Koerner K., Gollan J. K. et al. (1996) A component analysis of cognitive–behavioral treatment for depression. Journal of Consulting and Clinical Psychology 64, 295–304. Lejuez C. W., Hopko D. R. & Hopko S. D. (2001) A brief behavioral activation treatment for depression: treatment manual. Behavior Modification 25, 255–86. Lejuez C. W., Hopko D. R., Acierno R., Daughters S. B. & Pagoto S. L. (2011) Ten year revision of the brief behavioral activation treatment for depression: revised treatment manual. Behavior Modification 35, 111–61. Lindsay W. R. (2006) That poor laddie cannae tell his thoughts fae his actions: a reply to Sturmey. Journal of Applied Research in Intellectual Disabilities 19, 119–20.

McCabe M. P., McGillivray J. A. & Newton D. C. (2006) Effectiveness of treatment programmes for depression among adults with mild/moderate intellectual disability. Journal of Intellectual Disability Research 50, 239–47. McGillivray J. A. & Kershaw M. M. (2013) The impact of staff initiated referral and intervention protocols on symptoms of depression in people with mild intellectual disability. Research in Developmental Disabilities 34, 730–8. McGillivray J. A. & McCabe M. P. (2007) Early detection of depression and associated risk factors in adults with mild/moderate intellectual disability. Research in Developmental Disabilities 28, 59–70. McGillivray J. A., McCabe M. P. & Kershaw M. M. (2008) Depression in people with intellectual disability: an evaluation of a staff-administered treatment program. Research in Developmental Disabilities 29, 524–36. Manos R. C., Kanter J. W. & Luo W. (2011) The behavioral activation for depression scale – short form: development and validation. Behavior Therapy 42, 726–39. Moodgym Training Program (2004) The Australian National University. Available at: http:// moodgym.au.edu.au/ (retrieved 14 October 2003). Morin D., Cobigo V., Rivard M. & Lepine M. (2010) Intellectual disabilities and depression: how to adapt psychological assessment and intervention. Canadian Psychology 51, 185–93. Moss S. (2001) Assessment: conceptual issues. In: Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental Retardation (ed. N. Bouras), pp. 18–37. Cambridge Press, London. National Institute for Clinical Excellence (2004) Depression: management of depression in primary and secondary care, Clinical Guideline No. 23, London. Nezu C. M., Nezu A. M., Rothenberg J. L., DelliCarpini L. & Groag I. (1995) Depression in adults with mild mental retardation: are cognitive variables involved? Cognitive Therapy and Research 19, 227–39. Perez-Achiaga N., Nelson S. & Hassiotis A. (2009) Detecting depression: Instruments for the detection of depressive symptoms in people with intellectual disabilities: a systematic review. Journal of Intellectual Disabilities 13, 55–76.





Rose J., West C. & Clifford D. (2000) Group interventions for anger in people with intellectual disabilities. Research in Developmental Disabilities 21, 171–81. Sams K., Collins S. & Reynolds S. (2006) Cognitive therapy abilities in people with learning disabilities. Journal of Applied Research in Intellectual Disabilities 19, 25–33. Smiley E. & Cooper S. (2003) Intellectual disabilities, depressive episode, diagnostic criteria and diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation (DC-LD). Journal of Intellectual Disability Research 47, 62–71. Stenfert Kroese B., Dagnan D. & Konstantinos L. (eds) (1997) Cognitive–Behaviour Therapy for People with Learning Disabilities. Routledge, London. Sturmey P. (2004) Cognitive therapy with people with intellectual disabilities: a selective review and

critique. Clinical Psychology and Psychotherapy 11, 222–32. Sturmey P. (2006) On some recent claims for the efficacy of cognitive therapy for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities 19, 109–17. Sturmey P. (2009) Behavioral activation is an evidencebased treatment for depression. Behavior Modification 33, 818–29. White P., Chant D., Edwards N., Townsend C. & Waghorn G. (2005) Prevalence of intellectual disability and comorbid mental illness in an Australian community sample. Australian and New Zealand Journal of Psychiatry 39, 395–400. Willner P. (2005) Readiness for cognitive therapy in people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities 19, 5–16.

Accepted 25 November 2013


This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities.

Cognitive Behavioral Therapy for Depressed Adults with Mild Intellectual Disability: A Pilot Study.

Why do we need national guidelines for adults with intellectual disability and dementia?

Stability of cognitive performance in children with mild intellectual disability.

Intellectual Disability, Mild Cognitive Impairment, and Risk for Dementia.

Modification of motivational interviewing for use with people with mild intellectual disability and challenging behaviour.

Structured Medication Review to Improve Pharmacotherapy in People with Intellectual Disability and Behavioural Problems.

Changes in catastrophizing and depressed mood during and after early cognitive behaviorally oriented interventions for pain.

Important aspects of participation and participation restrictions in people with a mild intellectual disability.

A Review of Self-Management Interventions for People With Dementia and Mild Cognitive Impairment.

Letter: Recruitment of patients with both epilepsy and intellectual disability.

Is EMDR an effective treatment for people diagnosed with both intellectual disability and post-traumatic stress disorder?

Young People with Intellectual Disability Transitioning to Adulthood: Do Behaviour Trajectories Differ in Those with and without Down Syndrome?

Conceptualizing inclusive research with people with intellectual disability.

Do we need GPs?

Consequences of Learned Helplessness and Recognition of the State of Cognitive Exhaustion in Persons with Mild Intellectual Disability.

The effectiveness of psychosocial interventions for children with a psychiatric disorder and mild intellectual disability to borderline intellectual functioning: A systematic literature review and meta-analysis.

Translating cognitive and everyday activity deficits into cognitive interventions in mild dementia and mild cognitive impairment.

Choice and control for people ageing with intellectual disability in group homes.

Glucometer for kids: what do we need?

Asthma in intellectual disability: are we managing our patients appropriately?

[Schooling and care of mild intellectual disability children].

How do people with intellectual disabilities view abuse and abusers?

Co-occurring disorder clusters in adults with mild and moderate intellectual disability in residential treatment settings.