Effectiveness of treatment programmes for depression among adults with mild/moderate intellectual disability

Journal of Intellectual Disability Research doi 101111j1365-2788200500772x

pp

ndash

239

The Authors Journal Compilation copy

Blackwell Publishing Ltd

Blackwell Science LtdOxford UKJIRJournal of Intellectual Disability Research

-


4239347

Original Article

Treatment for depressionM P McCabe

et al

Correspondence Marita P McCabe PhD FAPS School of Psychology Deakin University

Burwood Highway Burwood Victoria

Australia (e-mail maritamdeakineduau)

Effectiveness of treatment programmes for depression among adults with mildmoderate intellectual disability

M P McCabe J A McGillivray amp D C Newton

School of Psychology Deakin University Victoria Australia

Abstract

Background

The current study describes the devel-opment and evaluation of group treatment pro-gramme for people with mildmoderate intellectual disability (ID)

Methods

A total of

participants (

males

females) completed the treatment programme and

participants (six males nine females) comprised a control group

Results

Compared to the control group the inter-vention group showed an improvement in levels of depression positive feelings about the self and lower levels of automatic negative thoughts after the intervention These changes were maintained at

-month follow-up

Conclusions

These results demonstrate that inter-vention programmes are effective for the treatment of depression among people with ID

Keywords

depression efficacy intellectual disability treatment programme

Introduction

The existence of depression and other mood disor-ders among people with intellectual disability (ID) is now well accepted (Menolascino

) and it has

been argued that depressed mood is one of the most common psychiatric symptoms experienced by indi-viduals with ID (Nezu

et al

) In fact claims have been made that individuals with ID may be at a higher risk of depression than the general popula-tion (Meins

) Studies investigating depressive symptoms among people with ID typically report very high rates of depression ranging from

(Marston

et al

) to

(Meins

) A review of the depression literature suggests that as many as

in every

people with ID may experience clinical depression at some stage (see Lowry

) This find-ing coupled with the likelihood that prevalence reports of depression in people with ID are an under-estimate due to difficulties associated with both detection and diagnosis (OrsquoBrien

) highlights the significance of this issue for this population

Research into cognitive factors related to depres-sive symptoms in individuals with ID has high-lighted some important relationships For example the frequency of negative automatic thoughts self-reproach and feelings of hopelessness have been shown to be significantly related to depressive symptoms among individuals with mild ID (Nezu

et al

) Depressed individuals with mild ID also report lower rates of self-reinforcement than non-depressed individuals (Nezu

et al

) Given the above associations it is not surprising to find that there is a strong association between self-esteem and depression among people with ID For example Dagnan amp Sandhu (

) found a nega-tive relationship between depression and self-

Journal of Intellectual Disability Research

M P McCabe

et al

bull

Treatment for depression240



esteem among people with mild and moderate ID These findings suggest that cognitive factors are strongly associated with depression among people with ID and so there is a need for cognitive factors to be addressed in the treatment of depressive dis-orders in this population

To date interventions for depressive disorders in individuals with ID have generally been restricted to the more severe and established cases (OrsquoBrien

) and treatment has been predominantly phar-macological (Meins

) Despite the widespread endorsement of cognitive behavioural therapy (CBT) programmes for individuals with depression in the general population and the recent accep-tance that cognitive approaches are appropriate for individuals with mild ID (Dagnan amp Chadwick

) there is a paucity of research into the effi-cacy of CBT programmes for the treatment of depression in this population A review paper that evaluated the effectiveness of cognitive approaches for people with ID found therapies that only focused on cognitions have limited effectiveness (Sturmey

)A review of treatment literature identified one case

study of an individual with mildmoderate ID who demonstrated an improvement in crying behaviour and behavioural symptoms of depression following the administration of CBT techniques (Dagnan amp Chadwick

) Another study showed an average

reduction in baseline depression scores of five individuals with mildmoderate ID at the conclusion of a CBT programme (Lindsay

) Further a CBT group intervention programme designed to reduce inappropriately expressed anger in people with ID was not only successful in significantly reduc-ing levels of anger but also levels of depression (Rose

et al

) In this study the use of CBT techniques applied within a problem-solving framework was found to encourage a sense of self-regulation among the participants

One of the distinct advantages of a CBT approach is that it equips individuals with skills that can be applied preventatively and subsequent to participa-tion in the intervention programme Clearly more research needs to be conducted into the efficacy of the CBT approach in treating depression in individ-uals with mildmoderate ID The current study was designed to evaluate the effectiveness of a CBT inter-vention programme designed to reduce levels of

depression among people with mildmoderate ID Both people who were depressed as well as those evidencing depressive symptoms and who were at risk of developing depression were included as partici-pants in the study

The programme was designed to enhance social skills promote participation in social activities iden-tify and change negative cognitions and somatic com-plaints Participants were taught how to self-monitor their moods and thoughts and were trained to self-reinforce adaptive behaviours Emphasis was placed upon reshaping cognitive distortions and on developing a more positive interpretation of events Techniques of modelling role-play and structured-feedback were used to develop these skills A group format was deemed to be beneficial as participants were able to practise skills with peers and operate within a social environment where trust and respect for others could be experienced

Method

Participants

A total of

participants (

males

females) com-pleted the intervention programme Fifteen partici-pants (six males nine females) comprised a control group All participants were currently working in supported employment designed for people with mildmoderate ID Participants were recruited from these workplace settings The mean age of the inter-vention group was

SD

=

and the mean age of the control group was

SD

=

Participants ranged in age from

to

years Par-ticipantsrsquo scores on the Beck Depression Inventory (BDI-II) were used to select individuals to be invited to participate in the study The mean BDI score for the intervention group was

SD

=

and the mean BDI score for the control group was

SD

=

Those participants who scored within the minimal depression range and above were eligible to take part in the programme This included both people with clinical depression as well as those evidencing depressive symptoms who were at risk of developing depression In addition the potential par-ticipants were required to have sufficient language skills to participate in the intervention programme The

participants who were allocated to the control group for the study acted as participants in the pro-


M P McCabe

et al

bull




gramme group after the

-month follow-up period Data were gathered at pretest and post-test for this group of respondents Thirty-four participants who met the requirements for inclusion in the study were randomly allocated to the intervention or control group These employment centres provide light assembly line factory work for this group of people The workers are generally picked up for work from the residences by buses and returned home in the evening A high level of supervision is provided in the work setting the workers generally work about

h each day and they received some remuneration for their services

Materials

Beck Depression Inventory II (BDI-II) (Beck

)

The BDI-II is a

-item self-report scale designed to measure the severity of depression in adults and ado-lescents aged

years and over Each item consists of four statements organized according to the severity of their content The participants are required to select the statement from each item that best repre-sents their current mood over the last two weeks The original wording of each of the items was deemed simple enough for use with individuals with mildmoderate ID and thus remained unmodified The BDI has been successfully used to assess depression in people with ID including in a study by Lindsay (

) where it was used to evaluate the effectiveness of cognitive behaviour therapy interventions for the treatment of depression

Social Comparison Scale (SCS) (Allen amp Gilbert

)

The SCS scale is designed to measure social rank-related comparisons social attractiveness compari-sons and comparisons of being accepted by others The SCS has been modified for use with individuals with ID (Dagnan amp Sandhu

) and the simplified wording of the items of the scale was selected for use in the current study The response scale involved the selection of one of the bipolar constructs to represent how participants generally feel with the option of selecting an lsquoin betweenrsquo state Use of the SCS with the modified wording of the items has been shown to have good concurrent validity and a psychometric structure similar to that of the original scale (Dagnan amp Sandhu

)

Rosenberg Self-esteem Scale (RSES) (Rosenberg et al

)

The RSES generates a global concept of self-esteem that is considered part of the wider concept of self-worth The current study utilized a six-item version of RSES that had already been adapted for use with individuals with ID (Dagnan amp Sandhu

) The original response categories were retained for use in the current study (lsquonever truersquo lsquohardly ever truersquo lsquosometimes truersquo lsquooften truersquo and lsquoalways truersquo) Psy-chometric analysis of this modified version of the RSES showed that it has good concurrent validity and good internal reliability (Dagnan amp Sandhu

)

Automatic Thoughts Questionnaire ndash Revised (ATQ-R) (Kendall amp Hollon

)

The ATQ-R consists of

items that measure the frequency of automatic negative statements about the self Negative self-statements have been shown to play a critical role in various psychopathologies par-ticularly depression (Schwartz amp Garamoni

) The items are originally measured on a

-point Likert scale For the purposes of this study however the scale was reduced to a

-point Likert scale Partici-pants were required to rate the frequency of occur-rence during the previous week of each item on a scale of lsquonot at allrsquo lsquosometimesrsquo or lsquofrequentlyrsquo The authors report that the psychometric properties of the ATQ-R are comparable to those of the original ATQ which indicate excellent internal consistency and good concurrent validity with measures of depression (Hollon amp Kendall

)

Cognitive behavioural intervention programme

The intervention programme was designed to be run over a period of

weeks Each session ran for approximately

h Each session was designed to cover one to two key areas and to allow participants ample time to discuss understand and develop skills in these areas Comprehensive handouts on the skills and strategies discussed were provided at each session The intervention programme was designed to create an environment where group members felt comfortable sharing their personal concerns with others and where they were able to learn skills to improve their quality of life Material


M P McCabe

et al

bull




used in the creation of the programme was taken from a variety of research including Infrapsych CBT Program (nd) Lindsay

et al

(

) Moodgym Training Program (

) and Dagnan amp Chadwick (

)The following is a programme outline

Session

introduction ndash getting to know one another

The general aim of session was to provide group members with a comfortable environment in which they could feel safe in discussing personal issues derive an understanding of what depressive symp-toms are and come to understand why they had been selected to participate in the group Session was also designed to teach them the skills to improve or main-tain their physical health

Key activities in this session were as followsbull Introductions and outline of programmebull Explanation of what it means to feel depressed andbull Discussion of how looking after onersquos physical health (exercise sleep eating habits) can improve onersquos mood

Session friends and fun

The aim of session was to assist group mem-bers in understanding the importance of having a strong social support network and if necessary facilitate the improvement of this area of their lives Group members were also taught the importance of engaging in pleasant activities to increase their mood and strengthen or extend social networks Key activities in this session were as followsbull Discussion about the importance of having a strong support network ndash group members asked to share their support network with the groupbull Activity scheduling and promotion of enjoyable activities andbull Group members were given a handout on commu-nity resources (eg social groups recreational groups etc) and encouraged to utilize these resources

Session liking yourself

The aim of session was to create an understanding of the link between thinking and mood Group mem-bers were taught strategies to try and reduce negative

thoughts and increase positive ones Key activities in the session were as followsbull Explanation of the link between feeling depressed and onersquos view of selfbull Discussion of how group members viewed themselvesbull Group members completed a handout listing their positive qualities and shared these with the groupbull The group was asked to list some positive qualities that they admired in other group membersbull Strategies for decreasing negative self-talk and thinking errors andbull Strategies for increasing positive self-talk

Session dealing with problems

The general aim of session was to assist group members with their problems by providing them with a structured approach to problem-solving This was reinforced through the use of role-playing and mod-elling Key activities in the session were as followsbull Discussion of recent problems that have arisen in group membersrsquo livesbull Structured problem-solvingbull Assertiveness skillsbull Role-play activity modelling effective solutions to problems andbull Group discussion about these examples and provi-sion of structured feedback

Session looking to the future ndash setting goals

The general aim of session was to provide a com-prehensive and detailed overview of the key areas covered by the programme and to remind group members of the strategies they had been taught In addition group members were encouraged to con-tinue to master these skills beyond the course and set personal goals for their future Key activities for session were as followsbull Discussion of mood over the past five weeksbull Detailed review of the past four sessionsbull Discussion of goals for the future andbull Assistance in setting realistic and attainable goals

Procedure

Participants who were eligible to participate in the intervention programme in terms of their scores on the BDI were given a plain language statement out-


M P McCabe et al bull Treatment for depression243

The Authors Journal Compilation copy Blackwell Publishing Ltd

lining the programme and a consent form to sign The managers at the Supported Employment Set-ting informed the researchers on the level of ID of the respondents This information was available from records on each individual that they had on file They also identified people who they suspected as evidencing depressive symptoms These people were then administered the BDI Any person who was deemed not able to participate in the pro-gramme due to limited language skills was not selected for inclusion in the study by the managers at the work centre They then completed the ques-tionnaires outlined in the Materials section The intervention programme was delivered to a total of participants (three groups of three individuals five groups of four individuals and one group of five individuals) The programme ran for h each week for a period of weeks on the premises of each grouprsquos workplace The intervention programme was initially delivered to participants while partic-ipants formed the control group The participants in the intervention group completed the questionnaires week after the conclusion of the programme The control group participants completed the question-naires at time then again weeks after time The participants in the control group then partici-pated in the intervention programme Follow-up assessment was conducted months following the conclusion of the programme on of the partici-pants who completed the intervention Only one respondent dropped out of the study from com-mencement to -month follow-up

Results

Descriptive data (means and standard deviations) for the treatment and control group at three different assessment times initial assessment (pretest) post-test and follow-up (portion of treatment group only) are presented in Table

A repeated measures multivariate analysis of variance was performed in order to determine the changes in the intervention and control group in the level of depressive symptomatology and other vari-ables over time The dependent variables were scores on the BDI-II SCS RSES and ATQ-R The inde-pendent variables were group (intervention control) and time of assessment (pretest post-test follow-up) Investigation of assumptions concerning normality linearity both univariate and multivariate outliers multicollinearity and homogeneity of variance was conducted No violations were noted

There was a statistically significant difference between the groups at the three times of assess-ment on the combined dependent variables F() = P lt Wilksrsquo Lambda = partial η2 = When the results for the depen-dent variables were considered separately using a Bonferroni adjusted alpha level of the fol-lowing variables reached statistical significance depression F() = P lt partial η2 = social comparison F() = P lt partial η2 = and frequency of nega-tive automatic thoughts F() = P lt partial η2 = Post hoc comparisons using the

Table 1 Descriptive data (means and standard deviations) for the treatment and control groups at three assessment times on the BeckDepression Inventory (BDI-II) Social Comparison Scale (SCS) Rosenberg Self-esteem Scale (RSES) and Automatic Thoughts Question-naire ndash Revised (ATQ-R)

Variable

Pretest Post-test Follow-up

Treatment Control Treatment Control Treatment

n ==== 34 n ==== 15 n ==== 34 n ==== 15 n ==== 18M SD M SD M SD M SD M SD

BDI 1456 451 1360 444 571 454 1280 423 539 277SCS 937 122 860 121 993 117 880 113 989 113RSES 2138 455 2120 545 2362 429 2120 460 2639 358ATQ-R 703 336 740 356 415 360 687 358 244 206




Tukey honestly significent difference (HSD) test indicated that there were no significant differences between the treatment group and the control group at pretest on any of the variables

The mean score on depression for the treatment group at post-test (M = SD = ) was signifi-cantly lower than the mean score on depression for the treatment group at pretest (M = SD = ) This indicated that the depression scores of the treatment group were significantly lower after completing the intervention programme The mean score of the treatment group at post-test on social comparison (M = SD = ) was significantly higher than the mean score of the control group at post-test (M = SD = ) This indicated that those individuals who participated in the intervention programme viewed themselves more positively when comparing themselves to others than those who did not complete the intervention programme The mean score of the treatment group at post-test on frequency of negative automatic thoughts (M = SD = ) was significantly lower than the mean score of the treatment group on frequency of negative automatic thoughts at pretest (M = SD = ) This demonstrated that participation in the interven-

tion programme significantly reduced the frequency of negative automatic thoughts

There were no significant differences on any of the variables for the treatment group between post-test and follow-up This indicated that there were no significant changes between the scores of this group following the intervention programme and at -month follow-up Thus it appears that the impact of the intervention group was sustained over time

In order to evaluate the clinical significance of the findings (see Jacobson amp Truax ) the number and percentage of respondents in both the clinical and control group who made a small (ndash improved score) and also more substantial improvement (gt improved score) on each of the dependent variables (BDI-II SCS RSES ATQ-R) were determined (see Table ) Because there has been limited research using the above measures with people with ID it was not possible to calculate the statistic summarized in Jacobson amp Truaxrsquos () paper Knowledge of the distribution of the scores on these scales for this population is not known return to normal functions has not been defined and normative data have not been gathered

Table 2 Number and percentage of respondents in both the clinical and control group who made a small improvement (ndash) or a substantialimprovement (gt) on each of the dependent variables

Variable

Small improvement (0ndash3)

Substantial improvement (gtgtgtgt3) Deterioration

End treatment Follow-up



n n n n n n

Treatment groupBDI 0 0 5 2632 19 100 3 1579 0 0 11 5789SCS 14 7369 6 3158 0 0 0 0 5 2632 13 6842RSES 5 2632 10 5264 11 5789 4 2105 3 1579 5 2631ATQ-R 4 2105 8 4211 12 6316 4 2105 3 1579 7 3684

Control groupBDI 6 40 1 1333 13 4667SCS 13 8667 12 0 0 1333RSES 8 5333 10 667 2 40ATQ-R 9 60 8 667 6 3333

BDI Beck Depression Inventory SCS Social Comparison Scale RSES Rosenberg Self-esteem Scale ATQ-R Automatic Thoughts Questionnaire ndash Revised




The results demonstrated that compared to the control group a greater percentage of the respon-dents in the programme group evidenced a substantial level of improved function in levels of depression self-esteem and level of negative auto-matic thoughts (see Table ) In contrast at the con-clusion of treatment the control group showed a greater deterioration in levels of depression self-esteem and frequency of automatic thoughts Fol-lowing participation in the programme a greater percentage of respondents in the control group made a small improvement in self-esteem and sub-stantial improvements in levels of depression and frequency of automatic thoughts

Discussion

The findings of the study indicated that participation in the intervention programme had a significant impact on depressive symptoms and other psychoso-cial variables The results indicated that the treatment group had significantly lower depression scores after completing the intervention programme The treat-ment group also experienced an increase in social comparison scores when compared to the control group who did not complete the programme This indicates that those people with ID who undertook the intervention programme were more likely to eval-uate themselves more positively when comparing themselves to others Finally the treatment group experienced significantly fewer negative automatic thoughts after completing the intervention programme

As well as evaluating the statistical significance of the effectiveness of the treatment programme in the current study the clinical significance of the pro-gramme was also evaluated This was an important process because as outlined by Jacobson amp Truax () clinical significance provides information on the actual efficacy of the programme the extent to which there is a recognizable difference in attitudes and behaviour after treatment an elimination of the presenting problem and a better state of functioning at the conclusion of the programme In the current study it was difficult to evaluate the clinical signifi-cance of the findings as there are limited data avail-able on the changes in questionnaire scores that would constitute a clinically meaningful result for

each of the scales used in the current study However the data did indicate that treatment led to improve-ments in levels of depression self-esteem and nega-tive automatic thoughts This applied to both the treatment condition and the control group once they completed treatment These findings were only par-tially maintained at follow-up

These findings demonstrate the effectiveness of the intervention programme in reducing the fre-quency and severity of depressive symptomatology It also indicates that the intervention programme is effective in increasing participantsrsquo sense of self-worth and in increasing participantsrsquo tendencies to view themselves more positively when making social comparisons At -month follow-up there were no significant changes from the assessment scores at post-test which would indicate that these positive changes were sustained over time An examination of the number of participants in the treatment group who maintained positive outcomes suggested that some treatment effects were maintained but not to the same level as at the end of treatment These results support previous studies concerning the effectiveness of CBT approaches for the treat-ment of depression (Lindsay Rose et al ) and suggest that the behavioural aspect is an important addition to cognitive therapy approaches (Sturmey )

Participantsrsquo comments on the efficacy of the inter-vention group indicated that they were happy they had participated in the group and felt that it had been an enjoyable experience for them Many partic-ipants stated that the information they received throughout the programme was lsquointerestingrsquo (Anne) and was lsquorelated easily to their livesrsquo (Paul)

One female participant felt that the information would lsquohelp me deal with any issues that come up in my lifersquo (Sue)

Another male participant commentedlsquoI learned a lot more about myself and now I know what depression isrsquo (Jimmy)

The feeling of social connectedness that the group format provided was frequently mentioned Partici-pants liked the fact that they could express them-selves openly and honestly in an environment where rules relating to confidentiality and trust had been clearly outlined

One female participant commented




lsquoI liked the fact that I could get other peoplersquos opinions on my problems itrsquos good to get other peoplersquos ideas everyone has a different point of viewrsquo (Debbie)

Similarly another female participant stated

lsquoI felt like I could talk openly in the group and get some helpful feedback on my problems and the way I think about thingsrsquo (Louise)

Participants liked the fact that the groups consisted of only ndash people and generally felt that groups any bigger than this would detract from the comfort they felt in the group environment Highlights of the pro-gramme were the sessions on assertiveness where participants were given the opportunity to role-play and the friends and fun session Participants par-ticularly liked the handout on social and recreational clubs and societies that was distributed in this ses-sion Many participants made contact with these societies throughout the course of the programme and were very excited about the prospect of making new social contacts Several participants expressed a desire to make new friends and go out more often but until they were exposed to the programme had lacked the necessary resources to do so

All participants found the handouts to be extremely useful One male participant commented on the importance of these handouts to him

lsquoI took them home and really thought about them and thought about ways to improve myselfrsquo (Dave)

Another male participant reported how he used them to help him control his behaviour

lsquoI think the handouts were really good I think theyrsquove helped me a lot with my anger when-ever I feel angry I go and read them so I donrsquot get so aggressive when Irsquom playing basketball anymore Mumrsquos really happy I did the programrsquo (John)

Drawing on reports from participants who com-pleted the intervention programme it appears that it was very important for participants to feel that they were in a safe and respectful environment They found it helpful to have time to discuss their personal problems to receive feedback on these problems and to have information that they could take away with them and review at a later stage They found it par-ticularly useful and to be provided with resources that

allowed them to develop their social circle and become more active in their everyday lives Overall participants felt that being part of the intervention programme had been a positive experience for them However given that it was implemented in a group setting there are no guarantees that all participants attended to all aspects of the programme An evalu-ation of attention needs to be incorporated into future evaluations of the programme

The present study demonstrated that the CBT intervention programme was effective in reducing depressive symptoms The multi-pronged approach of this programme was a particularly important fea-ture Consistent with the findings of Meins () social support and social interactions were important aspects to address in the intervention The interven-tion also improved the feelings that participants had about themselves in comparison to others and led to a decrease in the frequency of negative automatic thoughts However we did not evaluate changes in emotional expression or behaviour in the work set-ting These are important variables to include in any future evaluation of this programme However the findings from the current study suggest that the CBT intervention programme did successfully reduce cog-nitive and behavioural manifestations of depression These changes were evident in both the short (post-test) and medium term (-month follow-up) These findings are extremely positive in terms of the effectiveness of such a programme in addressing depressive symptoms among people with mild and moderate levels of ID

The findings from the current study seem to sug-gest that CBT may be an effective intervention for people with mildmoderate ID However it is too early to generalize these findings to people with mildmoderate ID from other settings Further the relative effectiveness of this programme for people with major depression as opposed to those with depressive symp-toms needs to be evaluated The CBT programme that was developed for the current study needs to be refined based on the feedback from respondents and the research findings from this study This pro-gramme should then be manualized and evaluated with a larger sample of people with mild and moder-ate ID from a range of backgrounds Further the long-term effectiveness of the programme needs to be evaluated by following up participants for a period of at least months




Acknowledgements

We wish to thank beyondblue and Victorian Centre of Excellence for providing the funding to allow this research

References

Allen S amp Gilbert P () A social comparison scale psychometric properties and relationship to psychopa-thology Personality and Individual Differences ndash

Beck A () Beck Depression Inventory-II (BDI-II) The Psychological Corporation Harcourt Brace San Antonio

Dagnan D amp Chadwick P () Cognitive behaviour therapy for people with learning disabilities assessment and intervention In Cognitive Behaviour Therapy with People with Learning Disabilities (eds B Stenfert-Kroese D Dagnan amp K Loumides) pp ndash Routledge London

Dagnan D amp Sandhu S () Social comparison self-esteem and depression in people with intellectual disability Journal of Intellectual Disability Research ndash

Hollon S amp Kendall P () Cognitive self statements in depression development of an automatic thoughts ques-tionnaire Cognitive Therapy and Research ndash

Infrapsych CBT Program for depression (nd) Available at httpwwwinfrapsychcomrootDepressionDepression_CBTMainhtm (retrieved October )

Jacobson N S amp Truax P () Clinical significance a statistical approach to defining meaningful change in psy-chotherapy research Journal of Consulting and Clinical Psychology ndash

Kendall P C amp Hollon S D () Automatic Thoughts Questionnaire In Measures for Clinical Practice A Sour-cebook (eds K Corcoran amp J Fischer) pp ndash Free Press New York

Lindsay W R () Cognitive therapy Psychologist ndash

Lindsay W R Howells L amp Pitcaithly D () Cognitive therapy for depression with individuals with intellectual disabilities British Journal of Medical Psychology ndash

Lowry M A () Assessment and treatment of mood disorders in persons with developmental disabilities Journal of Developmental and Physical Disabilities ndash

Marston G M Perry D W amp Roy A () Manifesta-tions of depression in people with intellectual disability Journal of Intellectual Disability Research ndash

Meins W () Prevalence and risk factors for depressive disorders in adults with intellectual disability Australia and New Zealand Journal on Developmental Disabilities ndash

Meins W () A new depression scale designed for use with adults with mental retardation Journal of Intellectual Disability Research ndash

Menolascino F J () Mental retardation and the risk nature and type of mental illness In Depression in Men-tally Retarded Children and Adults (eds A Dosen amp F J Menolascino) pp ndash Logon Press Leiden

Moodgym Training Program () The Australian National University Available at httpmoodgymanueduau (retrieved October )

Nezu C M Nezu A M Rothenberg J Dellcarpini L amp Groag I () Depression in adults with mild mental retardation are cognitive variables involved Cognitive Therapy and Research ndash

OrsquoBrien G () Dual diagnosis in offenders with intel-lectual disability setting research priorities a review of research findings concerning psychiatric disorder (excluding personality disorder) among offenders with intellectual disability Journal of Intellectual Disability Research ndash

Rose J West C amp Clifford D () Group interventions for anger in people with intellectual disabilities Research in Developmental Disabilities ndash

Rosenberg M Schooler C amp Schoenbach C () Self-esteem and adolescent problems modeling reciprocial effects American Sociological Review ndash

Schwartz R M amp Garamoni G L () Cognitive bal-ance and psychopathology Clinical Psychology Review ndash

Sturmey P () Cognitive therapy with people with intel-lectual disabilities a selective review and critique Clinical Psychology and Psychotherapy ndash

Accepted June


M P McCabe

et al

bull




esteem among people with mild and moderate ID These findings suggest that cognitive factors are strongly associated with depression among people with ID and so there is a need for cognitive factors to be addressed in the treatment of depressive dis-orders in this population

To date interventions for depressive disorders in individuals with ID have generally been restricted to the more severe and established cases (OrsquoBrien

) and treatment has been predominantly phar-macological (Meins

) Despite the widespread endorsement of cognitive behavioural therapy (CBT) programmes for individuals with depression in the general population and the recent accep-tance that cognitive approaches are appropriate for individuals with mild ID (Dagnan amp Chadwick

) there is a paucity of research into the effi-cacy of CBT programmes for the treatment of depression in this population A review paper that evaluated the effectiveness of cognitive approaches for people with ID found therapies that only focused on cognitions have limited effectiveness (Sturmey

)A review of treatment literature identified one case

study of an individual with mildmoderate ID who demonstrated an improvement in crying behaviour and behavioural symptoms of depression following the administration of CBT techniques (Dagnan amp Chadwick

) Another study showed an average

reduction in baseline depression scores of five individuals with mildmoderate ID at the conclusion of a CBT programme (Lindsay

) Further a CBT group intervention programme designed to reduce inappropriately expressed anger in people with ID was not only successful in significantly reduc-ing levels of anger but also levels of depression (Rose

et al

) In this study the use of CBT techniques applied within a problem-solving framework was found to encourage a sense of self-regulation among the participants

One of the distinct advantages of a CBT approach is that it equips individuals with skills that can be applied preventatively and subsequent to participa-tion in the intervention programme Clearly more research needs to be conducted into the efficacy of the CBT approach in treating depression in individ-uals with mildmoderate ID The current study was designed to evaluate the effectiveness of a CBT inter-vention programme designed to reduce levels of

depression among people with mildmoderate ID Both people who were depressed as well as those evidencing depressive symptoms and who were at risk of developing depression were included as partici-pants in the study

The programme was designed to enhance social skills promote participation in social activities iden-tify and change negative cognitions and somatic com-plaints Participants were taught how to self-monitor their moods and thoughts and were trained to self-reinforce adaptive behaviours Emphasis was placed upon reshaping cognitive distortions and on developing a more positive interpretation of events Techniques of modelling role-play and structured-feedback were used to develop these skills A group format was deemed to be beneficial as participants were able to practise skills with peers and operate within a social environment where trust and respect for others could be experienced

Method

Participants

A total of

participants (

males

females) com-pleted the intervention programme Fifteen partici-pants (six males nine females) comprised a control group All participants were currently working in supported employment designed for people with mildmoderate ID Participants were recruited from these workplace settings The mean age of the inter-vention group was

SD

=

and the mean age of the control group was

SD

=

Participants ranged in age from

to

years Par-ticipantsrsquo scores on the Beck Depression Inventory (BDI-II) were used to select individuals to be invited to participate in the study The mean BDI score for the intervention group was

SD

=

and the mean BDI score for the control group was

SD

=

Those participants who scored within the minimal depression range and above were eligible to take part in the programme This included both people with clinical depression as well as those evidencing depressive symptoms who were at risk of developing depression In addition the potential par-ticipants were required to have sufficient language skills to participate in the intervention programme The

participants who were allocated to the control group for the study acted as participants in the pro-


M P McCabe

et al

bull







Materials


)

The BDI-II is a





)



)


)



)


)






)






M P McCabe

et al

bull





et al

(




Session













Procedure






Results





Variable




BDI 1456 451 1360 444 571 454 1280 423 539 277SCS 937 122 860 121 993 117 880 113 989 113RSES 2138 455 2120 545 2362 429 2120 460 2639 358ATQ-R 703 336 740 356 415 360 687 358 244 206










Variable






n n n n n n








Discussion




























Acknowledgements


References























Accepted June


M P McCabe

et al

bull







Materials


)

The BDI-II is a





)



)


)



)


)






)






M P McCabe

et al

bull





et al

(




Session













Procedure






Results





Variable




BDI 1456 451 1360 444 571 454 1280 423 539 277SCS 937 122 860 121 993 117 880 113 989 113RSES 2138 455 2120 545 2362 429 2120 460 2639 358ATQ-R 703 336 740 356 415 360 687 358 244 206










Variable






n n n n n n








Discussion




























Acknowledgements


References























Accepted June


M P McCabe

et al

bull





et al

(




Session













Procedure






Results





Variable




BDI 1456 451 1360 444 571 454 1280 423 539 277SCS 937 122 860 121 993 117 880 113 989 113RSES 2138 455 2120 545 2362 429 2120 460 2639 358ATQ-R 703 336 740 356 415 360 687 358 244 206










Variable






n n n n n n








Discussion




























Acknowledgements


References























Accepted June





Results





Variable




BDI 1456 451 1360 444 571 454 1280 423 539 277SCS 937 122 860 121 993 117 880 113 989 113RSES 2138 455 2120 545 2362 429 2120 460 2639 358ATQ-R 703 336 740 356 415 360 687 358 244 206










Variable






n n n n n n








Discussion




























Acknowledgements


References























Accepted June










Variable






n n n n n n








Discussion




























Acknowledgements


References























Accepted June





Discussion




























Acknowledgements


References























Accepted June



















Acknowledgements


References























Accepted June




Acknowledgements


References























Accepted June

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