Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies.
In adults with ID and depression, high anxiety, low IQ, and hearing loss warn of poorer outcomes, while high hope and good attendance signal better gains—yet neither trait favors behavioral activation over guided self-help.
01Research in Context
What this study did
Researchers tracked 12-month depression scores in adults with intellectual disability who got either behavioral activation or guided self-help. They asked: which baseline traits predict who gets better, and do those traits favor one therapy over the other?
All adults had mild to moderate ID plus clinical depression. The team measured IQ, anxiety, hearing, attendance, and hope for change at the start.
What they found
People with higher anxiety, lower performance IQ, or hearing loss improved less, no matter which therapy they tried. Higher starting depression, stronger belief that therapy would help, and showing up for most sessions predicted bigger gains.
The two therapies worked about the same overall; none of the traits tipped the scale toward behavioral activation or guided self-help.
How this fits with other research
van Schrojenstein Lantman-de Valk et al. (2006) already showed that stressful life events forecast later depression in adults with ID. Waldron et al. (2023) now add client traits you can spot in intake: anxiety, low IQ, and hearing problems.
Palka Bayard de Volo et al. (2021) warn that aggression or self-injury in severe-profound ID can mimic depression. The new trial focused on mild-moderate ID and confirms you should still screen for anxiety and sensory issues before blaming behavior alone.
Stancliffe et al. (2007) validated Beck’s negative triad as a mood marker. Waldron et al. (2023) move the field forward by showing that cognitive hope—“I think this will work”—actually predicts real-world gains.
Why it matters
Check anxiety, IQ, and hearing at intake. If any are red flags, add anxiety coping skills, simplify language, and use visual aids. Praise attendance and ask, “Do you believe this can help?”—a quick hope rating can guide extra engagement efforts. Since both therapies work equally, let client preference and staff training decide the choice.
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02At a glance
03Original abstract
BACKGROUND: No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help. METHODS: This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect. RESULTS: Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2 = 0.353, F4, 128 = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help. CONCLUSIONS: Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.
Journal of intellectual disability research : JIDR, 2023 · doi:10.1111/jir.13063