0 - CBT For Adults With Intellectual Disabilities

Research in Developmental Disabilities 5152 (2016) 6075
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
Effectiveness of cognitive behavioural therapy (CBT)

programmes for anxiety or depression in adults with
intellectual disabilities: A review of the literature
Gemma Unwin a, , Ioanna Tsimopoulou a , Biza Stenfert Kroese a , Sabiha Azmi b
a
b
School of Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK

North East London NHS Foundation Trust, Good Mayes Hospital, Barley Lane, London, UK
a r t i c l e
i n f o
Article history:
Received 21 April 2015
Received in revised form 8 December 2015
Accepted 14 December 2015
Available online 22 January 2016
Keywords:
CBT
Psychotherapy
Anxiety
Depression
Intellectual disabilities
Intellectual and developmental disabilities
a b s t r a c t
Relatively little is known about the application of cognitive behavioural therapy (CBT) to
people with intellectual disabilities (ID). This review sought to synthesise available evidence
on the effectiveness of CBT for anxiety or depression to assess the current level of evidence
and make recommendations for future research. A comprehensive systematic literature
search was conducted to identify qualitative and quantitative studies. Robust criteria were
applied to select papers that were relevant to the review. Included papers were subject to
quality appraisal. Eleven out of the 223 studies considered met our inclusion criteria and
were included in the review in which CBT was used with participants with ID and anxiety
(n = 3), depression (n = 4) or a mixed clinical presentation (n = 4). There remains a paucity
of evidence of effectiveness, however, the studies indicate that CBT is feasible and welltolerated and may be effective in reducing symptoms of depression among adults with
mild ID. Qualitative data reect a positive perception of CBT amongst clients and carers.
Further research is required to investigate the components of CBT, suitability for CBT, and
requisite skills for CBT, which uses valid, sensitive and more holistic outcome measures.
2015 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.1.
Characteristics of the studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.2.
Characteristics of the interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.3.
Quality appraisal and methodological limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.4.
Effectiveness of CBT for anxiety and depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.4.1.
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.4.2.
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.4.3.
Qualitative data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Conicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Corresponding author.
E-mail address: G.L.Unwin@bham.ac.uk (G. Unwin).
http://dx.doi.org/10.1016/j.ridd.2015.12.010
0891-4222/ 2015 Elsevier Ltd. All rights reserved.
G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075
61
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Appendix A.
Example search terms for Embase, Medline and PsycInfo searches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Appendix B.
Quality appraisal of the studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
1. Introduction
Mental health problems are at least as common among people with intellectual disabilities (ID) as in the general population (Cooper, Smiley, Morrison, Williamson, & Allan, 2007; Cooray & Bakala, 2005; Deb, Thomas, & Bright,
2001; King, DeAntonio, McCracken, Forness, & Ackerland, 1994; Moss et al., 2000; Reid, Smiley, & Cooper, 2011;
Tsiouris, Kim, Brown, & Cohen, 2011) with anxiety and depression most common (Azam, Sinai, & Hassiotis, 2009;
Reid et al., 2011; Richards et al., 2001; Smiley, 2005; Tsiouris et al., 2011). Reported prevalence rates for emotional disorders among people with ID vary, but are likely to be at least consistent with the general population
rates of 48% (Lindsay et al., 2015). The prevalence of these conditions is currently unknown due to difculties in
diagnosing mental illness in people with ID, especially those with severe and profound ID, limited communication
skills, limited abilities to self-report psychological experiences, and co-morbid autism spectrum disorder (Deb et al.,
2001a; Hemmings, Deb, Chaplin, Hardy, & Mukherjee, 2013; Holden & Gitlesen, 2004a; Kannabiran & McCarthy, 2009;
Matson & Shoemaker, 2009; Sturmey, Reed, & Corbett, 1991) which may lead to under-diagnosis and under-reporting.
Authors have implicated diagnostic/behavioural overshadowing whereby presenting problems of challenging behaviour
could be indicative of an underlying mental illness, but serve to mask the condition, with clinicians (especially nonspecialists) giving excessive attention to behavioural symptoms or the co-morbid ID rather than investigating mental
health further (Deb, Thomas, & Bright, 2001; Hemmings et al., 2013; Lowry, 1997; Reiss & Szyszko, 1983; Tsiouris,
2001).
Cognitive behavioural therapy (CBT) is recommended for the treatment of anxiety or depressive disorders (American
Psychiatric Association, APA, 2004, 2010; National Institute for Health and Clinical Excellence, NICE, 2009, 2011). However,
the application of CBT for emotional disorders among people with ID is not considered in these guidelines which focus on the
general population. Recent guidance published in UK has considered a range of psychological and behavioural approaches
for behaviour that challenges among people with ID (NICE, 2015).
The Department of Health in the UK recommends that Improving Access to Psychological Therapies (IAPT) services
should provide effective psychological interventions to people with ID (Department of Health, 2009). However, there is
a lack of available evidence and access to psychological therapies remains limited. Lack of training of staff working in ID
services on mental health, and lack of knowledge and experience of working with people with ID among health workers may contribute to this disparity (Stenfert Kroese & Rose, 2011). High rates of medication prescription have been
reported despite a paucity of evidence of effectiveness (Deb, Unwin, & Deb, 2015; Holden & Gitlesen, 2004b; Matson
et al., 2000; Matson, Bielecki, Mayville, & Matson, 2003; Tsiouris, Kim, Brown, Pettinger, & Cohen, 2013). The Winterbourne abuse scandal in the UK (in which residents of a hospital for people with ID were subject to abuse by staff resulting
in a television documentary and media and public outcry) highlighted the overuse of medication and institutional care.
It is therefore especially pertinent to improve access to psychological therapies by developing an evidence base. Psychological interventions for people with ID have been dominated by the behavioural approach, however, mental health
clinicians are increasingly using a wide range of different therapies with this client group, including talking therapies. Furthermore, due to the mainstreaming agenda in the UK (Joint Commissioning Panel for Mental Health, 2013), ID services are
being recongured nationally so that general adult mental health practitioners are increasingly likely to work with clients
with ID.
Growing evidence indicates that CBT is effective in managing psychological and emotional problems among individuals
with ID, with most evidence for anger management (Hamelin, Travis, & Sturmey, 2013; Hassiotis & Hall, 2008; Hassiotis
et al., 2009; Nicoll, Beail, & Saxon, 2013; Vereenooghe & Langdon, 2013; Willner, 2005; Willner et al., 2013). A recent
meta-analysis of psychological therapies for children and adults with ID identied 14 controlled trials published before
July 2012 (Vereenooghe & Langdon, 2013). The authors report a moderate between-group effect size for psychotherapy across all studies. Three trials of CBT for depression were included which yielded a moderate to large effect size.
However, no controlled trials for anxiety were located. This synthesis provides important evidence of the effectiveness
of psychotherapy for people with ID. However, the study considered quantitative data only and imposed strict methodological inclusion criteria. Given the infancy of research in the eld, a detailed synthesis of all types of research is
warranted. Furthermore, synthesis of qualitative evidence may provide insights into processes that are most salient to
individuals and those around them engaging in therapy (MacMahon et al., 2014), and may provide indications of the effective components of interventions. The present review therefore aims to examine the evidence for the effectiveness of CBT
programmes for adults with ID and anxiety or depression, delivered by therapists or staff/carers, and including all study
designs and with a focus on process evaluation. Given the aforementioned difculties in diagnosing these conditions, the
review will also consider CBT for those with anxiety or depressive symptoms and who may not have a diagnosis of emotional
disorder.
62
257 records identified through database searching
223 records after duplicates removed
223 titles and abstracts screened
206 records excluded
17 full texts assessed for eligibility
10 records excluded
7 studies included
Plus 4 more studies from crossreferencing
11 studies included
Fig. 1. Process of study selection.
2. Materials and methods

The following databases were searched using terms relating to ID, CBT, and anxiety/depression (Appendix A) up to 30th
July 2014: Embase, Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations, and PsycINFO. After removal of duplicates,
the titles and abstracts of citations were scanned according to the inclusion criteria (see below) and irrelevant citations were
excluded. The review focused on adults with ID, therefore child studies were excluded. This reects the division of services
for children and adults and the different nature to service provision. For example, child services are more likely to work in
a predominantly behavioural way and may work more with parents, caregivers and third parties.
The remaining full texts were examined to identify papers for inclusion in the review. One reviewer (IT) completed
the study selection process and two reviewers read the full texts and extracted data (IT and GU). The reference lists of
all included papers were checked for any further studies and a hand search was performed. After the nal studies were
selected, information was extracted using a data extraction form. A quality criteria framework was used to appraise the
included studies (Kmet, Lee, & Cook, 2004). The framework is suitable for both qualitative and quantitative papers and can
accommodate a wide range of study designs. Different criteria are provided for quantitate and qualitative studies, and each
criterion is scored on a 3-point scale with the additional option of rating criteria as not applicable. The results of the quality
appraisal are given in Appendix B. A narrative synthesis is presented to extract key information relating to study design and
results relating to effectiveness.
The inclusion criteria were as follows:
Participants: adults with ID and anxiety or depression (author dened)

Intervention: any therapeutic intervention adopting a cognitive-behavioural approach (author or reviewer dened)
Comparator: the study may or may not use a comparator
Outcomes: data relating to the effectiveness of the intervention including measures of intensity and/or frequency of
emotional or mental health problems and qualitative experiential data
Study: any qualitative or quantitative study.
3. Results
The database search identied 257 papers, of which seven papers were relevant for inclusion (see Fig. 1 for the study
selection process). A further four papers were included from cross-referencing. Two studies were reported in a single paper
(Lindsay, 1999). Another two papers that met the inclusion criteria described four cases in detail (Lindsay, Howells, &
Pitcaithly, 1993; Lindsay, Neilson, & Lawrenson, 1997). However, these cases were also reported in the included paper
(Lindsay, 1999) and did not provide any additional detail so they were excluded to avoid duplicating data. Two papers report
qualitative data relating to the same group of participants who received the intervention: one paper from the perspective
of staff and professionals (Stenfert Kroese et al., 2014) and the other from the perspective of clients themselves (Pert et al.,
2013), these are regarded as a single study to provide a total of 11 studies included in the review. It is acknowledged that
they concern the same intervention and may risk the duplication of data, but both are included as they provide novel insights
63
into process issues and perspectives of effectiveness. Three out of the 11 studies that were reviewed were included in the
meta-analysis by Vereenooghe and Langdon (2013).
3.1. Characteristics of the studies
Tables 13 present an overview of the methodological characteristics and key ndings of the studies relating to anxiety,
depression and mixed clinical presentations. The target for intervention was anxiety in three studies (Lindsay, 1999: study
1; Douglass, Palmer, & OConnor, 2007: study 2; Marwood & Hewitt, 2012: study 3), depression in four studies (Lindsay,
1999: study 4; McCabe, McGillivray, & Newton, 2006: study 5; McGillivray, McCabe, & Kershaw, 2008: study 6; McGillivray &
Kershaw, 2015: study 7), and in four studies trans-diagnostic CBT was used for mixed clinical presentations, namely anxiety,
depression and/or anger (Ghafoori, Ratanasiripong, & Holladay, 2010: study 8; Hassiotis et al., 2013: study 9; Lindsay et al.,
2015: study 10; Stenfert Kroese et al., 2014: study 11a; Pert et al., 2013: study 11b); where possible, the results relating to
anxiety and depression are extrapolated from these studies.
A total of 265 participants with ID were included across the 11 studies (range: 570; n = 30 in studies on anxiety; n = 156
in studies on depression; n = 79 in studies on mixed clinical presentations). Where the level of ID was reported, the majority
of participants had mild ID; no study reported including participants with severe ID. Participants presented with a range
of anxiety or depressive symptoms and not all had a diagnosis of anxiety or depressive disorder (sub-clinical emotional
disorder). Three studies did not provide any detail on assessment of symptoms for eligibility or diagnosis (1, 11a, 11b);
three studies stated that problems with mood signicantly impacted on daily functioning (2), and required intervention (3,
8); three studies reported using the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) to screen for at least
minimal depression to include participants who were depressed as well as those manifesting depressive symptoms (57);
and one used the Mini PAS-ADD (Moss & Brennan, 2002) to screen for psychiatric disorder after referral (9). In only one
study did all participants have a clinical diagnosis of emotional disorder (10).
The majority of studies (n = 10) employed a quantitative design, utilising a range of scales to measure outcome. Of these,
ve had a control group which received no treatment, treatment as usual, or received the intervention after the initial
follow-up period (57, 9, 10); one of which employed a quasi-experimental design using a control group retrospectively
selected from the waiting list of a different service (10), and another compared three treatment modalities, each of which
was assigned to a different service provider (7). Eight studies had a follow-up period of 36 months (1, 4, 510). One study
used a qualitative interview design only (collecting data with staff members: 11a; and with people with ID: 11b) and a
further three studies used mixed methods (2, 3, 9).
3.2. Characteristics of the interventions
The number and content of CBT sessions varied across the studies. The mean number of sessions was 11.43 (range: 547
sessions) with each session lasting a mean 86.6 min (data were not available for studies 1 and 10). Six studies used group CBT
(2, 3, 58) and four stated that the CBT was manualised (6, 7, 9, 10). In all but one study the CBT was delivered by a qualied
therapist. In study 6, CBT was delivered by agency staff who had a degree in psychology or sociology and/or a specialist
qualication in working with people with ID, and who received training over two days in depression and the CBT approach
and ongoing mentoring throughout the study. Involvement of family carers and support staff varied across the studies with
four studies stating that signicant others were involved in some sessions to facilitate the client in completing homework
and developing and maintaining coping strategies (2, 3, 9, 10).
3.3. Quality appraisal and methodological limitations
Tables B1 and B2 in Appendix B show the results of the quality appraisal process. Kmet et al. (2004) suggest that a liberal
cut-off for quality could be around 55% of the total possible score. Three studies scored below this threshold, one mixed
methods and two quantitative (1, 2, 4). Two studies comprised brief case reports based on clinical experience and presented
little methodological information (1, 4). The qualitative component of the mixed methods evaluation was not reported in
detail and did not appear to employ robust qualitative methods (2). All the studies were retained for Tables 13, but those
not reaching the cut-off are not considered in the narrative.
The methodological quality of the studies varied. Sample sizes were generally small with a mean of 24 participants
per study. No controlled trial was located for anxiety-focussed CBT. Of the controlled trials, some comparison groups were
recruited from different services (7), were retrospectively selected from existing caseloads (10) and were quasi-independent
(5). No study undertook a power calculation however, study 9 aimed to use their data to determine sample size for a larger
trial. Only study 9 stated that they used intention to treat analysis; attrition was reported in other studies however, those
data were removed from analysis. Where participants were followed-up, the period was generally short with a maximum of
six months. An independent researcher administered the outcome measures in two studies (6, 9), however, only one stated
that they were blind to the group allocation (9). In study 7 the assessments were administered by the therapist, this was also
implied in study 8. The nal randomised study (5) did not describe blinding or the process of administering the outcome
measures.
64
Table 1
Characteristics of the studies on anxiety.
Study design
Participants
Mental health
condition
Intervention
Measures
Main ndings
1
Lindsay (1999)
Quantitative
Case series
Pre, post and
follow-up
assessments
N = 15
Age: not
mentioned
ID: not
mentioned
Country: USA
Anxiety
-Reported
frequency and
intensity of
problematic
cognitions
-Revised BAI or
revised ZAS
-Signicant decrease in BAI or ZAS (from 75% to around 40% of the total score
possible in each scale)
-Effect remained at follow-up
2
Douglass (2007)
Mixed methods
One-group
Pre and post
assessments
N = 7 (and one
carer for each
individual)
Age: 2265
2M/4F
ID:
mild-moderate
Country: UK
Generalised
anxiety
(participants
could identify
4+ situations
that caused
them anxiety)
Individual adapted
Becks Cognitive
Therapy
(simplied form)
Average of 23
sessions (range:
1547)
Delivered by
therapist
Group CBT
12 weekly, 2-h
sessions
Delivered by
therapist
-GAS-ID
-Purpose-designed
structured
self-rating
interview
-Purpose-designed
carer rating on
impact of anxiety
Quantitative:
-Clinically signicant decrease in GAS-ID scores for two participants
(examined individually due to small sample size)
N = 8 (and one
support person
for each
individual)
Age: 1773
Gender: not
clear
ID: mild
Country: UK
Range of
anxiety
problems
(obsessional,
social, etc.)
3
Marwood (2012)
Mixed methods
One group
Pre and post
assessments
(IPA for
qualitative
data)
Group CBT
Anxiety
Management
6 weekly, 1-h
sessions (plus one
last session for
supporters, 90 min)
Delivered by
therapist
-QOLS
- GAS-ID
- HoNOS-LD
-Purpose-designed
semi-structured
interview schedule
(with 4
participants)
Qualitative:
- All clients could identify a number of coping strategies that they had learnt
- All carers reported that clients could do things that they had found difcult
before
-2 clients reported that they had developed condence (4 carers supported
this)
-All carers felt they had developed a better understanding of anxiety and how
to support the client
-All clients and carers enjoyed meeting the other clients and carers
Quantitative:
-Scores on outcomes examined individually due to small sample size
-Clinically signicant decreases in GAS-ID for 2 participants
-Mean HoNOS-LD score decreased from 3.5 to 1.9 (indicating improved
functioning; not statistically analysed), 6 demonstrated reductions (the 2 who
did not were scored 1 on both occasions)
-Increased QOLS scores (not statistically analysed), 5 showed increase
Qualitative:
-Most participants found the group helpful and found talking about feelings
helpful
-1 participant described the group as providing weekly structure and an
activity; this was more important than the content of the group
-Talking in front of others in the group was challenging at rst
-The participants liked the involvement of support partners
-Several participants found lling in worry diaries helpful but some of the
written homework tasks were inaccessible due to limited literacy
ID, level of intellectual disabilities; IPA, Interpretative phenomenological analysis; M, males; F, females; EG, Experimental Group; CG, Control Group; IPA, Interpretative Phenomenological Analysis; CBT, Cognitive
Behavioural Therapy; CT, Cognitive Therapy; BT, Behavioural Therapy; TAU, Treatment As Usual; RCT, Randomised Controlled Trial.
Scales: GAS-ID, Glasgow Anxiety Scale-for people with an Intellectual Disability; GDS, Glasgow Depression Scale; BAI, Beck Anxiety Inventory; ZUS, Zung Anxiety Scale; QOLS, Quality of Life Scale; HoNOS-LD,
Health of the Nation Outcome Scale Learning Disability Version; BDI, Beck Depression Inventory; ZDS, Zung Depression Scale; SCS, Social Comparison Scale; BSI, Brief Symptom Inventory; ATQ-R, Automatic
Thoughts Questionnaire Revised.
ID
First Author (year)
Table 2
Characteristics of the studies on depression.
Study design
Participants
Mental health
condition
Intervention
Measures
Main ndings
4
Lindsay (1999)
Quantitative
Case series Pre,
post and
follow-up
assessments
N = 5 (referred between
1990 and 1996)
Age: not mentioned
ID: not mentioned
Country: USA
Depression
Individual adapted
Becks Cognitive
Therapy
(simplied form)
Delivered by therapist
-BDI or ZDS reduced from around 50% of total score to around 25%
(no statistical analyses due to small sample size)
-Decrease remained at 6-month follow-up
5
McCabe (2006)
Quantitative
RCT (quasiindependent)
Pre, post and
follow-up
assessments
(n = 18 for
follow-up)
EG
N = 34 (including 15 from
CG)
Mean age: 34
16M/18F
Depression (at
least minimal,
as measured by
the BDI-II,
clinical and
depressive
symptoms)
EG
Group CBT
5 weekly, 2-h sessions
Delivered by therapist
-BDI or ZDS
-Reported
frequency or
intensity of
problematic
cognitions
-BDI-II
-SCS
-ATQ-R
-Rosenberg
Self-esteem Scale
(RSES)
Depression (as
measured by
the BDI-II);
49% minimally
depressed, 17%
mildly
depressed, 15%
moderately
depressed, 19%
severely
depressed
EG
Manualised group
(n = 56) CBT
12 weekly, 2-h sessions
Delivered by agency
staff (N = 13)
6
McGillivray (2008)
7
McGillivray (2015)
Quantitative
RCT (cluster)
Pre, post and
follow-up
assessments
(n = 45 for
follow-up)
Quantitative
Controlled trial
Pre, post and
follow-up
assessments
CG
N = 15
Mean age: 40
6M/9F
ID: mild-moderate
Country: Australia
EG
N = 20
Mean age: 38
13M/7F
CG
N = 27
7Mean age: 31
19M/8 F
ID: mild (IQ 5070)
Country: Australia
CBTG
N = 23
CTG
N = 23
BTG
N = 24
42M/28F
Mean age: 36
ID: mild
Country: Australia
N = 24
minimally
depressed,
n = 28 mildly
depressed,
n = 13
moderately
depressed, n = 5
severely
depressed
according to
BDI-II cut-offs
CG
Waitlist, received
intervention after
follow-up for EG
complete
CG
Waiting list, received
the intervention after
follow-up for EG
complete
Manualised group CBT,
CT or BT
All 12 weekly, 1.5 h
sessions
Groups of 78
All delivered by same
therapist
-BDI-II
-ATQ-R
-SCS
-The Social
Readjustment
Rating Scale (SRRS;
10 items only)
-BDI-II
-ATQ-R (10 most
relevant items
only)
-Signicant difference between the groups at the three time points

on the combined outcome measures (p < .001).
-When the measures were considered separately, BDI-II (p < .001),
SCS (p < .001), and ATQ-R (p < .001) reached signicance.
-No difference in RSES
-Signicant reduction in BDI-II scores and frequency of negative
automatic thoughts, and increase in SCS scores (indicating that the
participants viewed themselves more positively) from pre-test to
post-test within the EG (p values not given)
-Signicant improvements remained at 3-month follow-up
-Signicant group by time (pre-test to post-test) interaction effect

on the combined outcome measures (p < .001). Signicant main
effect for time (p < .001), not group
-Signicant group by time interaction effect for BDI-II (p = .000),
ATQ-R (p = .021) and SCS (p = .015)
-No difference in SRRS
-Signicant decrease in BDI-II (p < .01) and ATQ-R (p < .01) scores
within EG from pre-test to post-test
-Positive effects on BDI-II and ATQ-R comparable across groups
(once CG also received intervention) over time (pre-test, post-test,
and follow-up)
-Changes were maintained at 3-month follow-up
-Signicant main effect of time but not group on BDI-II (p < .01and
p = .98, respectively) and ATQ-R (p < .01 and p = .13, respectively).
-No signicant interaction effect on BDI-II (p = .61) indicating that
effect of time did not differ between groups
-Signicant interaction effect on ATQ-R (p < .01). Individual tests
revealed a signicant reduction in the CBT group pre- to post-test
which was maintained at follow-up. No signicant reductions for
the CT or BT groups.
-At post-intervention, 53%, 47%, and 71% indicated recovery (to no
or minimal depression) from at least mild depression in the CBT,
CT and BT groups, respectively.
-The proportion of recovered individuals was 53%, 53% and 47% at
follow-up.
65
First Author (year)
66
Table 3
Characteristics of the studies on mixed clinical presentations (anxiety, depression and/or anger).
Study design
Participants
Mental health
condition
Intervention
Measures
Main ndings
8
Ghafoori, (2010)
Quantitative
One-group
Pre, post and
follow-up
assessments
N=8
Mean age: 20
2M/6F
ID: mild-borderline
Country: USA
Mood
difculties
(depression,
anxiety and
anger)
-Symptom
Checklist
90-Revised
(SCL-90)
9
Hassiotis (2013)
Mixed methods
RCT
Pre, post and
follow-up
assessments
(content
analysis for
qualitative
data)
EG
N = 16
Interviews: N = 13
Mean age: 34
5M/11F
Mood disorder
or symptoms of
depression
and/or anxiety
(72% with
depression
with/out
anxiety and
29% with
anxiety only)
Group
trans-diagnostic
CBT
9 weekly, 90-min
sessions
Delivered by
therapist
EG
Manualised
trans-diagnostic
individual CBT
16 weekly, 1-h
sessions
Delivered by
therapist
Plus TAU
-Signicant decrease in global severity index (p < .05), and anxiety

(p < .05), depression (p < .05), somatisation (p < .05),
obsessive-compulsive (p < .05), interpersonal sensitivity (p = .003)
and psychoticism (p < .05) subscale scores from pre-test to
post-test all with large effect sizes (Cohens d > 0.85)
-No change in hostility, phobic anxiety and paranoid ideation
-Signicant decreases maintained at follow-up
Quantitative:
-No signicant differences in interaction or main effects for the
two groups
-Participants in the intervention group presented a non-signicant
reduction only in depression scores (no matter if they also had
anxiety or not)
-CSQ-8 scores indicated the participants were highly satised with
services
-Participants were unable to complete the MANSA due to its
complexity
CG
N = 16
Mean age: 38
7M/9F
CG
TAU
ID: mild-moderate
Country: UK
10
Lindsay (2015)
Quantitative
Matched
controlled trial
(quasi
experimental)
pre, post and
follow-up
assessments
EG
N = 12
Mean age: 28.9
6M/6F
IQ: 62.4
CG (retrospective
waitlist control)
N = 12
Mean age: 33.1
6M/6F
IQ: 63.9
ID: mild
Country: UK
Diagnosis of
emotional
disorder
(anxiety n = 8,
depression
n = 6, mixed
anxiety and
depression
n = 7,
pathological
jealousy n = 1,
interpersonal
conict n = 2)
EG
Manualised
trans-diagnostic
individual CBT
Mean 10.75 (range:
814) sessions
Delivered by
therapist
CG
Waitlist, TAU (not
including CBT)
-BDI-Youth
-BAI-Youth
-Manchester Short
Assessment
Of Quality of Life
(MANSA)
-Client Satisfaction
Questionnaire
(CSQ-8)
-Client Service
Receipt Inventory,
adapted for the
study (CSRI)
-Interview
schedule
comprised 6 open
ended questions
-BSI (Anxiety,
Depression and
Global Severity
Index)
-GAS-ID (EG only)
-GDS (EG only;
self- and
informant-report)
Qualitative:
-8 gave examples where they had used CBT techniques including
reports of improved condence and increased calmness
-7 felt that CBT had a positive impact on mood but did not resolve
all their difculties
-6 would have liked the sessions to be free-oating rather than
task orientated
-7 participants were openly positive about their therapist
-8 would recommend therapy to others
-The role of support worker was viewed in a positive way
-8 would have liked further contact after sessions
-1 viewed homework tasks as persecutory by 1
-Signicant decrease in BSI Global Severity in EG compared with
CG (p = .001)
-Marginally signicant decrease in BSI Anxiety in EG compared to
CG (p = .07)
-No treatment effect for BSI Depression
-Within EG change in all BSI measures maintained at 6-month
follow-up
-Signicant decreases in GAS-ID (p < .01) and GDS (self- and
informant-report, p < .01 and p < .05, respectively) within EG preto post-test, changes maintained at 6-month follow-up.
First Author (year)
Table 3 (Continued)
Study design
Participants
Mental health
condition
Intervention
Measures
Main ndings
11a
Stenfert Kroese
(2014)
Qualitative
Interviews pre
and after the
rst phase of
therapy
(thematic
analysis)
Staff
1st interview
N = 11
3M/8F
Support workers = 5,
community nurses = 4,
social worker = 1,
supported
employment
worker = 1
N/A
Individual CBT
9 sessions between
interviews (rst
phase of CBT:
focused on
engagement and
socialising the
client into the
therapeutic model)
Delivered by
therapist
-Semi-structured
interviews with
paid support or
professional key
workers of people
with ID who were
participating in CBT
1st interview:
-Most felt it was benecial for the service user to talk to an outsider
-Some felt that CBT offered nothing new beyond what had already
been tried
-The majority had poor understanding of CBT and had negative
expectations of its effectiveness
Individual CBT
10
weekly/fortnightly,
1-h sessions
Delivered by
therapist
-Semi-structured
interview with
client participant
-Interview 1
between 4th and
5th session;
interview 2
(between 9th and
10th session)
2nd interview
N=9
3M/6F
People with ID
N = 15 (see 11b)
11b
Pert (2013)
Qualitative
2 interviews in
the initial stage
of therapy (IPA)
N = 15 (22 recruited to
take part in therapy)
Mean age: 39
8M/7F
ID: borderline-mild (IQ
5579)
Country: UK
Referred for
anxiety (4),
depression (4),
anger (4),
mixed
presentation
(3)
2nd interview:
-9 had observed positive outcomes including improved mental
health (e.g. more relaxed, more sociable, more condent,
improved self-esteem) and improved cognitive skills/processing
(e.g. better insight into problems and better problem solving
skills). All of these participants identied at least 1 aspect of the
therapists approach that had benetted (e.g. good liaison,
teaching appropriate coping strategies, giving emotional support
and normalising the problem)
-1 felt that the therapist functioned as a threat rather than a
positive inuence
-1 felt that the changes were due to medication
-1 felt that CBT was not helpful
-A number said that service users were easier to talk to
-Most expressed doubt that changes would be permanent and felt
that long-term sessions or top-ups would be required
(transcripts from the two interviews were analysed together)
-All participants found talking in sessions about problems helpful
in itself, including a sense of relief and immediate benet
-Participants identied positive changes that they attributed to
therapy, referring to improved self-perceptions, feeling more
condent, understanding and expressing problems better, getting
more out of life, being more sociable, improved relationships
-Many valued having an identied person (who was not a carer)
with whom they could talk
-A number valued the opportunity to talk without their carers in a
condential and private manner
-Talking was difcult at rst
-Participants appreciated the thorough approach of therapists and
that their problems were being taken seriously this made them
feel valued and their problems validated
-Participants beneted from an approachable and empathetic
therapeutic style
-Participants expressed cautious optimism about changes which
may be fragile and short-lived, and many felt they required
longer-term input
67
First Author (year)
68
Only two studies assessed delity to the treatment approach (9, 11a/b). This is perhaps less important for non-manualised
interventions delivered by a qualied therapist, however, delity was not assessed for the agency-staff-delivered intervention (6). There was little consideration of concomitant interventions including psychotropic medication and psychological
therapies. Only study 9 excluded those already in receipt of psychological treatment, however, medication and contact with other members of the multi-disciplinary team were permitted. Antidepressant medications were recorded in
three studies (5, 6: 12% taking antidepressant medication at baseline, 7: 26% taking antidepressant medication at baseline) and antianxiety medication in one study (3: remained stable for some time prior to the study). One study briey
described separate outcomes for those taking antidepressant medication: all those taking antidepressants also showed
a decrease in depressive symptoms and negative automatic thoughts. However, no other consideration was given to
the effects of concomitant interventions. Potentially confounding life events were also not considered in the studies.
Study 8 included participants who were all experiencing transition from school to college. It is not clear when the
transition occurred in relation to therapy and outcome assessment, therefore, reported changes in this study may have
been due to a successful move or support from other professionals involved in the transition planning process, especially as people with ID are likely to experience increased anxiety during the transition period due to changes and
uncertainties.
The quality of the qualitative studies also varied; this may be more an issue with reporting than conduct of research.
Three papers reported qualitative data alongside quantitative data and therefore may not have had space to present
in-depth descriptions. For example, one study did not present quotes in support of the analysis and provided little information on data collection (2). A further study reported very limited data on participants perception of the intervention
in the discussion section so was not considered as a qualitative study (5). The methodologies and recruitment strategies employed in the qualitative studies were appropriate for the research questions. However, a signicant number
of participants included in mixed-methods studies were not interviewed introducing potential for bias. Data collection methods were adequately described in most studies. Two studies used Interpretative Phenomenological Analysis
(IPA; 3, 11b) and thematic analysis (11a) and one used content analysis (9). One IPA study presents a thin analysis that does not reect/interpret the experience of participants in their context with little description of the themes
(3). Two studies report auditing and cross-checking of the analysis (9, 11a/b). There was little evidence of reexivity
in the papers in terms of the researchers role, relationships to the participants and potential bias. This is especially
problematic in two studies in which participants were interviewed by therapists involved in running the groups (2,
3). One study describes the use of the reexive diary and supervision but does not discuss this in relation to the
results (3).
3.4. Effectiveness of CBT for anxiety and depression
3.4.1. Anxiety
Three studies reported on anxiety-focused CBT (1, 2, 3). Studies 2 and 3 used Jacobson and Truaxs (1991) denition of
a clinically signicant improvement (post-intervention scores that are more than two standard deviations above or below
the mean score of the pre-intervention sample). Twenty-nine and 25% of participants demonstrated a clinically signicant
improvement.
The studies that included participants with mixed clinical presentations do not provide separate data for those with
anxiety, however, study 8 reports a signicant reduction in scores on the anxiety subscale of their outcome measure that was not maintained at 4-month follow-up. Studies 9 and 10 report no between group treatment effects on
anxiety.
3.4.2. Depression
Seven studies provide quantitative data on the effectiveness of CBT on depressive symptoms (410) of which ve were
controlled studies. Two studies using depression-focussed CBT report between group treatment effects on depressive symptoms and negative automatic thoughts with results maintained at 3-month follow-up (5, 6). However, in study 5 deterioration
from post-test was evident among 58%, 68% and 37% for depressive symptoms, self-perception and negative automatic
thoughts, respectively. Similarly, the proportion of participants showing substantial improvements reduced from 80% to
60% and 70% to 50% for depressive symptoms and negative automatic thoughts. Comparable treatment effects were reported
for cognitive-focused, behavioural-focused and CBT in study 7. However, only the CBT group showed a signicant reduction in negative-automatic thoughts at post-test. Seventy-one per-cent, 47% and 53% were classed as recovered in the
behavioural-focussed, cognitive-focused and CBT groups, respectively. At six month follow-up, the recovery rates were 47%,
53%, and 53% suggesting that behavioural focused therapy may provide short-term clinical gains, however, the cognitive
component may play a role in longer term outcomes.
Studies 810 utilised trans-diagnostic CBT. Signicant repeated measures effects are reported in study 8, but these were
not maintained at 4-month follow-up. Studies 9 and 10 report non-signicant treatment effects. However, the groups in
study 10 were not comparable at baseline with higher scores for depression among the treatment group. In study 9 those
who screened positive for the presence of depressive disorder showed a 3.21 point reduction in depression scores compared
to 1.92 in the control arm suggesting a tendency for greater improvement.
69
3.4.3. Qualitative data

Qualitative data and feedback from participants and carers indicate positive effects with a wide range of benets reported.
In study 3, participants enjoyed the opportunity to talk about their feelings, go out of the home, and the sense of being
supported by their partners. Similarly, in study 5 participants were happy to have taken part and enjoyed the ability to
express themselves in a non-judgmental setting, feeling safe, and being respected by the others. For these participants the
most important features of the intervention were a safe and respectful environment; the opportunity to discuss problems
and gain feedback; information to take away and refer to later; and resources to develop a social network and become
more active. The participants also valued the feeling of social connectedness that the group-therapy format provided. In
study 9, the participants felt that therapy had helped them, although not all of their problems were solved. Eight participants reported positive changes such as using the strategies they were taught, improved condence and increased
calmness. Seven participants were positive about their therapist and the role of the support worker was viewed in a
positive way. Eight would recommend the therapy to others and would like to have further contact after the allocated
sessions.
One study used semi-structured interviews pre- and post-rst phase of therapy to explore the views and experiences
of people with ID who had participated in the initial phases of CBT (11b) as well as the perspectives of their carers
(11a). Participants with ID said that talking in sessions was helpful in itself. Individuals reected on positive changes
in themselves such as feeling happier, feeling more condent, understanding their problems better, increased patience
and being better able to express themselves (11b). The participants also reported changes in their broader lives such
as getting out more, being more sociable, and improved relationships. However, they also felt that changes were fragile and expressed cautious optimism about the outcomes of therapy, indicating an external locus of control requiring a
long-term supportive relationship to maintain progress. What was considered important and valued most was not the
technical aspects of CBT, but the sense of being listened to and taken care of by a therapist that treated them as equals.
The majority of staff participants also reported positive changes despite initial negative expectations of CBT (11a). Carerreported changes in participants in the second interview included improved mental health (for example, going out more,
socialising more, feeling more relaxed, feeling more condent, improved self-esteem, improved assertiveness) and cognitive skills (for example, improved insight into problems and better coping skills). The two staff participants who did
not report positive changes suggested that the client seemed stuck or demonstrated that they had learned some adaptive strategies but had not yet put them into practice. As with client participants, staff did not consider changes to be
permanent.
4. Discussion
The review located 11 studies that report on the effectiveness of CBT for anxiety or depression. Most of the studies have
methodological limitations including small sample sizes, few control groups, short-term follow-ups, and lack of treatment
delity assessment. Three RCTs were identied, two evaluated CBT for depression (McCabe et al., 2006; McGillivray et al.,
2008) and one evaluated CBT for mixed clinical presentations (Hassiotis et al., 2013). No controlled trials were identied
for anxiety-focussed CBT. These trials report varying results with the trial by Hassiotis et al. (2013) reporting no overall
treatment effect. The other studies report signicant treatment effects that were maintained at 3-month follow-up. These
discrepancies may be due to methodological differences, as discussed below.
There remains a paucity of evidence, but the studies indicate that CBT is feasible and well-tolerated, with some evidence
to indicate that CBT may be effective in reducing symptoms of depression, including negative automatic thoughts. There is
currently equivocal evidence for anxiety: studies demonstrated some positive results, however, these tended to be uncontrolled. Varying quantitative results were reported across the studies; the qualitative data were more consistent and reect
a positive perception of treatment amongst clients and carers. Participants especially valued the space and time to discuss
their thoughts and feelings, the validation of their problems, and the formation or development of empathetic relationships
with therapists and, in the case of group therapy, other group members.
The studies all included mild-moderate ID only and all had eligibility criteria relating to verbal skills. In this way,
suitability for CBT was (informally) assessed. However, emotional disorder (anxiety, depression or mixed clinical presentation to include anxiety/depression and anger) was not always assessed and few studies imposed standardised,
objective criteria relating to a diagnosis or certain level of symptomatology. The inclusion of participants with subclinical anxiety or depression may have resulted in oor effects on symptomatic outcome measures resulting in a lack
of sensitivity to detect change. Similarly, some studies used a trans-diagnostic approach which may have diluted the
effect of CBT, and it was difcult to differentiate between participants presenting with depression or anxiety. Hassiotis
et al. (2013) did not nd a signicant group effect in their feasibility RCT, however, a trend towards treatment effect
was observed for those who screened for clinical depression, but not for those with anxiety disorder. Smaller effect
sizes are reported in this study than those reported in other studies which report large effect sizes. The authors suggest that effects may have been previously over-estimated, especially for anxiety. Alternatively, it may be argued that
a more targeted approach is needed for anxiety. Further research should investigate these issues, perhaps by comparing trans-diagnostic and targeted approaches for both clinical and sub-clinical samples of people with depression and/or
anxiety.
70
The lack of statistical signicance reported in some studies may be due to studies being under powered due to small
sample sizes. None of the studies reported using a power calculation to determine sample size. Hassiotis et al. (2013) aimed
to use the results of their pilot RCT to determine the required sample size for a larger trial. Their results indicated that a
sample size of 162 would be needed which is very large in the eld of ID research given the known difculties recruiting
people with ID to RCTs.
The choice of outcome measures may have also contributed to the varying results. Some studies used measures that
were developed for the general population with or without adaptations. Sometimes the adaptations were not evaluated
and therefore may have invalidated the measure or affected its reliability. Hassiotis et al. (2013) used a quality of life
measure in their study, however, they could not report these results as it proved too complicated to be of use for this
population. The outcome measures may have lacked sensitivity to change or may have missed effects outside of changes
in symptomatology. It could be argued that the CBT seeks to improve recognition and normalising of symptoms so leads
to improved reporting by people with ID who may be particularly at risk of social desirability bias. There is a need to use
holistic, personally meaningful measures which address the clients aims of therapy, rather than relying on symptomatic
measures which may not capture treatment effect. Furthermore, informant report of behavioural changes may be useful. A
recent trial of CBT for anger management found no signicant effect on the primary outcome measure, namely a provocation
inventory, however, both client and staff ratings of anger signicantly reduced as did clients ratings on a more personally
meaningful anger measure (Willner et al., 2013). Furthermore, both clients and staff reported signicant increases in coping
skills which were not quantitatively assessed in studies included in this review. In one study included in this review, all
participants reported a reduction in worries, an outcome that was not captured on the quantitative outcome measure
(Douglass et al., 2007).
In some studies, treatment effects were short-lived with some participants reverting to pre-treatment levels of distress within six months. This suggests that booster sessions may be required to sustain the positive impact of treatment.
Alternatively, deterioration could be an indication of clients having gained greater levels of insight and improved vocabulary and therefore notice and report symptoms more readily. Further studies with longer follow-up periods are needed
to explore whether deterioration continued, and whether booster sessions would reverse this trend. Three of the studies
that included carers in the intervention reported effects that were maintained at follow-up (the other study that involved
carers failed to nd a signicant treatment effect; Hassiotis et al., 2013). It may therefore be important to involve carers to
maintain longer-term treatment effects. Previous research has found that engaging carers in psychological therapies benets
clients, especially in reinforcing and sustaining the techniques learnt, transferring these skills to home life, and supporting with homework (Rose, Loftus, Flint, & Carey, 2005; Rose, West, & Clifford, 2000; Stimpson et al., 2013; Whitehouse,
Tudway, Look, & Stenfert Kroese, 2006). Furthermore, qualitative data from the studies indicates that people with ID value
the involvement of carers. However, condentiality issues should be considered, and involvement should be optional.
Therefore, a systemic approach to include staff, professionals and family may be of particular value when working with
people with ID. Psychotherapists currently often work in this way (Jones, 2014) however, future research needs to investigate different methods for involving care staff and the impact on outcome (Jahoda et al., 2009; Stenfert Kroese et al.,
2014).
One study in this review successfully employed CBT for depression that was delivered by agency staff (McGillivray et al.,
2008). The authors suggest that train the trainer models may be a cost-efcient, sustainable method of perpetuating the
impact of an intervention beyond the initial implementation. In the largest RCT of CBT amongst people with ID, Willner et al.
(2013) trained care staff to act as lay therapists and deliver a manualised CBT programme for anger management. Willner
et al. found that this method of delivery was effective in reducing anger and improving use of coping strategies. Further
research could investigate whether this approach could be used for anxiety.
Care staff-delivered CBT in non-health/community settings may be a sustainable approach, especially for sub-clinical
emotional presentations, and may lead to improved generalizability of techniques learnt in therapy as clients participate in
the intervention in more natural settings and have more opportunity for contact with therapists. In this way, care staff-led
CBT could be used as preventative mental health promotion and may improve access to psychological therapies for people who rarely have access to appropriate mental health services (Stenfert Kroese et al., 2014). Research has shown that
providing mental health training to carers improves their ability to recognise mental health problems, improves knowledge and attitudes, and condence in response to service users difculties (Costello, Bouras, & Davis, 2007; Quigley,
Murray, Mckenzie, & Elliot, 2001; Tsiantis et al., 2004; Woodward & Halls, 2009; Zijlmans, Embregts, Gerits, Bosman, &
Derksen, 2011). Furthermore, one study in the review indicated that carers have very limited knowledge of CBT and may
hold sceptical views (Stenfert Kroese et al., 2014); involving carers in therapy either directly or indirectly may improve
perception.
The qualitative data indicates that CBT is valued by people with ID who found the process of talking in-depth about their
problems and being listened to benecial and validating. The participants appreciated the collaborative approach of CBT.
Other research has demonstrated that clients with ID adopt a collaborative rather than passive role in the therapeutic process,
contributing to the analytic process and dialogues (Jahoda et al., 2009). The importance of the therapeutic relationship in
psychotherapy has been highlighted (Keijsers, Schaap, & Hoogduin, 2000; Lambert & Barley, 2001; Power, 2010) and the
studies in this review corroborate this for people with ID: participants engaged in individual and group therapy placed great
importance on a supportive therapeutic relationship. Therapists, working with people with ID, also view the therapeutic
relationships as fundamental to their work, inuential on outcome and more important than theoretical approaches (Jones,
71
2014). Therapeutic relationships may have a greater impetus for people with ID than the general population due to limited
relationship experience (Jones, 2014). Research has not yet investigated the association between quality of relationship and
outcome (Jones & Donati, 2009). In the study by Hassiotis et al. (2013), CBT was delivered by qualied cognitive behavioural
therapists who received induction to communication and engagement with people with ID. The lack of experience of working
and engaging with people with ID may have affected the therapeutic relationship and ultimately the outcome. Therapists
working with clients with ID suggest that experience of working with this client group is important for the development of
a therapeutic relationship (Jones, 2014).
Participants engaged in group therapy also valued the development of relationships with other group members, perceiving the group as a shared social experience and appreciating the opportunity for social interaction. Research on CBT
groups for anger management has also highlighted the importance of relationships in the therapeutic process both in
relation to the lay therapist as well as bonding and closeness with other group members and suggest that it is these
aspects that are more important than specic elements of the CBT intervention (MacMahon et al., 2014). Group therapy may therefore be a more appropriate model for individuals with ID who often face social isolation, discrimination,
stigma and have few opportunities for developing close relationships. Few studies have investigated the experience
of and satisfaction with CBT amongst people with ID. Qualitative studies provide an insight into the therapeutic process and further research is needed. The existing evidence highlights the importance of addressing social support and
social interactions to mitigate against the social isolation commonly experienced by people with ID and emotional
problems.
This review has some limitations: the search was not exhaustive so it is possible that some papers have been missed,
especially as we did not search the grey literature. However, it is unlikely that any large-scale studies were omitted and
none were excluded on the basis of language. A systematic review and meta-analysis of the literature may be benecial in the
future; at present, meta-analysis would be premature. More RCTs need to be conducted. The difculties in conducting trials
with this population are known, however, they are essential to determine effectiveness of interventions to allow people
with ID to benet from evidence-based healthcare. Future research should compare various credible treatment modalities
including psychological therapy and psychotropic medication. Further research with large sample sizes should also examine
whether there are prerequisite skills for CBT and whether comprehension of the cognitive model, for example, the ability
to differentiate between feelings, thoughts and behaviours, and verbal communication skills affects outcome. Most of the
studies in this review used multi-component interventions, including relaxation, behavioural and cognitive strategies. Only
McGillivray and Kershaw (2015) compared behavioural-, cognitive-focussed and CBT and found some evidence of longer
lasting effects with CBT. Further research should examine the mechanisms for change to look at the various components of
CBT as to which are most important.
Future research could:
Compare trans-diagnostic and targeted CBT approaches for clinical and sub-clinical samples
Compare various treatment modalities, including group versus individual CBT, other therapies and medications
Examine the components of interventions and the mechanisms of change as well as evaluating treatment delity
Use more personally meaningful outcome measures, including measures adapted to individual aims from therapy and more holistic measures beyond symptom measurement, as well as well as triangulation with informant
measures
Include longer follow-ups to explore whether deterioration continues, and whether booster sessions would reverse this
trend
Investigate care staff-led interventions for anxiety
Investigate whether there are prerequisite skills for CBT, and whether comprehension of the cognitive model affects
outcome
Investigate whether therapist competence and quality of therapeutic relationship affects outcome.
Therapists may consider:
Involving carers to maintain longer-term effects, and to reinforce and sustain the techniques learnt, however, condentiality issues should be considered and involvement should be optional.
Taking a systemic approach to include staff, professionals and family. This may improve the perception of staff and carers.
Providing booster sessions to maintain effects.
Facilitating care staff-delivered CBT in non-health/community settings as a preventative approach.
The importance of the therapeutic relationship which may have a greater impetus for people with ID than the general
population due to limited relationship experience.
Group therapy which may be a more appropriate model for individuals with ID who often face social isolation, discrimination, stigma and have few opportunities for developing close relationships.
Addressing social support and contact as part of therapy.
72
Conicts of interest
There are no conicts of interest.
Acknowledgements
Birmingham Community Healthcare NHS Trust funded the review. Ioanna Tsimopoulou was a Scholar of Alexander S.
Onassis Public Benet Foundation at the time this study took place.
Appendix A. Example search terms for Embase, Medline and PsycInfo searches
1.
Terms related to Learning Disabilities: learning disabilit*.mp. OR exp intellectual impairment/

OR *mental deciency OR intellectual disabilit*.mp. OR mental* retard*.mp.
Terms related to mental health problems: anxiety.mp. OR anxiety/OR exp anxiety disorder/
OR depression.mp. OR exp depression/
Terms related to CBT: cognitive behav* therap*.mp. OR CBT.mp. OR cognitive behav* treatment
1 AND 2 AND 3.
2.
3.
4.
Appendix B. Quality appraisal of the studies
Table B1
Quality appraisal of quantitative studies.
Paper no.
Criteria
Summary
score
10
11
12
13
14
Total sum/total
possible sum
1
2
3
4
5
6
7
8
9
10
1
2
2
1
2
2
2
2
2
2
1
1
1
1
2
2
2
1
2
1
0
1
2
0
2
2
2
1
2
1
0
2
2
0
2
2
1
2
2
2
n/a
n/a
n/a
n/a
1
1
0
n/a
2
0
n/a
n/a
n/a
n/a
0
0
0
n/a
2
0
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0
1
2
0
2
2
2
1
2
2
1
1
1
0
2
2
2
1
2
2
0
2
2
0
2
2
2
1
2
2
0
0
2
0
2
2
2
2
2
2
0
0
0
0
0
0
0
0
0
1
1
2
2
1
2
2
2
2
2
2
1
2
2
1
2
2
2
1
2
2
5/22
14/22
18/22
4/22
21/26
21/26
19/26
14/22
24/26
19/26
Summary
score
0.9
0.7
0.65
0.75
0.4
0.2
n/a
0.7
0.7
0.75
0.7
0.05
0.9
0.85
0.23
0.64
0.81
0.18
0.81
0.81
0.73
0.63
0.92
0.73
Criteria:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
Question/objective sufciently described?

Study design evident and appropriate?
Method of subject/comparison group selection or source of information/input variables described and appropriate?
Subject (and comparison group, if applicable) characteristics sufciently described?
If interventional and random allocation was possible, was it described?
If interventional and blinding of investigators was possible, was it reported?
If interventional and blinding of subjects was possible, was it reported?
Outcome and (if applicable) exposure measure(s) well dened and robust to measurement/misclassication bias? Means of assessment reported?
Sample size appropriate?
Analytic methods described/justied and appropriate?
Some estimate of variance is reported in the main results?
Controlled for confounding?
Results reported in sufcient detail?
Conclusions supported by the results?
Scoring: 2 = Yes; 1 = Partial; 0 = No; n/a, Not Applicable.
73
Table B2
Quality appraisal of qualitative studies.
Paper no.
Criteria
10
2
3
9
11a
11b
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
1
2
2
2
2
1
2
2
2
2
0
2
2
2
2
0
2
2
2
2
1
2
2
2
2
0
2
1
2
2
Summary score
0.9
0.9
0.9
0.8
0.8
0.9
0.7
Total sum/total
possible sum
Summary
score
10/20
20/20
19/20
20/20
20/20
0.50
1
0.95
1
1
Criteria:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Question/objective sufciently described?

Study design evident and appropriate?
Context for the study clear?
Connection to a theoretical framework/wider body of knowledge?
Sampling strategy described, relevant and justied?
Data collection methods clearly described and systematic?
Data analysis clearly described and systematic?
Use of verication procedure(s) to establish credibility?
Conclusions supported by the results?
Reexivity of the account?
Scoring: 2 = Yes; 1 = Partial; 0 = No; n/a, Not Applicable.
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Research in Developmental Disabilities 5152 (2016) 6075

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Effectiveness of cognitive behavioural therapy (CBT)

School of Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

257 records identified through database searching

223 records after duplicates removed

223 titles and abstracts screened

206 records excluded

17 full texts assessed for eligibility

Plus 4 more studies from crossreferencing

2. Materials and methods

Participants: adults with ID and anxiety or depression (author dened)

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

-Signicant difference between the groups at the three time points

-Signicant group by time (pre-test to post-test) interaction effect

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

First Author (year)

-Signicant decrease in global severity index (p < .05), and anxiety

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

First Author (year)

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

First Author (year)

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

3.4.3. Qualitative data

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

Terms related to Learning Disabilities: learning disabilit*.mp. OR exp intellectual impairment/

Appendix B. Quality appraisal of the studies

Question/objective sufciently described?

Scoring: 2 = Yes; 1 = Partial; 0 = No; n/a, Not Applicable.

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

Question/objective sufciently described?

Scoring: 2 = Yes; 1 = Partial; 0 = No; n/a, Not Applicable.

Papers included in the review are indicated by an asterisk.

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

G. Unwin et al. / Research in Developmental Disabilities 5152 (2016) 6075

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