Depression is a common mental health problem in the overall adult population, regardless of the presence of a physical or learning disability. Depressive symptoms, however, appear more persistent and resistant to treatment in adults with learning disabilities.
Treatment options generally comprise anti-depressant medication and/or psychosocial interventions, with particular attention given to cognitive behavioural therapies, behavioural activation, and more recently mindfulness-based therapies. The range of psychosocial approaches offered to people with learning disabilities, however, is often limited to cognitive behavioural therapies for which the evidence base is strongest. This leaves them with little choice of treatment, despite behavioural activation being found equally effective in the general population.
Behavioural activation is more than merely increasing activity levels, instead it intends to increase purposeful behaviour directed at situations and environmental factors that are likely to be associated with improvements in mood and depressive thoughts.
In this study, the researchers explored the feasibility and efficacy of an individual behavioural activation intervention for adults with depressed mood in Scotland.
The pilot study used a single group design in which adults with learning disabilities were recruited to complete a behavioural activation intervention. Potential participants were referred to the study by clinicians and community nurses who identified the person as having both a learning disability and depressive symptoms.
The intervention was based on a brief behavioural activation treatment used in the general population1(Lejuez et al 2001). In addition to making session materials accessible to people with learning disabilities, the researchers adapted the intervention to target both the person with a learning disability and one significant other, typically a paid carer or family carer. The intervention was delivered by a research psychologist, under the supervision of an experienced clinical psychologist and ran over 10 to 12 weekly or fortnightly sessions at the clients’ home.
Masked assessment of depressive symptoms, activity levels and general well-being was conducted at three time intervals: prior to the intervention, after 3 months and upon completing the intervention, and a follow-up 6 months after starting the intervention.
Twenty-one out of twenty-three recruited participants and their supporters completed the intervention, with a further two participants dropping out prior to the follow-up assessments. This illustrates that it is possible to identify people with depressive symptoms and that the behavioural activation intervention was well-received.
Upon completing the intervention, depressive symptoms had decreased substantially, as recorded by both self-reports and supporter ratings. These changes in mood continued to improve between post-intervention and follow-up.
Behavioural activation did not lead to a significant increase in either community-based activities (for example, pub visits or engaging in sports activities) or domestic activities (for example, cleaning, gardening or cooking).
Finally, the changes in depressive symptoms were accompanied by a simultaneous improvement in general well-being, as reported by the supporters.
Behavioural activation appeared a feasible, acceptable, and possibly effective intervention to treat depressive symptoms in adults with learning disabilities. These findings, however, require replication in larger trials comparing its efficacy to that of a control group.
Strengths and limitations
First, it needs to be clarified that the behavioural activation intervention was not limited to activity planning, but also provided the client and their supporter with an opportunity to explore potential challenges they might face. This included addressing associated anxiety and anger issues.
Second, as with most small-scale pilot studies, there are a few limitations in terms of the sampling strategy. The signposting approach taken by the researchers may have identified people who would be expected to respond well to this type of intervention, and people with less severe depressive symptoms. Indeed, nearly half of the clients did not score above the clinical cut-off for depression at the start of the intervention. However, even for these sub-clinical clients improvements in mood were observed. Likewise, it could be argued that the nine people living in individual tenancies would be more independent and have more control over the scheduling of planned activities compared to those living in residential services with already over-stretched staff.
Third, the apparent lack of change in people’s participation in community and domestic activities may be indicative that the measures used to assess participation may be inappropriate for this study, rather than there being no intervention effect. This may be due to activities requiring more coordination to organise, but could also occur when the new ‘purposeful’ activities replace previously scheduled activities and therefore do not increase the frequency of participation in activities. To assess the behavioural impact of the intervention on activity participation these measure would need to address the meaningfulness and value of these activities for the person, in addition to the frequency of these activities.
In spite of its limitations in terms of sample size, lack of a control condition, potentially biased recruitment and appropriateness of assessment measures, this study makes a strong case for offering behavioural activation interventions to people with learning disabilities and low mood. Furthermore, the positive effects of behavioural activation extent to the supporters who reported an increased understanding of difficulties faced by their clients, which could only benefit their relationship and well-being.
The possibility to offer behavioural activation interventions led by a trained lay-therapist under the supervision of an experienced clinician is particularly encouraging given the search for accessible mental health services and treatments.
Taken together, the findings are promising and, if supported in future research, would widen the range of psychosocial treatments available to people with learning disabilities.
A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities, Jahoda, A., Melville, C. A., Pert, C., Cooper, S.-A., Lynn, H., Williams, C. and Davidson, C. in Journal of Intellectual Disability Research [abstract]
Lejuez, C. W., Hopko, D. R., & Hopko, S. D. A. (2001). Brief behavioral activation treatment for depression. Treatment manual. Behaviour Modification, 25, 255-286.
– Planning purposeful activities with a supporter may improve depressive symptoms.
– Behavioural activation does not increase actual participation in activities.
– Including a significant other may have benefits for both the person with a learning disability, as well as their carer.
– Widening the range of evidence-based treatments: behavioural activation shows promising results in treating depression.