Gender differences in self-reportedsymptoms of depression and anxiety inadults with intellectual disabilities

Rebecca Chester, Eddie Chaplin, Elias Tsakanikos, Jane McCarthy, Nick Bouras andTom Craig

Rebecca Chester is a Lecturer

Practitioner in Learning

Disability Nursing at the

University of Hertfordshire,

Reading, UK.

Eddie Chaplin is Research and

Strategy Lead at the Estia

Centre, South London and

Maudsley NHS Foundation

Trust, London, UK.

Elias Tsakanikos is a Reader in

Psychology at the Department

of Psychology, Roehampton

University, London, UK and the

Health Service and Population

Research Department, Institute

of Psychiatry, King’s College

London, London, UK.

Jane McCarthy is a Clinical

Director, Nick Bouras is a

Professor Emeritus and Tom

Craig is a Professor, all at the

Institute of Psychiatry, King’s

College London, London, UK.

Abstract

Purpose – This study aimed to examine for differences on how symptoms relating to depression and

anxiety were reported by males and females with intellectual disability as part of the development of the

Self-Assessment Intervention Package (SAINT), a guided self-help tool.

Design/methodology/approach – Three self-report questionnaires were administered ( The Glasgow

Depression Scale – Learning Disabilities (GDS-LD)), Glasgow Anxiety Scale – Intellectual Disabilities

(GAS-ID) and Self-Assessment Intervention Package (SAINT ) to a group of people with mild intellectual

disabilities (n¼ 36), to allow comparison of symptom reporting between genders, in particular examining the

SAINT across the two groups.

Findings – Statistically significant differences in self-reported symptoms as assessed with SAINT were

found between males and females. The symptoms where related mainly to mood and self-esteem. Overall,

endorsement of self-reported depressive symptoms was between 2.7-3.2 times higher in female than

male patients.

Originality/value – There was evidence to suggest differences in self-report and symptom profiles of

depression and anxiety of males and females with mild intellectual disabilities with females reporting higher

in terms of symptoms using the SAINT. The SAINT is a valid tool for screening and self-reporting symptoms

of anxiety and depression in people with intellectual disabilities.

Keywords Intellectual disabilities, Depression, Anxiety, Gender, Self-report, Disabilities

Paper type Research paper

Introduction

This study aimed to examine gender differences in adults with mild intellectual disabilities

in terms of symptoms of depression and anxiety. The working hypothesis was that females

self-report differently to males.

Mood and anxiety disorders are the most common diagnoses of mental illness in people with

intellectual disabilities with estimates for mood disorders 5.5 per cent, depression 3.8 per cent

(Cooper et al., 2007) and anxiety disorder 6 per cent (Smiley, 2005). It is acknowledged that

people with intellectual disabilities are at greater risk of developing mental illness than the

general population with rates reported between 10 and 39 per cent (Deb et al., 2001). This

variation is likely for a number of reasons including definition used, identification and sampling

issues such as the inclusion and exclusion of challenging behaviour (Brothwick-Duffy, 1994).

There is some evidence of gender differences for specific diagnoses such as depression

(Smiley, 2005), with prevalence estimates for affective disorder reported at 5.5 per cent for

males and 8 per cent for female in people with intellectual disabilities (Cooper et al., 2007).

A number of studies have provided evidence to support higher rates of depression in women

DOI 10.1108/AMHID-03-2013-0025 VOL. 7 NO. 4 2013, pp. 191-200, C Emerald Group Publishing Limited, ISSN 2044-1282 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 191

(Birleson, 1981; Esbenson et al., 2005; Lunsky, 2003; Meins, 1993), although there are studies

that have found no relationship with gender (Aliley, 2009).

The higher levels of depression experienced by people with intellectual disabilities may be due to

a range of factors including a biological predisposition, increased exposure to adverse

psychosocial experiences and limited cognitive ability (McGillivray and McCabe, 2007). There is

evidence to suggest that symptoms of depression for people with intellectual disabilities are

similar to those within the general population, such as abusive experiences, poor social support

unemployment and social disadvantage (Meins, 1993; Aliley, 2009). A population-based study

of affective disorders for people with intellectual disabilities identified distinct characteristics

relating to female depression not only were rates of depression higher but the diagnosis was

associated with the following characteristics: more significant life events, smoking,

incontinence, type of accommodation including level of support; with a higher prevalence for

those living with paid carer support, lower ability, increased consultations and the absence of

severe physical disabilities and immobility, (Cooper et al., 2007).

To be able to identify signs of mental illness in people with intellectual disabilities we need to

understand how they present. This means knowing how individuals express themselves and if

this is different between the sexes. This is not only in line with recovery-focused approaches that

put the individual at the centre of services but challenges the notion of the “typical presentation”.

Two of the measures used in this study identify symptoms to assist making a diagnosis. The third

the Self-Assessment Intervention Package (SAINT) as well as self-report statements it has an

emphasis on self-management and also contains coping strategies and a diary offering

scope not only to examine how males and females differ in reporting but also in coping with

these symptoms.

Method

The study used three measures to examine differences in the reporting of symptoms of anxiety

and depression in males and females:

1. The Glasgow depression scale for people with intellectual disabilities (GDS-LD) (Cuthill

et al., 2003) consists of 20 items, with three response categories: never/no (0), sometimes (1)

or always/a lot (2), with five items reverse scored.

2. The Glasgow anxiety scale for people with intellectual disabilities (GAS-ID) (Mindham and

Espie, 2003) was developed as a self-rating tool to assess anxiety disorders in people

with intellectual disabilities it has 27 items and is scored like the GDS-LD. There are three

sub-groups to the tool, worries (ten questions), specific fears (nine questions) and

physiological symptoms (eight questions).

3. The SAINT (Chaplin et al., 2012a, b) is a self-assessment tool for people with intellectual

disabilities to use on a daily basis to identify symptoms of mental distress. There are two

sections: a feelings list and a list of things people can do to help them cope. It is a short

ten-item questionnaire written in an accessible format to promote independent use. The

Cronbach’s a suggested high internal consistency for the questionnaire at 0.868 (all n¼ 46

unless stated). With inter item correlation for internal consistency for any item deleted

ranged from 0.821 to 0.853. For convergent validity the Spearman’s r correlation coefficient

was calculated for the SAINT Total, GDS-LD Total and GAS-ID worries The SAINT showed

significant correlation at the 0.01 level (two-tailed) with the GDS-LD (r¼ 0.801), GAS-ID

worries (r¼ 0.658). The test-retest showed statistically significant correlation between Time

1 and Time 2 (r¼ 0.914, po0.01) (Figure 1).

Participants

The inclusion criteria for participants were:

’ aged over 18;

’ mild intellectual disabilities as defined by an IQ of between 50 and –70; and

’ evidence of/or history of affective disorder or anxiety disorder.

PAGE 192 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j VOL. 7 NO. 4 2013

Figure 1 SAINT, GDS-LD and GAS-ID items

4. Do you worry about what will happen in the future? (tailored to the individual; e.g. What will happen if you can’t live with your mum anymore?)

5. Have you made sure you have washed yourself, worn clean clothes, brushed you teeth and combed your hair?

Glasgow Anxiety Scale for People with IntellectualDisabilities Worries

1. Do you worry a lot? (...feel worked up/wound up/uptight/up to high doh)

2. Do you have lots of thoughts that go round in your head? (...thoughts that you can’t stop/come from nowhere)

3. Do you worry about your parents/family?

5. Do you worry that something awful might happen?

6. Do you worry if you do not feel well? (...if you feel sick)

10. Do you worry about death/dying?

9. Can you stop worrying? (reverse score)

8. Do you worry about what you are doing tomorrow?

7. Do you worry when you are doing something new? (...like for the first time)

Glasgow Depression Scale for People withIntellectual Disabilities

In the last week

1. Have you felt sad?a. Have you felt upset?b. Have you felt miserable?c. Have you felt depressed?

2. Have you felt as if you are in a bad mood?a. Have you felt bad-tempered?b. Have you felt as if you want to shout at people?

3. Have you enjoyed the things you have done?a. Have you had fun?b. Have you enjoyed yourself?

4. Have you enjoyed talking to people and being with other people?

a. Have you liked having people around you?

b. Have you enjoyed other people’s company?

a. Have you taken care of the way you look?b. Have you looked after your appearance?

a. Have you gone to sleep during the day?b. Have you found it hard to stay awake during the day?

6. Have you felt tired during the day?

7. Have you cried?

8. Have you felt you are a horrible person?a. Have you felt others don’t like you?

VOL. 7 NO. 4 2013 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 193

Figure 1 (continued )

9. Have you been able to pay attention to things (such as watching TV)?a. Have you been able to concentrate on things (like television programmes)?

b. What is your favourite [television programme]? Are you able to watch it from start to finish?

b. Have you found it hard to choose between two things?[Give concrete example if required.]

a. Have you found it hard to decide what to wear, or what you would like to eat, or do?

10. Have you found it hard to make decisions?

b. Have you been moving about a lot, like you can’t help it?

a. Have you fidgeted when you are sitting down?

11. Have you found it hard to sit still?

12. Have you been eating too little?

a. Have you been eating too much?

b. Do people say you should eat more/less?

c. [Positive response for eating too much OR too little is scored.]

13. Have you found it hard to get a good night’s sleep?

a. [Ask questions to clarify information. If a positive response is given to one of the following, score positively.]

b. Have you found it hard to fall asleep at night?

c. Have you woken up in the middle of the night and found it hard to get back to sleep?

d. Have you woken up too early in the morning? [Clarify time.]

14. Have you felt that life is not worth living? (GAS-ID)a. Have you wished you could die?

b. Have you felt you do not want to go on living?

15. Have you felt as if everything is your fault?

a. Have you felt as if people blame you for things?

b. Have you felt that things happen because of you?

16. Have you felt that other people are looking at you, talking about you, or laughing at you?

a. Have you worried a bout what other people think of you?

17. Have you become very upset if someone says you have done something wrong or you have made a mistake?

a. Do you feel sad if someone tells you.../gives you a row?

b. Do you feel like crying if someone tells you.../gives you a row?

18. Have you felt worried?

a. Have you felt nervous?b. Have you felt tense/wound up/on edge?

PAGE 194 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j VOL. 7 NO. 4 2013

Figure 1 (continued )

19. Have you thought that bad things keep happening to you?

a. Have you felt that nothing nice ever happens to you anymore?

20. Have you felt happy when something good happened? [If nothing good has happened in the past week

a. If someone gave you a nice present, would that make you happy?

SAINT

1. I am having bad thoughts

I feel people can control me

I have stopped activities and/or going out

• I feel like I can’t go on• I feel like hurting myself• I don’t want to be alive

People would be better off without me

2. I am not feeling myself• I am hearing things that are not there• I feel people know what I am thinking• I feel people can play with my thoughts

3. I feel in a panic• I feel my heart pounding• I feel hot and cold• I have the shakes

I am sweating

4. I find it difficult to do things (GDS-10)• I am losing interest in things• I don’t feel like going out• I can’t be bothered to change my clothes

5. I am having problems sleeping (GDS13)• I have trouble getting off to sleep• I have trouble waking up• I keep getting up during the night

I feel tired all the time

6. I feel down today (GDS 1)

• I am worried about my temper

I am worried about drinking too much and/or drugs• I feel angry

7. I don’t feel in control (GDS 2)

I feel stressed• I feel tense• I feel worried• I feel sad

VOL. 7 NO. 4 2013 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 195

Exclusion criteria for participants were:

’ service users who lack capacity.

Sample

This is a small sample with a large proportion of male participants recruited from inpatient

settings compared to females. Totally, forty-five participants were recruited to the study. Of these

nine participants (n¼ 9) did not take part or complete the study. Of the nine, seven participants

lacked capacity as defined under the principles of the Mental Capacity Act 2005 (Office of

the Public Guardian, 2005), one participant changed their mind and one became unwell and

was unable to participate. The total end sample consisted of 36 participants, all with mild

intellectual disabilities. The ratio of males to females was 21 males (58.3 per cent) and 15

females (41.7 per cent). Participants were aged between 18 and 65 with a total mean of 39 years

of age (SD¼ 12.021). Male participants were aged 18-59 with a mean age of 37 (SD¼ 11.879)

and female participants were aged 18-65 with a mean age of 41 (SD¼ 12.264).

Procedure

All participants were tested using the GDS-LD, GAS-ID and the SAINT. Interviews were

conducted in community and in-patient settings and took between 10 and 20 minutes to

complete. Ratings were made by two registered nurses experienced in working with people

intellectual disabilities and co-morbid mental health problems.

Analysis

Statistical analysis was undertaken using the Statistical Package for Social Science, Version 19

(SPSS 19). Independent-sample t-tests were used to compare scores on the employed

measures for males and females with intellectual disabilities.

Results

Total scores

For the SAINT scores, there was a statistically significant difference in total mean for males

(mean¼ 1.53, SD¼ 1.35) and females (mean¼ 4.67, SD¼ 3.31) with females reporting almost

three times more symptoms than males, t(17.387)¼�3.47, p¼ 0.003.

Figure 1 (continued )

I cannot concentrate on things• I am not washing or bathing• I am not eating well• I am not taking good care of myself

10. Looking after myself (GDS 5)

I am in pain• I feel unwell• I feel heartbroken• My mood keeps going up and down

9. I feel emotionalI keep letting people down

• I feel everyone hates and ignores me• I feel my life will not get any better• I feel people do not like me

8. I feel bad about myself (GDS 8)

PAGE 196 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j VOL. 7 NO. 4 2013

In terms of the GDS-LD scores, females had a higher total mean score (mean¼ 10.33,

SD¼ 8.73) than males (mean¼ 6.33, SD¼ 6.56), although this was not statistically significant,

t(34)¼�1.57, p40.10. The GAS-ID reported that females had a higher total mean score

(mean¼ 18.13, SD 13.01) than males (m¼ 13.0, SD 7.596) but again this was not significant

t(34)¼�1.49, p40.10. Overall, females had higher total scores of self-reported symptoms of

depression, anxiety and mental distress than male participants across the three measures. This

was statistically significant for the SAINT but not for the GDS-LD or GAS-ID scores.

Individual symptoms and sub-scales

Further comparisons between males and females were performed on individual symptoms and

GAS-ID sub-scales: worries, specific fears and physiological symptoms. A number of significant

differences were revealed in that females scored higher than males on the following items: “I feel

down today” (SAINT item 6), for females (mean¼ 0.60, SD¼ 0.51) and for males (mean¼ 0.19,

SD¼ 0.40), t(25)¼�2.59, p¼ 0.015; “I feel bad about myself” (SAINT item 8), it was higher for

females (mean¼ 0.53, SD¼ 0.51) compared to males (mean¼ 0.19, SD¼ 0.40), t(25)¼�2.15,

p¼ 0.041); ‘Have you felt that other people are looking at you, talking about you, or laughing at

you? (GDS-LD item 16), for males lower (mean¼ 0.14, SD¼ 0.478) than females (mean¼ 0.67,

SD¼ 0.816) t(20.823)¼�2.227, p¼ 0.037: “Have you worried about what other people think

of you?” and do you feel scared in wide open spaces? (y.nothing round about you) (GDS-LD

item 19), for males was lower (mean¼ 0.10, SD¼ 0.30) than females (mean 0.67, SD¼ 0.82).

The measurement of difference between males and females for this item was the largest of the

total scores and individual item scores with females reporting about seven times higher than

males, t(16.736)¼�2.588, p¼ 0.000.

Discussion

There is a scarcity of research that examines the different self-report profiles of males and

females with intellectual disabilities with depression and/or anxiety. There is concern that self-

reported symptoms are expressed differently in depressed males (Poutanen et al., 2009; Dekker

et al., 2007). In terms of choice of measures for the study recent reviews (Hermans and

Evenhuis, 2010; Hermans et al., 2011) have identified both the GDS-LD and GAS-ID as the most

capable of the tools in identifying self-reported symptoms of depression for people with

intellectual disabilities. The SAINT has also demonstrated good internal consistency and

reliability with significant correlation to the GDS-LD and GAS-ID suggesting that it is a valid

tool for screening and self-report for depression and anxiety in people with intellectual disabilities

(Chaplin et al., 2012b).

Many people that are referred to clinics do not meet the threshold for a clinical diagnosis but it

may be how people act and behave that necessitates referral. A recent study of a specialist

mental health clinic population found although females were less likely to receive a diagnosis

they were more likely to receive sedatives (Tsakanikos et al., 2011). The lack of a clinical

diagnosis can sometimes mask the real picture. An earlier study reported higher rates of

adjustment reactions (AR) in women with intellectual disabilities. AR is characterised by high

levels of anxiety and depression that fall below the threshold of a clinical diagnosis and is a

reaction to a stressor in the last three months (Tsakanikos et al., 2006).

The main aim of this study was to gain a better understanding of how males and females with

intellectual disabilities self-report symptoms of mental illness, primarily depression and anxiety.

Overall females reported higher levels of psychopathology including symptoms of depression

and anxiety using the SAINT, GDS-LD and GAS-ID compared to males. However, this was only

statistically significant for the SAINT, which measures mental distress as a general concept. Why

this should be so is unclear it may be that females with intellectual disabilities are more likely to

endorse general statements of distress as assessed by the SAINT rather than more specific

depressive symptoms. It may be that this style of questioning is more easily understood given

difficulties in reporting within this group (Larson et al., 2011). We found that females self-report

differently to males, evidenced by increased levels of self-report of symptoms using the SAINT

although this was not the case with the GDS-LD and GAS-ID. The general increased self-report

by females is in agreement with previous findings in the general population where there is

VOL. 7 NO. 4 2013 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 197

evidence regarding increased prevalence and self-report of depressive symptoms

by females (Dekker et al., 2007). Furthermore, the overall increase in depressive symptoms

for females with ID was consistent with other studies that employed either interviews or reports

by carers (Esbenson et al., 2005; Lunsky, 2003; Meins, 1993; Lunsky and Benson, 2001;

Heiman, 2001).

The SAINT total suggested that women self-reported symptoms of mental distress three times

higher than males. This is higher than identified from previous reports that females were

approximately one and a half times more likely to receive a diagnosis of affective disorders

(Cooper et al., 2007). Disparity may be due to differences in methodology and criterion used as

the SAINT identifies symptoms of mental distress including anxiety and depression. The SAINT

has not been developed as a diagnostic tool but as a tool for self-managing mental distress and

promoting wellness. The GDS-LD total score reported an increased ratio of self-report from

females of 1.6 times higher than males but this finding was not statistically significant.

Although women reported higher levels of anxiety, this did not reach significance using the

GAS-ID. This supports other studies where anxiety has not been reported to be significantly

increased for women with intellectual disabilities (Pickersgill et al., 1994; Glenn et al., 2003).

In terms of the GAS-ID fears section there was increased reporting of fears in females compared

to males for people without intellectual disabilities, but there was no significant increase in self-

report of fears for women compared to men with intellectual disabilities. In terms of symptom

profiles of mental distress, depression and significant differences were found for individual items

of the SAINT, GDS-LD and GAS-ID. Females had significantly increased self-report for SAINT6,

“I feel down today”, SAINT8, “I feel bad about myself”. GDS-16 “Have you felt other people are

looking at you, talking about you, or laughing at you? Have you worried what other people think

of you?” and GAS-ID19, “do you feel scared in wide open spaces?”

Women generally reported higher than males for individual items of the GDS-LD, GAS-ID and

SAINT although there were three individual items in the GDS-ID that males reported higher than

females and two items reported at the same or marginally different to females. This suggests that

the GDS-LD is sensitive to identifying symptoms of depression associated with men with

intellectual disabilities. Although these areas were not statistically significant, they warrant

discussion. The highest increased self-report for males compared to females was GDS-LD 12,

“Have you been eating too little/have you been eating too much?” Men were 2.174 times more

likely to report this symptom than females. Men also reported higher levels for GDS-LD 13, Have

you found it difficult to get a good nights sleep?’ and GDS-LD 6, “Have you felt tired during the

day?” These symptoms relate to somatic symptoms of depression opposed to psychological

symptoms of depression. The increased presence of tiredness in males compared to females in

people without intellectual disabilities has also been reported (Poutanen et al., 2009). There is no

evidence regarding gender, depression and intellectual disabilities to compare the findings of the

current study. The high ratio of males to females from inpatient services may have contributed to

a skew in the results as people in inpatient services may have higher mental health needs.

A larger sample would have been desirable to match participants for age, ethnicity and by

current services being accessed to infer more from the findings. The study has highlighted

differences in reporting between males and females. This type of study is difficult to generalise

with previous studies producing inconsistent results and finding no difference which may be

down to simple methodological problems such as sample size and measures (Heiman, 2001).

Conclusion

The present study showed clear gender differences in self-reported symptoms profiles of

depression and anxiety in a group of adults with ID. Using the SAINT, a self-report inventory

specifically designed for this population, females were found to report three times more

symptoms of depression and general distress. This supported the hypothesis that females

self-report differently to males evidenced by increased levels of self-report of symptoms of

mental distress using the SAINT in female participants. Using the GDS-LD female symptom

reporting was higher than males although this was not statistically significant. Finally the GAS-ID

self-report for females was 1.34 times higher than males.

PAGE 198 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j VOL. 7 NO. 4 2013

Data across the three questionnaires demonstrated that females had higher total scores

of self-reported symptoms of depression and anxiety than male participants with a number

of items reaching significance. The increase in self-report of females was statistically significant

for the SAINT total score but was not statistically significant for the total GDS-LD or total

GAS-ID score.

What do we already know on this topic?

’ prevalence estimates of affective disorders are reported to be higher in females than males

(Cooper et al., 2007);

’ higher rates of depression are reported by females than males (Birleson, 1981; Esbenson

et al., 2005; Lunsky, 2003; Meins, 1993);

’ there is a dearth of research in to the symptom profiles and characteristics of anxiety or

depression for males and females with intellectual disabilities; and

’ cooper et al. (2007) identified more significant life events, smoking, incontinence, type of

accommodation including level of support, lower ability, increased consultations and the

absence of severe physical disabilities and immobility with higher rates of depression in

female patients with intellectual disabilities.

What more does this study contribute?

’ the present study showed clear gender differences in self-reported symptoms profiles of

depression and anxiety in a group of adults with intellectual disabilities;

’ females were found to report three times more symptoms of depression and general distress

than males with intellectual disabilities;

’ the SAINT is a valid tool for screening and self-reports of symptoms of depression and

anxiety; and

’ due to the self-report element of the SAINT this tool could be used to support recovery

focused approaches for people with intellectual disabilities.

References

Aliley, S. (2009), “The sensitivity and specificity of depression screening tools among adults with intellectual

disabilities”, Journal of Mental Health Research in Intellectual Disabilities, Vol. 2 No. 1, pp. 45-64.

Birleson, P. (1981), “The validity of depressive disorder in childhood and the development of a self-rating

scale: a research report”, Journal of Child Psychology and Psychiatry and Allied Disciplines, Vol. 22 No. 1,

pp. 73-88.

Brothwick-Duffy, S.A. (1994), “Epidemiology and prevalence of psychopathology in people with mental

retardation”, Journal of Consulting and Clinical Psychology, Vol. 62 No. 1, pp. 17-27.

Chaplin, E., Craig, T. and Bouras, N. (2012), “Using service user and expert opinion, to identify and review

items for the SAINT: a guided self-help pack for adults with intellectual disability”, Advances in Mental Health

and Intellectual Disabilities, Vol. 6 No. 1, pp. 17-25.

Chaplin, E., Chester, R., Tsakanikos, E., McCarthy, J., Craig, T. and Bouras, N. (2012), “Reliability and validity

of the SAINT: a guided self help tool for people with intellectual disabilities”, Journal of Mental Health

Research in Intellectual Disabilities, Vol. 110 No. 6, pp. 469-81.

Cooper, S.A., Smiley, E., Morrison, J., Williamson, A. and Allan, L. (2007), “An epidemiological investigation

of affective disorders with a population-based cohort of 1023 adults with intellectual disabilities”,

Psychological Medicine, Vol. 37 No. 6, pp. 873-82.

Cuthill, F.M., Espie, C.A. and Cooper, S-A. (2003), “Development and psychometric properties of the

Glasgow depression scale for people with a learning disability individual and carer supplement versions”,

British Journal of Psychiatry, Vol. 182 No. 4, pp. 347-53.

Deb, S., Matthews, T., Holt, G. and Bouras, N. (2001), Practice Guidelines for the Assessment and Diagnosis

of Mental Health Problems in Adults with Intellectual Disability, Pavilion, Brighton.

VOL. 7 NO. 4 2013 j ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES j PAGE 199

Dekker, J., Koelen, J.A., Peen, J., Schoevers, R.A. and Gijsbers-Van Wijk, C. (2007), “Gender differences in

clinical features of depressed outpatients: preliminary evidence for subtyping of depression?”, Women &

Health, Vol. 46 No. 4, pp. 19-38.

Esbenson, A.J., Seltzer, M.M., Geenberg, J.S. and Benson, B.A. (2005), “Psychometric evaluation of

a self-report measure of depression for individuals with mental retardation”, Vol. 110, pp. 469-81.

Glenn, E., Bihm, E.M. and Lammers, W.J. (2003), “Depression, anxiety and relevant cognitions in persons

with mental retardation”, Journal of Autism and Developmental Disorders, Vol. 33 No. 1, pp. 69-76.

Heiman, T. (2001), “Depressive mood in students with mild intellectual disability: students’ reports and

teachers’ evaluations”, Journal of Intellectual Disability Research, Vol. 45 No. 6, pp. 526-34.

Hermans, H. and Evenhuis, H.M. (2010), “Characteristics of instruments screening for depression in adults with

intellectual disabilities: systematic review”, Research in Developmental Disabilities, Vol. 31 No. 6, pp. 1109-20.

Hermans, H., van der Pas, F.H. and Evenhuis, H.M. (2011), “Instruments assessing anxiety in adults with

intellectual disabilities: a systematic review”, Research in Developmental Disabilities, Vol. 32 No. 3, pp. 861-87.

Larson, F.V., Alim, N. and Tsakanikos, E. (2011), “Attachment style and mental health in adults with

intellectual disability: self-reports and reports by carers”, Advances in Mental Health and Intellectual

Disabilities, Vol. 5 No. 3, pp. 15-23.

Lunsky (2003), “Depressive symptoms in intellectual disability: does gender play a role?”, Journal of

Intellectual Disability Research, Vol. 47, pp. 417-27.

Lunsky, Y. and Benson, B.A. (2001), “The association between perceived social support and strain and

positive and negative outcome for adults with mild intellectual disabilities”, Journal of Intellectual Disability

Research, Vol. 45 No. 2, pp. 106-14.

McGillivray, J.A. and McCabe, M.P. (2007), “Early detection of depression and associated risk factors

in adults with mild/moderate intellectual disability”, Research in Developmental Disabilities, Vol. 28 No. 1,

pp. 59-70.

Meins, W. (1993), “Prevalence and risk factors for depressive disorders in adults with intellectual disability”,

Australia and New Zealand Journal on Developmental Disabilities, Vol. 18 No. 3, pp. 147-56.

Mindham, J. and Espie, C.A. (2003), “Glasgow anxiety scale for people with an intellectual disability

(GAS-ID): development and psychometric properties of a new measure for use with people with mild

intellectual disability”, Journal of Intellectual Disability Research, Vol. 47 No. 1, pp. 22-30.

Office of the Public Guardian (2005), Mental Capacity Act 2005 Code of Practice, TSO, London.

Pickersgill, M.J., Valentine, J.D. and May, R. (1994), “Fears in mental retardation: part 1 – types of fears

reported by men and women with and without mental retardation”, Advances in Behaviour Research

Therapy, Vol. 16 No. 4, pp. 277-96.

Poutanen, O., Koivisto, A.M., Mattila, A., Joukamaa, M. and Raimo, K.R. (2009), “Gender differences in the

symptoms of major depression and in the level of social functioning in public primary care patients”,

European Journal of General Practice, Vol. 15 No. 3, pp. 161-7.

Smiley, E. (2005), “Epidemiology of mental health problems in adults with learning disability: an update”,

Advances in Psychiatric Treatment, Vol. 11 No. 3, pp. 214-22.

Tsakanikos, E., Bouras, N., Sturmey, P. and Holt, G. (2006), “Psychiatric co-morbidity and gender differences

in intellectual disability”, Journal of Intellectual Disability Research, Vol. 50 No. 8, pp. 582-7.

Tsakanikos, E., Underwood, L., Kravarti, E., Bouras, N. and McCarthy, J. (2011), “Gender differences

in co-morbid psychopathology and clinical management in adults with autism spectrum disorders”,

Research in Autism Spectrum Disorders, Vol. 5 No. 2, pp. 803-8.

Corresponding author

Eddie Chaplin can be contacted at: eddie.chaplin@kcl.ac.uk

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