Depression can co-occur with autism spectrum disorder. It presents some unique challenges for individuals, clinicians, and care providers. Signs and symptoms of depression may be more difficult to observe in individuals who also have symptoms of autism. Although treatments of depression are similar in people with or without autism, there is little research on how the combination of autism and depression may affect treatment outcomes. 

What is Depression

Major depressive disorder and other clinically diagnosed instances of depression are different from a passing feeling of sadness. Depression is a psychological disorder that persists for at least two weeks and may be intense. 

Symptoms of depression include: 

• Sadness
• Loss of interest in formerly enjoyable activities
• Changes in appetite
• Weight loss or weight gain
• Slowing of thought and physical movement
• Restlessness
• Fatigue and loss of energy 
• Feelings of worthlessness or excessive guilt
• Indecisiveness
• Thoughts of self-harm or suicide

An individual experiencing depression may also have signs of anxiety. Both of these conditions have symptoms that overlap with autism spectrum disorder. These similarities of symptoms necessitate careful evaluation by a knowledgeable professional to identify depression in an individual with autism.

How Common is Depression

Depression is among the most common psychiatric disorders in the U.S. Almost 7% of all U.S. adults experienced at least one major depressive episode in the last year. The incidence of depression is increased in people with autism. The CDC estimates that depression affects about 26% of people with autism (10:11 in this webinar on Anxiety, Depression & Sleep).

In her webinar on Anxiety, Depression & Sleep, Jana Rundle, Psy. D. says that individuals with autism may be three times more likely to have episodes of depression compared to the general population. The question is, why?

There are several theories. Dr. Rundle points out that many people with autism excel at attention to detail and focusing on one topic or idea. While this can be a valuable skill, it also puts people with autism at higher risk for depression. Rumination, the act of thinking over and over about a negative interaction or feeling, is a major contributor to depression. When attention to detail becomes fixated on negative experiences, individuals with autism may have a higher risk of depression. Some people with autism may also have differences in executive function, which can make it difficult for them to redirect their thoughts away from rumination

A study of adults with autism found that “Self-reported social impairments predicted depression in adults with autism spectrum disorder when accounting for symptom severity and cognitive ability. These findings suggest that more self-perceived social impairments are related to depressive disorders in autism spectrum disorder.” The pressure to interact in particular ways may make social interactions more difficult for some individuals with autism. Insufficient support and resources for challenges related to ASD may contribute to feelings of isolation, exclusion, or solitude, which can lead to depression. 

How to spot signs of depression

Signs of depression may be obvious, or they may be difficult to spot. Some individuals with autism, especially children, may struggle to recognize or express their feelings. Individuals and caregivers can stay alert to changes in behavior that might indicate depression. These could include: change in appetite, weight, sleep, energy, or interest. 

Depression can sometimes look like tiredness or irritability. Pay attention to how these behaviors change over time and whether they have an obvious cause. For example, staying up late to finish a report due the next day may cause tiredness and increased appetite. In that case, the symptoms have a clear cause. However, if they persisted for weeks, they might be signs of depression or another psychological disorder such as anxiety. 

Consider keeping a journal to track moods and behaviors. Written records tend to be more reliable than memory or casual observation – record changes in sleep patterns, appetite, weight, interest, and overall mood. 

Strategies to Address Depression

The treatments used to treat depression in individuals with autism are similar to those used in the general population. Some slight modification may be needed to account for differences in thinking, communication, or behavior.

• Psychotherapy – Specifically, modified cognitive behavioral therapy has been shown effective to treat depression in people who also have autism spectrum disorder. CBT and other psychotherapies can help address rumination and other thought processes related to depression.
• Medication – Antidepressant medications are most useful when combined with some form of therapy. Research shows that medication alone may be less effective than other treatments. More research is needed into the possible effects and side effects of depression medication in individuals with autism. 
• Combination of Psychotherapy and Medication – Research has shown that a combination of medication and psychotherapy is among the more effective treatments for depression.

Researchers are still investigating how these strategies and treatments can be modified to better support individuals with autism and depression. Work with your clinician to identify strategies and treatment options.

For more on depression and autism, check out this video presented by Amanda Tami, MA, BCBA, LBA, LPC.

ARI thanks Amanda Tami, MA, BCBA, LBA, LPC, of The Johnson Center for Child Health and Development for her contributions to this article.