therapist talking with autism patient with depression
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Summary: Evidence shows the best treatment for depression among people with autism is mindfulness -based psychotherapy, with promising results also identified for social, academic, and skills-based training modalities.

Key Points:

  • Although co-occurring depression in people with autism is common, the research base for evaluating treatment effectiveness is limited.
  • Many studies show inconsistent results and moderate quality of design, i.e. no control group, small sample size, narrow/limited range of participant characteristics and demographics.
  • Treatments modified for the specific population – adults with ASD, teens with ASD, children with ASD – showed greater effectiveness/efficacy than unmodified treatment approaches.

People With Autism/Autism Spectrum Disorders and Depression Treatment: The Latest Large-Scale Studies

In the publication “Treatment of Depression in Individuals with Autism Spectrum Disorder: A Systematic Review,” a group of mental health research noted that no thorough review of treatment for depression for people with autism had been conducted in over ten years, and therefore identified this goal:

“[We] aimed to systematically examine the efficacy of psychosocial and pharmacological treatments for depression in youth and adults with ASD to inform clinical practice.”

To that end, they reviewed data from 25 studies on depression in people with autism in order to answer the following two questions:

  1. What is the evidence supporting the efficacy of psychosocial treatments for symptoms of depression in individuals with ASD?
  2. What is the evidence supporting the efficacy of pharmacological treatments for symptoms of depression in individuals with ASD?

We’ll review their results in a moment. First, we’ll share the latest data on rates of co-occurring mental health disorders in people with autism. Here’s the most recent data on co-occurring mental health disorders among people with autism, collected from a variety of sources, listed below.

Autism and Mental Health Disorders: With ASD/No ASD

(% of people with disorder with ASD / % of people with disorder without ASD)

  1. Depressive disorders: 34% / 7.4%
  2. Anxiety disorders: 28% / 21%
  3. Attention-deficit hyperactivity disorder (ADHD): 22% / 6%
  4. Sleep-wake disorders: 21% / 20%
  5. Obsessive-compulsive disorder (OCD): 10% / 2.3%
  6. Schizophrenia spectrum disorders: 10% / 1.5%
  7. Impulse/conduct disorders: 7% / 4%
  8. Bipolar disorders: 9% / 4.4%

(Sources: “Prevalence of Co-Occurring Conditions in Children and Adults With Autism Spectrum Disorder: A Systematic Review and Meta-Analysis,” the Centers for Disease Control (CDC), Major Depression – National Institute of Mental Health (NIMH), Anxiety Disorders – National Institute of Mental Health (NIMH), Attention-Deficit/Hyperactivity Disorder (ADHD) – National Institute of Mental Health (NIMH), Obsessive-Compulsive Disorder (OCD) – National Institute of Mental Health (NIMH), Schizophrenia – National Institute of Mental Health (NIMH), Bipolar Disorder – National Institute of Mental Health (NIMH))

Those figures indicate that co-occurring mental health disorders among adults with autism are common, with co-occurring depression showing the highest rates, followed by anxiety and ADHD.

But why?

Research shows associations between increased risk of depression in people with autism and the following factors:

In addition, the authors of the study we focus on in this article suggest/hypothesize that the following factors also contribute to/increased risk of depression in people with autism:

  • Differences in social skills
  • Differences in communication ability/style
  • Negative social experiences including bullying and loneliness

With that information in front of mind, let’s take a look at the results of the study we introduce at the beginning of this section.

What Kinds of Depression Treatment Help People With Autism?

After a thorough methodological and statistical review of 25 peer-reviewed studies on depression in people with autism, the researchers reported the outcomes we share below. We’ll start with the results for the various psychotherapies/counseling approaches included for review.

Treatment for Depression in People With Autism: Psychotherapies

  1. Mindfulness-based therapy (MBT):
    • Significant improvement in depressive symptoms compared to control groups
    • Moderate strength of evidence
  1. Social/Academic/Vocational skills training:
    • Mixed outcomes
    • Some studies showed significant improvement in depressive symptoms
    • Some showed improvement in depressive symptoms in college-age students only
    • Others showed no improvement in depressive symptoms
    • Therefore, strength of evidence considered low
  1. Cognitive-Behavioral therapy (CBT):
    • Improvement in depressive symptoms observed in some studies
    • Inconsistent evidence
    • Low strength of evidence
    • More research needed to confirm efficacy
  1. Cognitive remediation therapy:
    • No improvement in depressive symptoms
  1. Behavioral therapy:
    • Small improvements in depressive symptoms identified
    • Low strength of evidence
  1. Combined psychosocial intervention:
    • No improvement in depressive symptoms

MBT showed the most promising results among psychotherapeutic modalities for treatment of depression in people with autism, based on clinical effectiveness and strength of study quality, followed by skills training approaches and cognitive behavioral approaches.

Next, we’ll share their findings on the various medications for depression in people with autism included for review and analysis.

Treatment for Depression in People With Autism: Medications

  1. Anti-epileptic drug (AED):
    • Small improvement in depressive symptoms
    • Low strength of evidence
  1. Norepinephrine reuptake inhibitor (NRI)
    • Small improvement in depressive symptoms in youth with autism
    • Low strength of evidence
  1. Stimulant medication:
    • Improvement in depressive symptoms identified in youth with autism
    • Low strength of evidence
  1. Atypical antipsychotic medication (AAs):
    • Significant improvement in depressive symptoms
    • Frequent negative side effects
    • Moderate quality study design
    • Low strength of evidence
  1. NMDA receptor antagonist:
    • One case study on one patient administered intranasal ketamine
    • Self-report only
    • Participant reported significant improvement in depressive symptoms
    • Due to nature of study – one participant self-reporting results – the strength of evidence for intranasal ketamine considered low

While these results favored the anti-epileptic medication reviewed, that study was restricted to a single case study. Results also showed improvement with NRIs, but over 90% of patients reported negative/problematic side effects.

We’ll discuss these results further, below.

Modified Treatments and Skills Training for Adults, Potential for Stimulant Medication in Adolescents

We won’t pull any punches here. Although some of these results are promising, the overall strength of evidence for treatment for depression in people with autism needs improvement.

The most promising results for psychotherapeutic approaches appeared in mindfulness-based therapy (MBT). However, those studies included only high-functioning adults, which explains why researchers consider the strength of evidence as moderate, rather than strong.

After MBT, both skills-based training and cognitive-behavioral therapies (CBTs) showed positive results and outcomes. However, like the studies on MBT, study design precluded classifying the results as moderate or strong, and instead – based on objective, established, third party criteria defined by the US Agency for Healthcare Research and Quality (AHRQ) – revealed the strength of evidence was appropriately classified as low.

The most promising results for medications were also constrained by study design. For instance, NRIs showed significant improvement, but the side effect profile was overwhelmingly negative, with 91 percent of participants reported unwanted, adverse experiences with NRIs. After NRIs, stimulant medication showed positive outcomes, but the study size and participants – 11 youth ages 9-15 – meant the overall strength of evidence was low.

We’ll reiterate something we mention above. Among the psychotherapies/therapies assessed, those with intentional modifications for people with autism were the most effective. In addition, five out of the seven studies on CBT showed significant reductions in depressive symptoms for people with autism, but due to inconsistent design parameters, the strength of evidence was classified as low.

In closing, we’ll offer this insight from the study authors:

“Future studies should investigate the replicability of findings regarding the effectiveness of MBT in adults with ASD for symptoms of depression. Also, as PEERS®, a social skills manualized treatment, has been found to improve symptoms of depression in youth with ASD, the intervention should be further investigated as a treatment for depression.”