Navigating The Challenges of Diagnosing Depression in ASD

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition with a wide range of challenges in communication, social interactions, and behavior. Many individuals with ASD suffer from sensory sensitivities to loud noises or bright lights and repetitive behaviors, ranging from hand flapping to rigid routine adherence.

ASD has an early onset where individuals can receive a diagnosis by two to three years of age. As the name implies, ASD is a spectrum with some individuals having minor symptoms compared to more severe cases, requiring significant support and assistance. Mild cases may be more difficult to diagnose.

Regardless of age at diagnosis, ASD is a lifelong condition. Without early and appropriate intervention, ASD can lead to mental health problems like depression. According to a 2019 study, people with ASD are four times more likely to experience an episode of depression than the general population. This is especially dangerous since ASD can mask symptoms and make a mental health diagnosis more challenging.

Risk Factors For Depression With ASD

While anyone can have the following risk factors for depression, people with ASD face additional symptoms and stressors contributing to poor mental well-being.

  1. Genetics: You are more likely to experience depression if you have a family history of mental health conditions. There are a lot of genetic markers for ASD and depression that overlap, so inherited genes can play a role in both ASD and the development of depression.
  2. Victim of Bullying: While anyone can struggle with childhood bullying, children with ASD are more likely to be bullying victims. Bullying can have long-term impacts on mental health, contributing to mental health conditions like anxiety and depression.
  3. Lack of Support: A lack of social support can influence your risk for depression. Specifically for young adults with ASD, many social support services are through school, and these drop off at graduation when transitioning to the adult disability system.
  4. Ruminating Thoughts: The act of thinking over and over again about something that has upset you is called rumination and is a risk factor for depression. Due to the ASD symptom of repetitive behaviors, obsessive interests, or repetitive motions can lead to rumination and increased depression risk.
  5. Isolation: Social isolation increases your depression risk. People with ASD can struggle with nonverbal and verbal communication. When you struggle to express your emotions and feelings, you internalize them, increasing your hopelessness, sadness, and feeling of isolation.

The Challenges of Diagnosing Depression With ASD

Typically, people suffering from depression can communicate their feelings when they need help. Individuals with ASD can have limited to no speech, making expressing themselves much more challenging.

Additionally, individuals with ASD often exhibit mood and affect incongruence. They show little facial emotion. For example, you can be extremely happy, and your face is expressionless. Because physical presentation or affect doesn’t necessarily match your mood, it can be harder to make an accurate diagnosis of depression.

Lastly, there’s an overlap of symptoms. A flat affect, low appetite, sleep struggles, low energy or motivation, and reduced social communication or complete social withdrawal are symptoms of both depression and ASD. It can be incredibly challenging to deduce if these symptoms stem from ASD or if a new bout of depression is causing them.

How To Recognize The Signs of Depression With ASD

Individuals with ASD can fall through the cracks regarding a mental health diagnosis because it typically takes someone who knows them well to pay attention and watch for any of the following indicators:

  • Regression: Regressing in a previously acquired skill like self-help abilities or communication can indicate emotional distress.
  • Different Communication Patterns: Especially if verbal communication is limited, distress can crop up in the form of increased agitation, self-stimulatory behaviors, or changes in facial expressions.
  • Changes in Behavior: Like the self-stimulatory behaviors mentioned above, there can be other significant changes in behavior indicating depression or distress. It could be withdrawing from social activities, less preoccupied with special interests, or simply increased irritability.
  • Physical Symptoms: While physical symptoms of depression overlap with ASD, watch out for any new signs of appetite changes, sleep problems, or unexplained physical aches and pains.
  • Self-Injurious Behavior: Behaviors like head-banging or biting oneself typically increase in response to emotional distress and are a large red flag for mental health problems.
  • Indirect Verbal Clues: Individuals with ASD may often express feelings of sadness indirectly, saying something like “I hate myself” or “I wish I were dead.” Always take expressions like these seriously, as it can indicate a deeper problem.

The Right Support and Intervention

There are protective factors that help prevent depression. The first is family support. By providing a nurturing and understanding environment, people with ASD are less likely to experience depression. And if they do, it’s typically diagnosed sooner.

Social isolation is a risk factor, but social connection is a protective factor. Family support can facilitate social interactions and social skill development in smaller, controlled settings. This goes a long way to build self-esteem, another protective factor against depression.

Emotional regulation techniques like deep breathing exercises or sensory reduction strategies can help manage emotional distress and prevent long-term buildup from turning into depression.

What Does Professional Help Look Like

Treatment for depression in individuals with ASD is very similar to standard treatment. However, slight modifications may need to account for differences in thinking, communicating, or behavior. For example, talk therapy isn’t going to be productive for someone who doesn’t communicate verbally often.

While antidepressant medications are helpful, they are most beneficial when combined with a form of therapy, which again could be a challenge with ASD. Additionally, their symptoms require close monitoring when starting medication as they often increase the risk of suicide initially. There are also often side effects that can be intolerable. Finding the right antidepressant for patients with ASD can be particularly challenging and risky.

Luckily, transcranial magnetic stimulation (TMS) is an alternative depression treatment option. It’s a quick, painless trip to an outpatient clinic. And it’s nonsystemic, so it doesn’t cause a long list of side effects that can worsen everyday life. It decreases depression and is well-tolerated in patients with ASD. One study even found family members reported improvements in ASD symptoms as well.

Recognizing depression is harder in the ASD population due to overlapping symptoms and communication issues. Once diagnosed, treatment options aren’t great, especially for those with more severe forms of ASD. However, TMS depression therapy is an excellent option that works well for individuals with ASD, too. Just plan on listening to music or watching a movie if sounds are a sensory sensitivity for you.