By Dr. Michelle Garnett and Professor Tony Attwood
Autistic people appear especially vulnerable to feeling depressed, with about one in three adolescents and two out of three adults having experienced at least one episode of severe depression in their life. The prevalence for non-autistic people is one in five people. In this article, we discuss some of the reasons for depression that are common for autistic people. We have found that uncovering and understanding the reasons an autistic person is experiencing depression can be very helpful in finding the pathway to recovery. First, we describe depression, and next, some of the reasons an autistic person may become depressed.
What is depression?
Depression is a clinical condition that is not easy to shrug off. People may say “I feel so depressed” but mean that they feel sad. A clinical depression is not sadness, although feeling sad is part of it. Well-meaning people may say, ‘Just think about something else’, or ‘Just get up and do something!’ Unfortunately, it isn’t that simple. We all experience momentarily feeling sad, even depressed at times, but these periods of sadness tend to be transitory, and very soon, we can put things in perspective and get back on track and feel optimistic and positive again. Deep sadness or a major depressive episode persists over weeks, months, and sometimes years.
- A major depressive episode may be diagnosed when a person experiences five of the following nine symptoms daily over a period of at least two weeks:
- sadness, emptiness, hopelessness and a sense of being a failure
- little interest or pleasure in nearly all activities
- significant weight loss without dieting, or a decrease or increase in appetite
- difficulty sleeping
- agitated or slow movements
- fatigue or loss of energy
- worthlessness or feelings of guilt
- difficulty thinking or concentrating; indecisiveness
- recurrent thoughts of death or suicide.
When the person is experiencing a major depressive episode, there will be significant distress and disruption to both their life and the lives of those who support and love them. The person commonly finds it difficult to attend school or university, find and maintain employment, or be emotionally available for friendship, intimacy, or parenting.
Why are Autistic people more vulnerable to experiencing depression?
The reasons Autistic people become depressed are many and include:
Feelings of social isolation and loneliness
Autistic people, like all people, need social connection, inclusion, and acceptance, but these needs can remain unfulfilled, as described by Debbie, an autistic woman, who described ‘the heartache of having unmet needs.’ In the past the problem was placed squarely with the autistic person, that they could not read other people because of ‘theory of mind’ deficits which were broadly referred to as ‘empathy deficits’ and thought to underlie the social communication difficulties that are part of the definition of autism. These perspectives did not consider that social interaction, by definition, involves at least two people and each person needs to be able to read the other for that social interaction to be successful. Damian Milton put forward ‘the double empathy problem’ of autism in 2012 where he theorises that as much as autistic people struggle to read non-autistic people, non-autistic people struggle to read them. Being different in a world that largely misunderstands and often misreads autism can lead to peer rejection, bullying, traumatic interpersonal experiences and social isolation. Placing the problem solely within the autistic person can lead to a sense of defectiveness from their own point of view, and stigma from a community perspective.
The long-term consequences on self-esteem of feeling rejected and not respected or valued by peers
The Autistic person may see other people as being ‘toxic’ to their mental health because of past experiences of adverse social experience. An Autistic person may choose solitude over company to stay safe and avoid pain. However, as one autistic person said, ‘I would rather be alone, but I cannot stand the loneliness.’ Most Autistic people have experienced bullying, rejection and humiliation, in their teenage years, before they have a well-defined and robust self-identity, so they cannot mentally counter what the bully says or cope with the social rejection and humiliation.
Many typical teenagers value specific qualities in their peers, such as the ability to make people laugh through quick wit, risk taking, being socially skilled, sporting ability and being perceived as ‘cool’. Being popular is erroneously equated to self-worth. The qualities that an autistic person brings to a friendship, however, might be loyalty, compassion, knowledge and open-mindedness, which may not be valued by typical teenagers. It is easy for the autistic person to believe that their friendship qualities are inferior to their peers, and that perhaps, therefore, they are not as valuable as other people. This may result in feelings of low self-esteem which contributes to feeling depressed.
The mental exhaustion from trying to succeed socially
Many Autistic people utilize their intellect to achieve social inclusion, by observing, analysing and imitating. Unfortunately, the psychological cost is high. The mental effort of intellectually analysing every interaction to know what to do and say is exhausting. As a Buddhist monk who is autistic said, ‘For every hour I spend socializing, I need an hour of solitude to recharge my energy levels.’ Energy depletion is a major cause of depression.
Internalizing and believing the peer criticisms and torments
Frequent bullying and humiliation by peers can lead the person to believe that they really are defective in the ways described by the predators of the school and workplace. As Faye, an autistic woman and public speaker, said, ‘If you are told each and every day by your peers, your teachers and your family that you are stupid, you learn pretty quickly that you are stupid.’ This can lead to beliefs about the self that are judgmental and critical, such as ‘I must be stupid,’ ‘I am defective,’ ‘There is something undeniably wrong with me,’ which can both make the person depressed, and keep them depressed. In contrast, typical adolescents, when criticized by peers, will often have several close friends who can quickly and easily repair their emotions and provide reassurance and evidence that the negative suggestions are not true.
A thinking style that focuses on errors and what could go wrong
Autistic people are very good at recognizing patterns and spotting errors, which is ideal when designing a bridge or analysing an MRI scan of the brain, but not so great when thinking about oneself or the future. Being able to focus on errors or anomalies is a very important employment skill; however, when the person always uses this style of thinking when contemplating themselves or their future, depression may be the outcome. An example of this style of thinking is: ‘I never get things right, I am hopeless, and I always will be.’ As the person achieves greater intellectual maturity, there may be increased insight into being different, with the resulting self-perception of being irreparably defective and/or socially stupid.
There can also be high expectations of social competence and an aversion to social errors with resulting self-criticism. As Caroline stated, ‘The worst thing about disappointing yourself is that you never forgive yourself fully,’ or Ruth’s comment that, ‘When something happens, such as not having your homework done, your inner voice blames and shames you for failing.’
Family history of depression
We have known for some time that there is a higher-than-expected incidence of mood disorders, including depression, in the family members of someone who is autistic Recent research has suggested that 44 per cent of mothers and 28 per cent of fathers of an autistic child reported having had a clinically diagnosed depression. If a parent has episodic depression, then their son or daughter may have a higher genetic risk of experiencing depression themselves.
Hyperarousal of emotional empathy
Conversely, given the historical discussions about lack of empathy in autism, recent research indicates that some autistic people experience intense levels of affective empathy, up to 79% in one recent study, where the autistic person feels the distress, anger, sadness or disappointment of other people, as it was their own. One of the reasons for self-imposed social isolation for autistic people can be to provide protection against negative feelings in others that are detrimental to one’s own mental health. As one autistic woman said, I am able to distinguish very subtle cues that others would not see, or it might be a feeling I pick up from them.
Where to from here?
In this article we have discussed seven reasons an autistic person may become depressed, and there are many more. Fortunately, depression is treatable. If this article has raised any concerns for you or some you love, please reach out for help. We can recommend these resources:
Beyond Blue – free emergency support 24/7 in Australia – 1300 22 4636
https://www.beyondblue.org.au/
Black Dog Institute – information and support for depression
Lifeline Australia – 13 11 14
We also recommend printing out this article, highlighting your areas of concern and making an appointment with your GP to discuss them. Your GP will talk to you about options for therapy, including cognitive behaviour therapy and medication.
Resources:
We have written a book on how to help an Autistic person to recover from depression:
Exploring Depression, and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger’s Syndrome [ASD-Level 1] by Tony Attwood and Michelle Garnett, published by Jessica Kingsley Publishers, Web: www.jkp.com
We wrote this as a programme to work through with a professional such as a psychologist, mentor or counsellor, but it can also be used as a self-help book.
Online Course
We highly recommend our online course on the topic:
References
Damian E.M. Milton (2012) On the ontological status of autism: the ‘double empathy problem’, Disability & Society, 27:6, 883-887, DOI: 10.1080/09687599.2012.710008
