Recent research published in natural mental health Our findings suggest that when adults with autism receive standard psychological treatments for depression and anxiety, there are mixed outcomes. Some people have shown improvement, while others’ symptoms have remained stable or worsened. The findings show that factors such as ethnicity and daily living difficulties influence the effectiveness of these therapies, highlighting the need for more tailored mental health care.
Autistic people are more likely to experience mental health conditions such as depression and anxiety than non-autistic people. They are also more likely to report negative experiences when seeking professional help for these issues. Evidence-based psychological therapies such as cognitive behavioral therapy are recommended as standard treatment.
Standard treatment approaches often fail to meet the unique needs of individuals with autism. Mental health interventions typically involve environmental adjustments, visual communication aids, and a focus on identifying the patient’s neurological differences. Neurodiversity-affirming care means that therapists prioritize the lived experiences of autistic people and embrace their natural way of being, rather than treating autistic traits as a symptom to be fixed.
Previous research has shown evidence that autistic people generally have lower rates of recovery during psychotherapy than non-autistic people. But scientists don’t have a clear understanding of why outcomes vary so widely among people with autism.
“This study was motivated by the goal of improving mental health care for autistic people. Research shows that autistic people are often less likely to benefit from standard psychological treatments than non-autistic people, and many report negative experiences with services,” said study author Richard Pender, clinical research fellow at University College London.
“Using large-scale data from routine mental health services across the UK, we investigated how symptoms of depression and anxiety in people with autism changed during treatment. We looked at different patterns of improvement, worsening or little change, and examined which factors were associated with the direction and speed of change. Our aim was to better understand how treatments can be adapted and improved to meet the needs of autistic people more effectively.”
The researchers analyzed data from the MODIFY dataset. They focused on 7,175 adults with autism who received routine psychotherapy for anxiety or depression between 2012 and 2019. These patients had received at least three treatment sessions through general adult health services.
The researchers tracked changes in symptoms over the first eight treatment sessions using a standard clinical questionnaire. They measured depression with a nine-item questionnaire and anxiety with a seven-item questionnaire. These tools ask patients to rate the severity of their symptoms on a numerical scale and help clinicians track progress over time.
The researchers also measured difficulties with daily living. This concept considers the extent to which a person’s mental health impacts their home life, work, social activities, and relationships. They used advanced statistical models to group patients based on how their symptoms changed over the course of their treatment program.
This analysis revealed that there are five distinct pathways for depressive symptoms. Most autistic patients were categorized as having either no improvement or only limited improvement in their moderate to severe depression. A small group of patients experienced rapid improvement, moving from severe to mild depression.
Another group showed gradual improvement in depression scores over eight sessions. A small number of patients had moderate depression that worsened over time to moderately severe depression.
To ensure these changes were real and not just random fluctuations in test scores, the researchers calculated a mathematical check called a reliable change index. This test confirmed that the group that improved rapidly had a true reduction in symptoms beyond the standard error range. Most people in this rapidly improving category have achieved solid recovery. This means that the score has dropped significantly enough to fall into the non-clinical, healthy range.
For anxiety, researchers identified seven distinct patterns of symptom change. Similar to the findings for depression, the majority of the sample showed no or minimal improvement across different levels of anxiety severity. Although some groups showed rapid or gradual improvement, about 3 percent of patients started with moderate anxiety and worsened to severe anxiety.
“We found that there were differences in how autistic people experienced changes during treatment for anxiety and depression,” Pender told SciPost. “While most people’s symptoms remained largely the same, some people’s symptoms improved gradually or rapidly, and some people’s symptoms worsened.”
The researchers noted that they could often predict a patient’s overall course by the third treatment session. “This could be a key point to review progress and consider adapting the approach if necessary,” Pender said. “Future research will more closely examine how neurodiversity intersects with race and ethnicity, and how this shapes people’s service experiences and mental health outcomes.”
When considering background factors, the researchers found that higher levels of difficulty with daily living before starting treatment were associated with worse outcomes. People who had a very hard time with social leisure activities were less likely to have rapid or gradual improvement in their severe anxiety.
Social leisure activities include doing things with other people, such as attending parties, going on dates, and entertaining guests. Autistic people often practice camouflage, which means hiding their innate autistic traits in order to adapt to social situations. Excessive camouflage requires a lot of effort and often leads to exhaustion, known as autistic burnout.
Patients experiencing this type of burnout may be less likely to respond to standard anxiety treatments. Standard treatments often encourage more social interaction, which can inadvertently increase fatigue in people with autism. Researchers suggest that burnout may need to be specifically addressed for treatment to be effective.
Demographic factors also influenced treatment success. Identifying as a member of an ethnic minority in the UK was associated with a higher likelihood of experiencing worsening of anxiety symptoms during treatment compared to white participants. This provides evidence that individuals from minority backgrounds face multiple disadvantages that impact mental health treatment.
Although this study relies on a large dataset, it has several limitations. Questionnaires used to measure anxiety and depression are designed for the general public and may not capture the unique ways that people with autism experience distress. Standard tools can confuse signs of autistic burnout with normal symptoms of depression.
The researchers also lacked information about whether the treatments offered in the study were actually applicable to people with autism. The data relied on broad categories of race and gender, which precluded a more detailed analysis of how diverse identities influence mental health outcomes. Because the data only included those who attended at least three sessions, this study cannot account for the experiences of those who quickly dropped out.
“This study is part of a broader research program focused on improving psychotherapy for people with autism,” Professor Pender explained. “MODIFY is a large, detailed dataset that our team will use in further research to better understand what influences outcomes for neurodiverse people who access mental health services.”
“But numbers can only tell us so much. It is essential that we listen to the views of autistic people who have first-hand experience of these services to improve treatments. For this reason, we are also conducting qualitative research to explore people’s views about why treatments work or don’t work for them. This includes cross-sectional research examining the experiences of autistic people from minority ethnic backgrounds, with the aim of improving access to services and the support they receive.”
“The results of this study highlight the importance of adapting psychological interventions to people with autism,” Pender added. “This includes improving accessibility by adjusting communication and sensory environments. We also need to ensure that mental health care is culturally responsive and neuro-affirming. This means championing the voices of autistic people, embracing rather than pathologising the autistic way of life, and understanding the ways in which environmental contexts shape individual difficulties.”
The study, “Symptom changes in depression and anxiety during psychotherapy for adults with autism,” was authored by Richard Pender, Céline El Baou, Elizabeth O’Nions, Aimee Spector, Joshua EJ Buckman, Marcus Richards, Steve Pilling, Amber John, Joshua Stott, Rob Saunders, Laura Crane, and Will Mandy.
