This page provides a summary. The full paper includes the complete methods, analytic approach, and full results mapped to diagnostic constructs.

Why this study matters

Most depression criteria and many screening tools were developed using non-autistic samples and can rely on prototypical assumptions about how symptoms “should” look. Autistic adults may describe the same diagnostic constructs using different language, different examples, or different salience, which has implications for recognition and assessment.

What we did

Autistic adults, and where relevant their supporters, responded to co-designed questions about depressive experiences. Responses were analysed qualitatively and mapped to depressive symptom constructs to identify common descriptions, patterns of expression, and areas where autistic adults’ accounts extended typical expectations.

Depressed mood often looked different

• Depressed mood was commonly described as irritability or anger, emotional emptiness or numbness, and hopelessness or despair, rather than sadness or crying.

“Feel like just this empty vessel… there’s nothing there. Depression isn’t sadness. It’s just emptiness.”

Anhedonia can be missed if the assessment focuses on doing less, rather than enjoying less

• Some autistic adults described continuing their deep and focused interests, but with a marked reduction in enjoyment, reward, or satisfaction from those activities.

• For some, continued participation may be maintained by routine, sameness, or obligation, even when enjoyment has reduced.

• Practical implication: rather than asking only whether activities continue, it can help to ask about the felt experience during the activity (e.g., dullness, effort, reduced reward) and how this differs from the person’s usual baseline.

Continuing an activity does not necessarily mean the person is still enjoying it.

Distress and crisis experiences

• Around one third of participants described recurring thoughts of death or suicidal ideation during depressive episodes, ranging from passive thoughts to active ideation.

• Some participants described “depression attacks”, abrupt episodes of overwhelming depressive affect in which suicidal ideation or despair escalated rapidly and felt difficult to control.

“The worst bit about the depression is when it becomes like a depression attack … wanna die now … 
but with a depression attack, it’s like you’re this close to doing it.”

“A deep out of control feeling that can lead to very dangerous thinking in a short time as the dangerous impulses try to take over.” 

• Some participants also described non-suicidal self-injury as a depression-related regulatory behaviour. In some accounts it had a repetitive or ritualised quality (e.g., same method, same pattern), and was described as a way to manage or shift internal pain.

Depression commonly involved changes in sensory experience, routine needs, and social tolerance

• Many participants described heightened sensory sensitivity during depression (e.g., sound, light, social noise), with reduced capacity to tolerate everyday environments.

• Participants also described increased need for sameness and routine during depressive episodes, including stronger reliance on predictability and difficulty managing change.

• Social withdrawal and reduced daily functioning were frequently reported as part of the depression experience, including reduced self-care and reduced engagement in daily activities.

• In several accounts, withdrawal was described as a direct response to sensory overwhelm and reduced coping capacity (e.g., environments being too loud, too bright, or too socially demanding), rather than simply “not wanting to socialise”.

These patterns highlight why understanding the person’s usual baseline is essential, because depression-related change can resemble stable autistic characteristics unless the clinician explicitly asks what has changed and why.

What the study found

Autistic adults’ descriptions of depression mapped onto the nine DSM-5-TR depressive symptom domains, meaning depression was recognisable within standard constructs. The key difference was how symptoms were described and which features were most prominent.

What this may mean for practice

• Depression in autistic adults can be recognisable within DSM-5-TR symptom constructs, but symptoms may be expressed, described, or prioritised in ways that differ from common clinical expectations. This includes the two required symptoms for identifying a major depressive episode: depressed mood and loss of interest or pleasure.

• Assessment is strengthened when clinicians ask autism-informed follow-up questions about how symptoms are experienced, not only whether a behaviour is present. For example, anhedonia may involve reduced reward or felt engagement even when routines and interests continue.

• Standardised measures can be useful as part of assessment, but interpretation is improved when clinicians attend to item-level responses rather than relying only on total scores. Item-level review supports targeted follow-up questions that clarify meaning, context, and change from baseline.

• Understanding the person’s baseline is essential. Depression-related changes can resemble stable autistic characteristics (e.g., social withdrawal, sensory intolerance, stronger reliance on routine), so assessment benefits from explicitly asking what has changed, when it changed, and why the change is occurring.

• Where relevant, integrating information from supporters can improve recognition of functional change and observable differences, particularly when internal experience is difficult to communicate.

• A differential assessment approach that considers both DSM-5-TR depression constructs and autism-related characteristics, and their interaction, may reduce misclassification and support timely, appropriate care.

Key takeaway:

Ask about change from baseline, ask about felt experience, and treat item responses as prompts for clarification rather than endpoints.