Psychologists Share ‘A Different Approach’ to Identifying
Depression in Autistic Adults
This paper is available as a preprint and is currently under peer review. The content may be updated following the review process.
Study Three overview
Study 3 examined how psychologists assess and interpret depression in autistic adults, including how they apply DSM-5-TR criteria and what additional indicators they consider when DSM descriptions do not align with autistic presentation.
Methodology
We conducted qualitative, semi-structured interviews with psychologists experienced in working with autistic adults, then analysed the interviews using direct content analysis anchored to DSM-5-TR criteria, while also capturing non-DSM indicators raised by the psychologists.
What the study found
Psychologists used a flexible, autism-informed approach rather than relying on literal DSM descriptors.
Clinicians emphasised interpreting depressive symptoms in relation to a person’s autistic profile and baseline, because literal DSM mapping can misinterpret stable autistic characteristics as depression and can also miss depression-related change.
Depressed mood was often recognised as a broader pattern, not only sadness
Sadness and low mood were commonly assessed, but psychologists reported that hopelessness and despair, anger or irritability, and incongruent outward affect were often more clinically informative in autistic adults. Flat affect alone was considered unreliable by some psychologists.
“Might be an increased distress inside, but their affect is completely flat ... not matching the internalised symptoms that they're describing”
Anhedonia could be missed if the assessment focuses on doing less rather than enjoying less
Psychologists described changes in deep and focused interests as a salient marker. Interests may cease in more severe depression, but they may also continue due to routine or scaffolding while enjoyment or reward markedly reduces.
“Most significant indicator of depression for autistic adults is a change in the special interest. They're either not talking about it, they're not doing it, or something has changed”
Suicidality was often described as high-risk, but not always outwardly visible
Psychologists described suicidal ideation as potentially persistent and difficult to disengage from, sometimes reported in a matter-of-fact or humorous style, increasing the risk of under-recognition. Cognitive rigidity and altruistic motives were also described as relevant in some presentations.
Co-occurring ADHD was described as potentially increasing impulsivity and acute risk in some adults.
“They might self-present to emergency department with suicide ideation, quite pervasive, strong with plan and method but telling in a very kind of matter of fact, blunt way, they even crack a couple of jokes as a way of coping. Do they get admitted? No, they get sent home … could explain why we have such a high rate … of complete suicides”
“Depression attacks” and self-injury reflected acute distress states
Psychologists described “depression attacks” as abrupt, time-limited crises characterised by intolerable affect and rapid escalation of suicidal thinking. Self-injurious behaviour was described as sometimes serving a regulatory function and requiring functional interpretation in context.
“It can be so strong that the person will lose complete perspective … they need a very clear emergency plan”
What this may mean for practice
The paper synthesised autism-informed recommendations for improving diagnostic and risk precision. Key practice implications include:
Psychologists emphasised that assessment of depression in autistic adults requires holding two knowledge sets at once: (1) DSM depressive symptom constructs and (2) autism-related characteristics that influence how distress is expressed, communicated, and observed.
This approach supports accurate differential assessment in both directions: depression-related change can be misattributed to autism, and stable autism-related characteristics can be misinterpreted as depressive symptoms. A practical focus on change from the person’s baseline remains central.
For core depressive symptoms, psychologists recommended autism-informed interpretation rather than relying on prototypical cues. Examples included depressed mood expressed as hopelessness, irritability, numbness, or incongruent outward affect, and anhedonia expressed as reduced felt reward even when deep and focused interests continue.
Psychologists highlighted that suicide risk may be high even when outward distress is minimal or expressed through humour, so direct, explicit exploration of ideation, intent, and rapid escalation was viewed as essential.
Standardised measures can contribute to assessment, but psychologists described greater value in item-level interpretation and follow-up questioning than reliance on total scores alone, particularly when wording does not align with autistic communication styles.
Where relevant, integrating information from supporters can improve detection of functional change and risk escalation, particularly when internal experience is difficult to express in conventional emotional language.
Psychologists highlighted that alexithymia and interoceptive differences can affect how mood, bodily distress, and emotional change are noticed and described. They recommended attending to sensory shifts and physiological distress during depressive episodes, and differentiating depression from overlapping states such as anxiety, autistic burnout, and physical health issues by context, onset, and trajectory over time.
Key takeaway
Apply DSM depression constructs through an autism-informed approach: establish baseline, ask about lived experience, not only observable cues, and interpret symptoms in context.
