Diagnosis: Depression. Now what?
This is the second of two articles about depression in children and adults on the autism spectrum. Part 1 is Diagnosing Depression in Autism. Part 2 focuses on treatment.
Children and adults with autism face depression at higher rates than the general population. Once their depression is recognized and diagnosed, what treatments work best for them?
Doctors typically give them the same antidepressant drugs that they prescribe to depressed patients who don’t have autism spectrum disorder (ASD). But in autism, the brain works differently. Do these medicines work the same way?
The short answer? We don't know. No one has published a rigorous scientific study of the subject. Several years ago, Dr. Christopher McDougle, director of Massachusetts General Hospital’s Lurie Center for Autism, wrote, "To date, we don’t have a single published systematic clinical trial of an antidepressant medication for the treatment of depression in individuals with autism."1 That remains true today, he confirmed recently.
Research into treating depression and mood disorders in autism is lagging behind efforts to describe and assess these problems, according to an article by Louisiana State University psychologist Johnny L. Matson and Lindsey Williams.2 This is not surprising, they point out, because scientists need to understand a problem before they can treat it.
There is some research into antidepressant medication use in autism. Several studies have investigated whether two types of antidepressants improve the symptoms of autism itself, such as social and communication problems, and repetitive behaviors and obsessive interests. But those studies did not look at the drugs' effect on depression in people with autism.
What do antidepressants do?
Antidepressants are typically used to treat depression, anxiety, and Obsessive Compulsive Disorder (OCD) in people who don't have autism. The drugs affect serotonin, a chemical that transmits signals between nerves. Serotonin levels can affect mood, sleep, social interaction, and obsessive-compulsive behaviors. Researchers wondered if they could help similar types of problems common to autism. For example, obsessive thoughts and compulsive behaviors in OCD, such as fear of germs and excessive hand-washing, may look a little like the unusual interests and repetitive motions found in autism, such as a preoccupation with train tables and hand-flapping. (They are not the same thing, although someone can have both autism and OCD).
Two types of antidepressant, the newer selective serotonin reuptake inhibitors or SSRIs, and the older tricyclic drugs, affect serotonin. Tricyclic antidepressants, so named because of their three-ringed chemical structure, have more side effects than the newer drugs. However, they may work best for some patients.3
Reviewers from the Cochrane Collaboration, an independent network of scientists and researchers, examined published studies of both the tricyclic and SSRI antidepressants on autism symptoms. They found no evidence that SSRIs are effective for autistic symptoms in children, and said SSRIs should be used on "a case-by-case" basis for depression in autism.4 SSRIs include brand names such as Prozac, Luvox and Celexa.
In a separate report, Cochrane reviewers said more research is needed before tricyclic antidepressants can be recommended for autism.5
Relying on Experience
I'm sure it helps a lot of people, but for me it's kryptonite. - Kate Gladstone
Faced with limited research data, doctors often rely on their experience actually treating depressed patients about what works. That clinical experience suggests that SSRI antidepressants "are useful and generally safe" in autism, according to an article by two psychiatrists at the University of North Carolina-Chapel Hill.6 However, they note that people with ASD may be more likely to have medication side effects, such as sleep problems or irritability, than people who don’t have ASD.
Kate Gladstone, a business owner with Asperger's Syndrome, said she experienced bad side effects and no benefits from antidepressants, even when she took them in very low doses. "I could be derailed by an SSRI even if walked slowly by the medication bottle," she joked. "I'm sure it helps a lot of people, but for me it's kryptonite."
Other adults with autism say an antidepressant has helped. For example, Temple Grandin, PhD, a Colorado State University professor and autism advocate, has said a low dose of antidepressant helped stop her panic attacks.7 Panic attacks are related to anxiety, a common problem in ASD.
Many doctors have been prescribing antidepressants for children and adults with autism, for various reasons. For example, 17 percent of the children in the Simons Simplex Collection project have taken an antidepressant.8
Doctors are prescribing other drugs for depressed patients with developmental disorders. A small study of adults who were hospitalized with depression found that antipsychotic medicines were especially common treatments for the patients who also had autism. In this study, all 53 patients had intellectual disability, and 13 of them also had autism.9 Almost all of the 13 adults with autism received antipsychotic medication, compared to about half of the 45 patients who did not have ASD.9 It wasn’t clear why.
The U.S Food and Drug Administration has approved several antipsychotic medications to treat irritable behavior, such as aggression and self-injury, in autism. Antipsychotics were first created to treat delusions and paranoia in schizophrenia and other disorders. These drugs include risperidone (brand name Risperdal) and aripripazole (Abilify). Doctors sometimes prescribe certain antipsychotics in combination with other medication to treat severe depression in the general population, according to the National Institute of Mental Health.
The art of diagnosis and treatment
It's not good enough to say to a parent, 'Your child's depressed, and we'll give him Prozac.' - Desmond Kaplan, MD
Before prescribing a treatment, it is important to do a complete evaluation of a child's developmental, medical, family, social, and educational history, said Desmond M. Kaplan, MD, founding Service Chief, Child and Adolescent Neuropsychiatry Unit at Sheppard Pratt Hospital. The unit treats children with autism and other developmental disorders, and is part of the Autism Inpatient Collection (AIC) research project.
"It's not good enough to say to a parent, 'Your child's depressed, and we'll give him Prozac,'" Dr. Kaplan said. A complete evaluation helps him determine what other problems or psychiatric conditions a patient has, as well as what conditions he doesn't have. This process doesn't end when he prescribes a drug, he said. There may be some "trial and error" to see which medication works best for each patient, he said.
Therapies that don’t involve medication
In addition, some health care providers have proposed some non-drug therapies for symptoms of depression in autism. Research into these therapies is limited.6
In Cognitive Behavioral Therapy, or CBT, a therapist helps a patient challenge the way he thinks about problems and adopt a pattern that is more helpful. CBT is a proven treatment for depression and anxiety in typically-developing children and adults.10 According to clinical psychologists Tony Attwood and Michelle Garnett, CBT therapy involves the following ideas:
- our perceptions or thoughts about events, people and situations determine our behaviors,
- the consequences of our behavior affect how often we repeat them, and
- our thoughts and behaviors can be monitored and changed over time.13
Therapists have tried to adapt CBT for people with autism in recent years, particularly for anxiety. A small Australian study showed that a CBT program called "think well, feel well and be well" helped reduce symptoms of depression and stress in people diagnosed with Asperger's Syndrome and "high functioning autism" ages 15 to 25. In this group program, participants were taught that how they look at a situation, whether as a threat or a challenge, affects their emotions and thoughts.11 This study used "high functioning autism" to refer to people who can speak and do not have intellectual disability. (For help finding a cognitive therapist, talk to your health care provider or see the Additional Resources section below.)
Similarly, another study of adults with ASD showed that a different form of therapy helped reduce depression, anxiety and rumination (obsessing about problems or negative thoughts).12 In that study, Dutch researchers used a mindfulness-based therapy adapted for autism. Mindfulness therapy teaches people to pay attention to experiences "in the present moment in a nonjudgmental and accepting way," they said. Patients are taught to accept their thoughts and feelings as temporary "mental phenomena" that don’t need to be analyzed or changed.12
Twenty adults in the therapy group learned breathing exercises and how to meditate for 40 to 60 minutes daily, for six days a week. A similar group of 21 adults with ASD received no therapy and served as "controls" for the treatment group.12
The therapy group showed a drop in symptoms of depression, anxiety and rumination compared to the control group. All adults in that study had scored above 85 on an intelligence test; the results may not apply to people with lower scores.
Meditation is feature of some approaches to mindfulness. Meditation is a powerful tool for improving self-awareness, and particularly important in Asperger's Syndrome (a form of ASD), according to Drs. Attwood and Garnett, of the Minds and Hearts ASD clinic near Brisbane, Australia. They explain meditation in their book, "Exploring Depression, and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger's Syndrome." Meditation assists those parts of the brain that are often affected by ASD — areas that process sensory information, thoughts and emotions, and that allow attention, processing speed, working memory, and time management, they say.13
Researchers have called for studies of both drug and behavioral treatments for depression in children and adults with autism.6 "A great deal of research is still needed to determine how best to assess and treat these disorders within the context of ASD," Dr. Matson and Ms. Williams said.2
Research note: Families and individuals with autism spectrum disorder play a critical role in helping researchers and clinicians better understand the disorder. Find out how you can participate in Interactive Autism Network (IAN) Research in a secure, online setting. By participating, you can help make new discoveries and empower advocates to improve the lives of children and adults with ASD.
- Part 1 of this Depression Series, Diagnosing Depression in Autism
- IAN to participate in mindfulness research study comparing stress management approaches
- Website to help find a cognitive therapist in your area: Academy of Cognitive Therapy
- The National Association for the Dually Diagnosed for people with developmental disabilities and mental health needs.
- IAN article on Cognitive Behavioral Therapy and Autism Spectrum Disorders
- National Institute of Mental Health article on antidepressant, antipsychotic, and other "Mental Health Medications"
- Exploring Depression and Beating the Blues: A CBT Self-Help Guide to Understanding and Coping with Depression in Asperger’s Syndrome, by Tony Attwood and Michelle Garnett. ISBN: 978-1-84905-502-4
- Take our nonscientific poll, Did you suspect depression in yourself/a family member with ASD?
- McDougle, C. (2013). What's the connection between autism and depression? Retrieved from https://www.autismspeaks.org/blog/2013/05/13/whats-connection-between-autism-and-depression
- Matson, J. L., & Williams, L. W. (2014). Depression and mood disorders among persons with autism spectrum disorders. Research in Developmental Disabilities, 35(9), 2003-2007. doi:10.1016/j.ridd.2014.04.020 [doi] Abstract.
- The National Institute of Mental Health. (2016). Mental health medications. Retrieved from http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml
- Williams, K., Brignell, A., Randall, M., Silove, N., & Hazell, P. (2013). Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD). The Cochrane Database of Systematic Reviews, (8):CD004677. doi(8), CD004677. doi:10.1002/14651858.CD004677.pub3 [doi] Abstract.
- Hurwitz, R., Blackmore, R., Hazell, P., Williams, K., & Woolfenden, S. (2012). Tricyclic antidepressants for autism spectrum disorders (ASD) in children and adolescents. The Cochrane Database of Systematic Reviews, (3):CD008372. doi(3), CD008372. doi:10.1002/14651858.CD008372.pub2 [doi] Abstract.
- Chandrasekhar, T., & Sikich, L. (2015). Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan. Dialogues in Clinical Neuroscience, 17(2), 219-227.
- Grandin, T. (2012). Temple grandin, ph.D.: Frequently asked questions. Retrieved from http://www.templegrandin.com/faq.html
- Mire, S. S., Nowell, K. P., Kubiszyn, T., & Goin-Kochel, R. P. (2014). Psychotropic medication use among children with autism spectrum disorders within the simons simplex collection: Are core features of autism spectrum disorder related? Autism : The International Journal of Research and Practice, 18(8), 933-942. doi:10.1177/1362361313498518[doi] Abstract.
- Charlot, L., Deutsch, C. K., Albert, A., Hunt, A., Connor, D. F., & McIlvane, W. J.,Jr. (2008). Mood and anxiety symptoms in psychiatric inpatients with autism spectrum disorder and depression. Journal of Mental Health Research in Intellectual Disabilities, 1(4), 238-253. doi:10.1080/19315860802313947 [doi] Abstract.
- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31. doi:10.1016/j.cpr.2005.07.003 Abstract.
- McGillivray, J. A., & Evert, H. T. (2014). Group cognitive behavioural therapy program shows potential in reducing symptoms of depression and stress among young people with ASD. Journal of Autism and Developmental Disorders, 44(8), 2041-2051. doi:10.1007/s10803-014-2087-9 [doi] Abstract.
- Spek, A. A., van Ham, N. C., & Nyklicek, I. (2013). Mindfulness-based therapy in adults with an autism spectrum disorder: A randomized controlled trial. Research in Developmental Disabilities, 34(1), 246-253. doi:10.1016/j.ridd.2012.08.009 [doi] Abstract.
- Attwood, T., & Garnett, M. (2016). Exploring depression, and beating the blues: A CBT self-help guide to understanding and coping with depression in Asperger's syndrome (ASD-level 1). London and Philadelphia: Jessica Kingsley.