Standard mental health therapies often fall short for autistic adults, study suggests

A recent study published in Nature Mental Health suggests that autistic adults experience varying results when receiving standard psychological therapy for depression and anxiety. Some individuals showed improvement, while others saw their symptoms remain stable or worsen. The findings indicate that factors like ethnicity and difficulties with daily living tasks play a role in how well these therapies work, highlighting a need for more tailored mental health care.

Autistic individuals are more likely to experience mental health conditions like depression and anxiety compared to non-autistic people. They also tend to report negative experiences when seeking professional support for these issues. Evidence-based psychological therapies, such as cognitive behavioral therapy, are generally recommended as standard treatments.

Standard therapeutic approaches often fail to meet the specific needs of autistic patients. Mental health interventions usually require environmental adjustments, visual communication aids, and a focus on affirming the patient’s neurological differences. Neurodiversity-affirming care means that therapists prioritize the lived experience of autistic people and accept their natural ways of being, rather than treating their autistic traits as symptoms to be fixed.

Previous research provides evidence that autistic people generally have lower rates of recovery during psychological therapy compared to non-autistic individuals. But scientists have lacked a clear understanding of why outcomes vary so widely among autistic patients.

“The study was motivated by a goal to improve mental health care for autistic people. Research shows that autistic people are often less likely than non-autistic people to benefit from standard psychological therapies, and many report negative experiences with services,” said study author Richard Pender, a clinical research fellow at the University College London.

“We used large-scale data from routine mental health services across England to explore how symptoms of depression and anxiety changed for autistic people during therapy. We looked at different patterns of improvement, worsening, or little change, and examined which factors were linked to direction or speed of change. Our aim was to better understand how treatments might be adapted and improved to meet autistic people’s needs more effectively.”

The researchers analyzed data from the MODIFY dataset. They focused on 7,175 autistic adults who accessed routine psychological therapies for anxiety or depression between 2012 and 2019. These patients received at least three treatment sessions through general adult healthcare services.

The scientists tracked symptom changes across the first eight therapy sessions using standard clinical questionnaires. They measured depression using a nine-item questionnaire and measured anxiety with a seven-item questionnaire. These tools ask patients to rate the severity of their symptoms on a numerical scale, which helps clinicians track progress over time.

The researchers also measured difficulties with daily functioning. This concept looks at how much a person’s mental health affects 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 the therapy program.

The analysis revealed five distinct paths for depression symptoms. Most autistic individuals fell into groups where their moderate to severe depression either did not improve or showed only limited improvement. A small group of patients experienced rapid improvement, moving from severe to minimal depression.

Another group showed gradual improvement in their depression scores over the eight sessions. A small fraction of patients saw their moderate depression worsen into moderately severe depression over time.

To ensure these changes were genuine and not just random variations in test scores, the researchers calculated a mathematical check called a reliable change index. This check confirmed that the rapidly improving group experienced a true reduction in symptoms that went beyond the standard margin of error. Most people in this rapidly improving category achieved reliable recovery. This means their scores dropped significantly enough to fall into a non-clinical, healthy range.

For anxiety, the researchers identified seven different patterns of symptom change. Similar to the depression findings, the majority of the sample experienced no improvement or minimal improvement across various levels of anxiety severity. Some groups showed rapid or gradual improvement, while about three percent of the patients started with moderate anxiety that worsened into severe anxiety.

“We found differences in how autistic people experienced change during therapy for anxiety and depression,” Pender told PsyPost. “Most people’s symptoms stayed largely the same, but some showed gradual or rapid improvement, while others experienced worsening symptoms.”

The researchers noted that by the third therapy session, it was often possible to predict a patient’s overall trajectory. “This may be an important point to review progress and consider adapting the approach if needed,” Pender said. “Future research will look more closely at how neurodivergence intersects with race and ethnicity, and how this shapes people’s experiences of services and their mental health outcomes.”

When looking at background factors, the researchers found that higher levels of difficulty with daily functioning before treatment began were linked to worse outcomes. Individuals who struggled heavily with social leisure activities were less likely to experience rapid or gradual improvement in their severe anxiety.

Social leisure activities involve doing things with other people, such as attending parties, dating, or entertaining guests. Autistic people often engage in camouflaging, which means they hide their natural autistic traits to fit into these social situations. Excessive camouflaging requires immense effort and often leads to the deep exhaustion known as autistic burnout.

Patients experiencing this type of burnout might have a harder time benefiting from standard anxiety treatments. Standard therapies often encourage more social interaction, which could inadvertently increase exhaustion for an autistic person. The researchers suggest that therapies might need to address burnout specifically to be effective.

Demographic factors also played a role in treatment success. Identifying as a member of an ethnically minoritized group in England was associated with a higher likelihood of experiencing worsening anxiety symptoms during therapy, compared to white participants. This provides evidence that individuals from minoritized backgrounds face compounded disadvantages that affect their mental health treatment.

While the study relies on a massive dataset, it has some limitations. The questionnaires used to measure anxiety and depression were designed for the general public and might not capture the unique ways autistic people experience distress. Standard tools might confuse signs of autistic burnout with symptoms of regular depression.

The researchers also lacked information on whether the therapies provided in the study were actually adapted to accommodate autistic patients. The data relied on broad categories for race and sex, which prevented a more detailed analysis of how diverse identities impact mental health outcomes. Because the data only included people who attended at least three sessions, the study cannot explain the experiences of those who dropped out immediately.

“This study is part of a wider research programme focused on improving psychological therapies for autistic people,” Pender explained. “MODIFY is a large and detailed dataset, and our team is using it in further studies to better understand what affects outcomes for neurodivergent people using mental health services.”

“However, numbers can only tell us so much. To improve therapy, it is essential to listen to autistic people who have first-hand experience of these services. For this reason, we are also carrying out qualitative research to explore people’s views on why therapy does or does not work for them. This includes intersectional work that looks at the experiences of autistic people from ethnically minoritized backgrounds, with the aim of improving access to services and the support they receive.”

“The findings of this study underline the importance of adapting psychological interventions for autistic people,” Pender added. “This involves improving accessibility, by adjusting communication and sensory environments. We also need to ensure mental health care is culturally responsive and neuroaffirming. This means championing autistic people’s voices, accepting rather than pathologizing autistic ways of being, and appreciating the ways that environmental contexts shape individuals’ difficulties.”

The study, “Symptom change in depression and anxiety during psychological therapy for autistic adults,” was authored by Richard Pender, Céline El Baou, Elizabeth O’Nions, Aimee Spector, Joshua E. J. Buckman, Marcus Richards, Steve Pilling, Amber John, Joshua Stott, Rob Saunders, Laura Crane, and Will Mandy.