Psychologists Share ‘A Different Approach’ to Identifying Depression in Autistic Adults

ABSTRACTBackgroundAlthough autistic adults experience depression at higher rates than non-autistic adults, little is known about how psychologists assess depression in this group. It is unclear whether psychologists apply DSM-5-TR criteria directly, adapt them, or supplement them with additional considerations, given that autism-related characteristics may influence how depressive symptoms are described and interpreted. This study examined how psychologists interpret depressive symptoms in autistic adults, and whether the use of DSM-5-TR criteria differs from assessments with non-autistic adults.MethodsWe conducted an exploratory qualitative study with 20 psychologists who had experience assessing and treating depression in autistic adults. We conducted semi-structured interviews between October 2024 and January 2025. Using direct content analysis, we coded responses according to DSM-5-TR criteria and employed inductive analysis to identify additional features outside these criteria.ResultsPsychologists described using DSM-5-TR criteria as a guiding framework while adapting interpretation to account for autistic baselines. They described depressed mood as pervasive hopelessness, anger, or somatic complaints, more often than sadness, and more entrenched than in non-autistic adults. They described autistic anhedonia and depression attacks as alternative variations of core DSM-5-TR criteria, with depression attacks characterised as sudden episodes of acute hopelessness and suicidality distinct from chronic mood disturbance. Worthlessness reflected lived experiences of exclusion rather than cognitive distortion. Psychologists considered several DSM-5-TR symptoms diagnostically ambiguous. They also noted depression-related modulation of autistic characteristics and self-injurious behaviour as meaningful clinical indicators. Psychologists provided clinical observations across criteria to inform assessment.ConclusionPsychologists emphasised that while DSM-5-TR criteria remain applicable, they require adaptation when assessing autistic adults. Psychologists highlighted autistic anhedonia, depression attacks, self-injurious behaviour, and depression-related changes in autistic characteristics as critical for accurate diagnosis and risk assessment. These findings underscore the need for autism-informed clinical guidance and co-designed diagnostic tools that reflect autistic experiences of depression.