Depression and its Treatment in Neurodivergent Individuals

Depression is a state of being that is characterized by feelings of irritability, sadness, apathy or numbness. There are changes in brain functioning and subsequent behavior, such as sleeping much less or more, eating much less or more, ruminative thinking spirals, inability to recall or see positives for very long, thinking about death or morbid things, and in extreme moments- suicidality. These feelings, thoughts and behaviors are not a choice and a person cannot choose to stop experiencing them. But, they can do some things to help reduce the impact of depression and over some time, hopefully lift the depression entirely. 

Depression tends to occur in cycles- called “episodes”. Someone may have just one episode that lasts some weeks or months and then never have one again in their lifetime. More commonly, people may have a few episodes throughout their lifetime. In some cases, people have cycles of depression but never really feel ok in between those- they may not feel as bad as when in an episode, but they still don’t get a sense of enjoyment in life. 

In neurodivergent individuals, depression may look different than in neurotypical people. It’s more likely to look like irritability than sadness. Neurotypical people often already have unusual sleep or eating patterns, so you have to check to see if the patterns have changed from before- but this still may not be an accurate indicator. Neurodivergent people often think differently than neurotypical people, in more creative ways, able to see more patterns, or they may have a tendency to perseverate (become stuck on a thought). Those things can be mistaken for signs of depression, or they may increase in intensity when the person is depressed. Suicidality is a complicated thing, that has many factors that go into it. A lot of the time suicidal actions or urges in neurodivergent individuals are spurred by anxiety rather than depression. Anxiety is also extremely common, and in my observations, it seems to almost always co-exist with depression for neurodivergent individuals. And lastly, under extreme stress or depression neurodivergent individuals seem more likely to have psychotic symptoms than neurotypical people; this includes hallucinations and delusions. 

Depression is very often related to the brain’s reaction to significant stress over a long period of time that cannot be escaped from or changed. The brain can only take so much, and when the stress keeps coming and nothing changes, it isn’t useful to keep fighting or trying to escape, so the person goes into a state of collapse. Then it can become hard to get back out of the apathy and immobility of depression. This is a normal part of human existence. Unpleasant and sometimes dangerous as it might be, this is essentially a normal human reaction to chronically bad experiences.

In some cases, depression is “biological”. What I mean by that is probably not what you think. All depression is related to neurotransmitters in our brain, so in a way every experience of depression has biological things happening. The brain and person interact with the environment, that causes varying neurotransmitters to be active as our brain works, and then we feel particular ways as that happens. That’s why antidepressants work for so many people. Now, in some people, their brain seems to go all wonky in a big way and they have a major mental illness. This may be called Bipolar Disorder, though there are also other mood disorder labels depending upon that individual person’s symptoms. Bipolar type disorders are not related to environmental stressors as far as we know. Environmental stressors may speed up the onset of the illness, but it does not cause it. This instead seems to be a genetically determined illness. It is not possible to cure it. It is possible to control with the right medication. Most of the time it is not possible for someone with Bipolar disorder to remain stable, or live a happy and productive life without medication treatment. Bipolar disorder is a big topic and very different from the depression I am going to address in the rest of this article. 

It’s common for neurodivergent individuals to have been depressed for so long, frequently since childhood, that they and their loved ones don’t know that they could function differently. Their state seems normal because they haven’t had much time in a non-depressed state yet. Why would that be? Well, it has to do with stressors. Stressors are things that it is difficult to deal with, process or change and they cause a stress reaction in the brain. A stress reaction includes feelings of distress, a desire to escape or get away from the stressor and physiological signs like increased heart rate, increased breathing, sweating, body movement, feeling nauseous, and at the highest end the fight, flight or freeze reaction. 

So, what kind of stressors are so prevalent and significant that neurodivergent people are bombarded enough to become depressed? So many! In best case scenarios it’s things like sensory overwhelm, difficulty communicating with others, difficulty building satisfying relationships or finding their people, demands in school that don’t match their abilities or needs and just not being understood by people in their life. But, it’s fairly common for there to be many more stressors such as getting consistent negative feedback from adults, getting consistent ostracization or teasing from peers, bullying from peers, abusive behavior from adults, not having the option to leave bad situations because “rules” prevent that, negative feedback from adults when they do leave bad situations, etc. And for most neurodivergent people these come in chunks, not just one or two, but they have multiple to deal with most of the time. Can you imagine if this was your life? The best way to really get a picture of the stressors that occur is to ask your loved one who is neurodivergent- ask them to tell you everything in their average day that causes stress- everything. And read some autobiographies by people who are neurodivergent or some articles. www.neuroclastic.com is a good place to get this info. 

Ok so with all those stressors the brain just can’t manage it all. Contrary to popular opinion that neurodivergent individuals aren’t able to handle as much stress as neurotypical people, I find that neurodivergent individuals are remarkably resilient and persistent because they’ve had to be. However, the odds are so stacked against them that it’s almost impossible for anyone to weather their life as a neurodivergent person without experiencing anxiety, burnout and depression. 

There are a lot of things that people out in the world may suggest to a loved one who is depressed, out of caring and encouragement. However, if you are not informed about depression those suggestions are likely to hurt the person rather than help, and it may drive that person away. For example, well meaning people may say things like “Think more about the good things”, or “You just need to value yourself”, etc. These are things the person who is depressed is unable to do while they are depressed, and they may have had few good things in their life to think about or very few experiences of being valued to fall back on. 

Here’s what does work for neurodivergent individuals who are dealing with depression. Please keep in mind that each individual person may need different things or be open to different things. 

In the short term, I often first recommend that someone consult with a psychiatrist about medication. General practitioners and pediatricians rarely have the necessary training and expertise in neurodivergence to be able to prescribe effectively for this population. Medication is not a fix for the problem that is occurring, but it is a way to hopefully have something that will tone down the intensity of the distress to a level at which the person then has energy and internal resources to be able to do the work that is needed to make changes in their life. In many cases, a good medication saves lives because it reduces intensity enough that suicidal thoughts or impulses are not as strong. However, medication is also tricky for neurodivergent individuals and they frequently have different reactions to it than neurotypical people- it can take time and trials of many different medications to find one that both works and does not have intolerable side effects. 

Second, the next layer of getting better from depression involves Behavioral Activation. This is a plan that is constructed by the individual and their therapist, or in some cases people do this on their own. Behavioral Activation refers to small changes in routine behavior that compound to provide different input into the brain and reduce the effects of depression. Typically, this includes things like exercise in some form, regulating sleep habits, doing one thing that results in a feeling of accomplishment, having one social interaction, etc. These are small things that feel doable to that person at that time, and it’s absolutely ok that they don’t happen consistently. Just over time the goal is to slowly build in a way that feels feasible to that person. Behavioral Activation is simple in theory but can easily become complicated by fear of failure, lack of positive reinforcement for effort, lack of success with a task, etc. That’s why it’s helpful to have a therapist work with the person on this to ensure it’s not going to feel overwhelming instead of helpful. 

Third, there must be changes in their life to reduce or remove the stressors. Of course, there is no one on earth who can have no stressors, and that is not the goal. The goal is to reduce the stressors to a normal level, a level that the individual person can effectively cope with on a regular basis. Given what I said above about the stressors experienced by neurodivergent people you may be thinking right now that seems like a tough prospect, and you are right. You will also notice I did not say that the person needs to learn more coping skills. I have an article about coping skills that explains why that is on my blog. So, to reduce and remove the stressors we have to accurately identify what they are, and then consider how much choice that person has about engaging with that stressor. Children also have much less choice than adults do, so we adults must advocate for them to get the needed changes in their lives. Which stressors can really be modified or removed? Things like school, hurtful peer groups, bad jobs, toxic relationships, etc. You might be thinking, school can be removed?! Yes it can. In some cases it has to be for a while. For this level of intervention you need to think big, don’t get stuck in thinking that this person has to do things the usual way, or be involved in the usual things. That’s what caused their stress in the first place. This is why a therapist can be so helpful, as an outside viewer who has ideas and suggestions that the person may not have encountered before. For stressors that can’t be removed or changed, (which are few outside that person’s own brain and body) then that person learns how to cope with that. 

Fourth, many neurodivergent individuals have psychological trauma. They have had many small experiences or some large experiences as well, which have resulted in trauma. Trauma arises from states of extreme distress from which it is not possible to escape or fight effectively. The person then has to deal with significant fear and avoidance of things associated with the traumatic experience, along with other symptoms of trauma. Trauma must be effectively treated for someone to reduce the risk of depression. In general just know that there is Big T trauma and Small t trauma. Big T trauma refers to “classic” trauma and includes things like rape, serious bodily harm, disasters, etc. There are many, many different trauma treatment methods and it can take some work to determine which is the best fit for an individual person. The person may need to see a trauma specialist who is different from their regular therapist. Small t trauma usually refers to the death by a thousand cuts type situation, in which someone has many, many negative experiences interacting with people. This can be being dismissed, not listened to, not validated, being told their own experience is wrong, being told they are bad or not good enough, etc. Rarely are people told these things so directly, instead they are implied or more subtle. That makes it easy to think that there really is something wrong with them and that they are a bad person, which fuels depression of course. Small t trauma treatment is an integral part of regular therapy. While it is certainly important that the therapist have expertise in neurodivergence, they don’ have to have specialty trauma training to work with small t trauma – though of course it doesn’t hurt. 

Fifth, the neurodivergent person may benefit from what are called “habilitative therapies”. These are therapies that are designed to improve various aspects of their functioning from their baseline to a higher, new baseline. These are typically things like occupational therapy for sensory and motor functioning, speech language therapy for language and social communication, or social skills training. It’s a standard of care for children to have access to these therapies if they are neurodivergent. It is much harder for an adult to get access to those as insurance rarely covers those things for adults unless they’ve had a specific physical or brain injury. Social skills training is provided by lots of different types of providers, but usually a speech language therapist, occupational therapist, applied behavior analyst or psychologist. As someone experiences improvement in these areas then that means less stress on them from having to deal with sensory issues, or movement differences, or negative social feedback. However, please keep in mind that some things do not change even with good therapy. For many people, sensory sensitivities do not ever go away and they may not become less intense over time either. Attention problems associated with ADHD do not ever go away, though the person may learn some tools to help them or their attention may improve some as their brain grows into adulthood. One important thing to keep in mind about habilitative therapies is the issue of consent, especially for children. There may be things in these therapies that can be helpful, but they have to be done with full awareness and consent of the child or individual. This has been an issue through the years for many neurodivergent people and has resulted in trauma for many of them. 

Sixth, for those internal things that cannot change, the person must figure out how to live their life despite having those problems. This often entails balancing what they have the ability and energy to deal each day, with what their life demands of them. This can be a losing battle if not taken seriously. In many cases, the person needs help with certain tasks from other people and not just learning skills. In some cases, that person may be unable to do particular tasks or jobs at all and have to figure out how to live their life without that task or job. This is why some neurodivergent people are disabled. 

So, you may be saying – hey what about this thing I heard of called Cognitive Behavioral Therapy. Isn’t that what everyone recommends? Yes it is a commonly recommended form of psychotherapy for many people, neurotypical and neurodivergent. Why is that? Partly because it is the second most researched behavioral intervention for neurodivergent individuals (I put the first at Applied Behavior Analysis). Partly because it is the easiest form of psychotherapy to learn. Partly because it does have many aspects that are indeed helpful. However, please keep in mind that CBT was originally developed for neurotypical people and it relies upon a “normal” brain functioning in how it operates. This can cause harm or problems for people with divergent brains if it is not modified properly. So, where CBT fits in is usually in work with a psychologist, for people to understand how their own individual mind (not brain) work. What thoughts are linked to which experiences and feelings? How to manage various feelings? How to identify what you are feeling? These are all very useful skills. They are also generally not enough to effectively treat depression for neurodivergent individuals. 

What about anxiety, the frequent friend of depression? Yes this requires treatment as well and that needs to occur with a psychologist or psychotherapist trained in working with neurodivergent individuals. Anxiety treatment is a huge topic in and of itself, but the short version is that the sources of fear and worry have to be identified and the person has to be exposed to them in small, safe dosages for the brain to learn that those things are not actually dangerous- which is a tough prospect if they have been part of bad experiences in the past. 

So you are now armed with the information you need to help yourself or the neurodivergent person in your life that you care about. But don’t stop here, keep learning more and most importantly get to know the individual’s own experience of life as they have had it. Listen carefully, it may not be what you expect. 

For more information about depression and neurodivergence please see these resources:

1. “Exploring Depression and Beating the Blues” by Tony Attwood and Michelle Garnet

2. “Overcoming Anxiety and Depression on the Autism Spectrum: A self help guide using CBT” by Lee Wilkinson

3. “Living Well On the Spectrum: Use your strengths to meet the challenges of Asperger Syndrome/High functioning autism” by Valerie Gaus

4. “Living Through Suicide Loss with an Autism Spectrum Disorder: An insiders guide for individuals, family, friends and professional responders” by Lisa Morgan, Med

5. “The Guide to Good Mental Health on the Autism Spectrum” by Jeanette Purkis, Emma Goodall, Jane Nugent. 

6. www.neuroclastic.com