Tuesday, 22 March 2011

Mental health and autism

This is a topic I have been wanting to blog about for quite a while. There are lots of reasons why; mainly centred around discussions on the resources and facilities available to support and improve good mental health for people with autism in these times of austerity and cuts, but also to do with the conversations I have had with various people about factors potentially determining quality of life for people with autism (perhaps another post in itself).

First a definition: what are the mental health problems commonly associated with autism? Well the term 'mental health problem' is really a catch-all for lots of different things which according to the UK National Autistic Society (NAS) includes: depression, anxiety, obsessive-compulsive disorder (OCD) and schizophrenia. I know that there are probably other conditions which fit under the umbrella (eating disorders such as anorexia being one of them), but these are the main ones which seem most relevant to the majority of the autism spectrum conditions.

An important distinction to make at this point relates to chronological age. Some of the mental health issues highlighted above are relevant across the age groups (early infancy?). Others become more of a 'problem' as a child with autism / Asperger syndrome turns into an adult with autism / Asperger syndrome. Added to this are the issues of acute vs. chronic episodes and also the changing nature of mental health patterns, including where multiple conditions are overlapping.

So, how prevalent are mental health problems in autism? Well it very much depends on what sample you are looking at and what you define as a mental health problem as to what the research tells us.

A recent study documented behaviour and emotional problems as being present in approximately three-quarters of children with high-functioning ASD. This European study determined varying rates of mental health problems amongst adults with an autism spectrum condition ranging from mood disorders (53%) to anxiety disorder (50%), and changing according to sub-diagnosis. Prevalence is further complicated by other issues such as co-morbidity (physical and/or psychiatric) alongside the autism diagnosis.

What we can probably infer from these and other studies is that a sizeable proportion of people with an autism spectrum condition will also present with a mental health problem at some point in their lives. It does sound a little bit scary when put like this; and of course we must also take into account that many people without autism also present with mental ill-health at some point in their life. Depression for example is estimated to be present in approximately 15% of the UK population over a lifetime influenced by factors as diverse as physical ill-health and co-morbidity with other mental health problems.

What can, and do we do about mental health problems in autism? Another million dollar question (probably a billion dollar question nowadays with the rate of inflation). I would perhaps forward the view that this depends on which professionals become involved and what services are 'on offer' geographically given the shortage of national (and international) guidance on this issue.

A Psychologist or similar professional might be more inclined to examine the usefulness of the so-called 'talking therapies' as an intervention option. Certainly there is a growing evidence base to suggest that psychological interventions like cognitive behaviour therapy (CBT) can be quite successful for helping things like anxiety in Asperger syndrome. More work is required however to ascertain success rates and what elements (if any) of successful intervention might also be transferable to other autism sub-diagnoses.

The use of pharmacotherapy is another potential option. There are several good review papers discussing the various drugs of choice for tackling mental health issues; one or two have been included in one of my previous posts. Medication, whilst useful in some cases, does not however have a great reputation either in autism or outside of autism with regards to mental health problems. I don't know if it is something to do with the notion of putting something into the body, or the fact that many preparations have such powerful effects on the body and brain - see discussion on the so-called 'chemical cosh'. People generally feel a little uneasy about pharmacotherapy.

Aside from the various 'issues' raised with some medications, there is some disquiet on the potential side-effects from various formulations and indeed some fairly unfavourable reviews on how effective certain preparations are specific to autism. This, however has to be balanced against the number of people who do show positive effects from various medications aimed at alleviating mental health problems; especially when accompanied by good medicines management and appropriate monitoring.

I must add a disclaimer at this point that I am not making any judgements on the effectiveness or safety of any particular intervention for a mental health problem, merely presenting some facts.
There are other approaches that may similarly positively impact on mental health in autism spectrum conditions. The use of spirituality and meditation come to mind, and in particular the writings of people like Chris Mitchell who discusses his use of Theravada Buddhism to tackle worry and anxiety. These are quite fascinating areas of interest which have been barely touched by scientific research.

Societal effects have neither hitherto been mentioned in this post. If one were to assume that some of the underlying source/s of certain mental health problems could lie in the multitude of issues confronting particularly an adult with autism (money, employment, relationships, etc) one could also suggest that some 'adaptation' on the part of society could also be used to improve mental health. How many people for example in the general population develop depression as a result of a lack of employment? Likewise, how does gaining employment affect depression? How would employment affect any co-morbid depression in autism or Asperger syndrome?

As you can see, this is a very, very complicated area of autism research and practice.