Autism in clinical practice: two great challenges

In this blog post I will tell you about the two great challenges facing psychiatrists in the field of adult autism.

The first is the ever-increasing demand for autism assessments, which now massively exceeds clinical capacity across the country. The second is the high prevalence of autism in all mental health settings and the challenges and opportunities this presents to psychiatrists.

I work in a specialist autism diagnostic service in Leeds (for international readers, Leeds is a city in the North of England, home to 800,000 people and an exceptional football team). My service is called LADS, which is nothing to do with the ‘extreme male brain’ theory of autism, but in fact stands for Leeds Autism Diagnostic Service. LADS was founded by my predecessor and mentor, Dr Alison Stansfield, over ten years ago. At that time it consisted of a part-time psychiatrist, part-time learning disability nurse, and whatever admin support could be cobbled together. The service received five or six referrals a month.

Today, LADS is a full MDT with 14 staff, including three psychiatrists. Despite this, we are struggling to cope with a tsunami of demand. At this point you might be thinking, ‘yeah, join the club’. It is true that psychiatric services everywhere are facing greater demand following the pandemic. However, the situation in autism services is particularly stark. As public awareness of autism grows, particularly how it presents more subtly in females, more and more people are coming forward for autism assessment. Referral rates have risen exponentially in recent years and show no sign of abating. Waiting times for autism assessment in the UK are now typically two to three years or more.

Meanwhile, it is becoming crystal clear that autism is exceedingly common in mental health settings. Autistic people are more vulnerable to mental health problems, for a variety of reasons. At least one third of adults with autism have one or more co-occurring mental health conditions. Most often this is anxiety or depression, but major mental illnesses like schizophrenia and bipolar disorder are also more common. A conservative estimate is that 1 in 25 Community Mental Health Team patients, and 1 in 10 adult inpatients, are autistic. It follows that all psychiatrists, regardless of specialty and setting, are seeing large numbers of autistic people in their clinical practice.

Despite this, autistic people consistently report difficulties accessing appropriate mental health support, and lack of reasonable adjustments and adaptations in mental health treatment. Outcomes are poor as well, including greatly increased risk of death by suicide. The leading autism researcher William Mandy recently described this situation as a ‘crisis’. He writes:

“The autism mental health crisis can be described with the following paradox: autistic people have a high chance of developing mental health problems but a low chance of receiving effective help.”

Mandy suggests six ideas to address this. Amongst them is more timely recognition and diagnosis of autism. I would argue this is particularly important in mental health settings: it is unacceptable for patients to be in the psychiatric system for long periods of time – sometimes many years – before their autism is picked up and treatment adapted accordingly.

Another of Mandy’s recommendations is improved autism training for mental health professionals. In July this year it became mandatory for all health and social practitioners in England and Wales to have autism training. Here, there is a great opportunity for psychiatrists. We are highly skilled in the assessment, differential diagnosis, and formulation of psychiatric conditions. We have a deep understanding of neurological development and functioning. We are clinical leaders and set the tone within our teams and services. Psychiatrists should be at the vanguard of improving mental health services for autistic patients. You can help by making autism part of your Personal Development Plan, booking onto appropriate training, and visiting your local specialist autism team or autism community hub. At the College, we are working on enhancing our autism CPD offer for psychiatrists; I will tell you more about this in future blog posts.