“With the system as it is, I honestly don't know there's anything available that would help me”: COVID-19 experiences for autistic and non-autistic adults with pre-existing mental health concerns.

Objective: Widespread mental health impacts occurred early in the COVID-19 pandemic, especially for those with pre-existing mental health conditions. Less is known about how these groups fared in later phases and post- pandemic. We compared late-pandemic mental health impacts on adults with pre-existing mental ill-health and other vulnerabilities to enable better service planning for future crises.Design and methods: This mixed-method study surveyed 532 adults online, in 2021-2022. All participants self-reported pre-existing mental ill-heath and either formal autism diagnosis (181), self-identification of autism (167), or were non-autistic (184). Self-ratings of mental health, need for mental healthcare and ease of access to mental healthcare during COVID were compared across autism groups and other demographics. Responses to an open question were analysed using Reflexive Thematic Analysis. Results: Most participants reported poor mental health, high needs for mental healthcare and great difficulty obtaining appropriate care during the pandemic. Significant differences were found for age, neurotype and education level: younger participants reported worse mental health; younger people and those with neurodivergent conditions other than autism (NDCs) reported greater need for mental healthcare; and participants with NDCs or lower education levels reported greater difficulty obtaining care. Thematic analysis identified four themes/sub-themes: “Greater mental health needs for most”; “Exceptions to the rule: improvements in mental health for some (mainly autistic people)”; “Navigating access to a scarce resource”; and “Telehealth: an enabler for some, a barrier for others”. Conclusions: Having a pre-existing mental health condition rather than autism status was more important in determining pandemic impacts.