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Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis

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Lai, Meng-Chuan, Kassee, Caroline, Besney, Richard, Bonato, Sarah, Hull, Laura, Mandy, William, Szatmari, Peter, Ameis, Stephanie H·2019·The Lancet Psychiatry
DOI 10.1016/s2215-0366(19)30289-5
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Abstract

Background Co-occurring mental health or psychiatric conditions are common in autism, impairing quality of life. Reported prevalences of co-occurring mental health or psychiatric conditions in people with autism range widely. Improved prevalence estimates and identification of moderators are needed to enhance recognition and care, and to guide future research.Methods In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and grey literature for publications between Jan 1, 1993, and Feb 1, 2019, in English or French, that reported original research using an observational design on the prevalence of co-occurring mental health conditions in people with autism and reported confirmed clinical diagnoses of the co-occurring conditions and autism using DSM or ICD criteria. For co-occurring mental health conditions reported with at least 15 datapoints (studies), we assessed risk of bias and we determined pooled estimates of prevalence for different co-occurring conditions in autism using random-effects models, and descriptively compared these with prevalence estimates for the general population from the literature (post hoc). We investigated heterogeneity in prevalence estimates using random-effects meta-regression models. This systematic review is registered with PROSPERO, CRD42018103176.Findings Of 9746 unique studies identified, 432 were selected for full-text review. 100 studies were eligible for inclusion in our qualitative synthesis, of which 96 were included in our meta-analyses. 11 categories of co-occurring conditions were investigated, of which eight conditions were included in the meta-analyses and three were descriptively synthesised (ie, trauma and stressor-related disorders, substance-related and addictive disorders, and gender dysphoria). From our meta-analyses, we found overall pooled prevalence estimates of 28% (95% CI 25-32) for attention-deficit hyperactivity disorder; 20% (17-23) for anxiety disorders; 13% (9-17) for sleep-wake disorders; 12% (10-15) for disruptive, impulse-control, and conduct disorders; 11% (9-13) for depressive disorders; 9% (7-10) for obsessive-compulsive disorder; 5% (3-6) for bipolar disorders; and 4% (3-5) for schizophrenia spectrum disorders. Estimates in clinical sample-based studies were higher than in population-based and registry-based studies, and these estimates were mostly higher than those in the general population (post hoc). Age, gender, intellectual functioning, and country of study were associated with heterogeneity in prevalence estimates, yet remaining heterogeneity not explained was still substantial (all I 2 >95%).Interpretation Co-occurring mental health conditions are more prevalent in the autism population than in the general population. Careful assessment of mental health is an essential component of care for all people on the autism spectrum and should be integrated into clinical practice.Funding Academic Scholars Awards, Department of Psychiatry, University of Toronto; O'Brien Scholars Program, Slaight Family Child and Youth Mental Health Innovation Fund, and The Catherine and Maxwell Meighen Foundation via the Centre for Addiction and Mental Health Foundation.

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  • Autistic adults are at much higher risk for co-occurring mental health conditions than the general population.

    “Autistic adults are at much higher risk for co-occurring mental health conditions than the general population (Croen et al., 2015;Lai et al., 2019;Rydzewska et al., 2018).”

    From A mixed methods study of autistic adults' mental health therapy experiences (2023) · cites this paper as Lai et al., 2019

    The Discussion reports that co-occurring mental health diagnoses are mostly significantly more prevalent in the autism population than in the general population. That comparison covers people with autism across ages, not autistic adults specifically; the paper also says its meta-analyses cannot yield reliable odds ratios for the comparison. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • ADHD, anxiety, obsessive-compulsive disorder (OCD), intellectual disability, academic challenges, irritability and disruptive behaviours become more apparent in school-aged children with ASD.

    “By comparison, ADHD, anxiety, obsessive-compulsive disorder (OCD), intellectual disability, academic challenges, irritability and disruptive behaviours become more apparent in school-aged children 165”

    From Autism spectrum disorder (2020) · cites this paper as [165]

    The MAIN ANALYSES moderator table (page not given) reports co-occurring ADHD, anxiety disorders, OCD, and disruptive disorders in the autism population. It does not establish that these conditions become more apparent at school age, or support the added claims about intellectual disability, academic challenges, and irritability. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • A meta-analysis of 83 studies estimated rates of co-occurring psychiatric conditions in autism: ADHD 33%, anxiety disorders 23%, sleep-wake disorders 13%, depressive disorders 12%, obsessive-compulsive disorder 10%, disruptive/impulse-control/conduct disorders 10%, schizophrenia spectrum disorders 5%, and bipolar disorders 5%.

    “A recent meta-analysis by Lai, Kassee, Besney et al (2019) of 83 studies produced the following estimated rates of co-occurring psychiatric conditions in autism: ADHD 33%, anxiety disorders 23%, sleep-wake disorders 13%, depressive disorders 12%, obsessive-compulsive disorder 10%, disruptive/impulse-control/conduct disorders 10%, schizophrenia spectrum disorders 5%, and bipolar disorders 5%.”

    From Annual Research Review: Looking back to look forward – changes in the concept of autism and implications for future research (2020) · cites this paper as Lai, Kassee, Besney et al (2019)

    Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • Estimates for ADHD in autistic adults have been reported as high as 28% (Lai et al., 2019).

    “estimates for ADHD in autistic adults have been reported as high as 28% (Lai et al., 2019).”

    From Are prediction error modifications domain specific in autism but domain general in ADHD? (2025) · cites this paper as Lai et al., 2019

    Table 1 reports a pooled ADHD prevalence of 28% in the autism population, so the figure is supported. It is not identified as an estimate for autistic adults specifically; the pooled analysis includes studies of children as well as adults. The table also reports a 34% estimate for clinical community samples, so 28% is not the highest estimate reported. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Autism and schizophrenia are often comorbid.

    “autism and schizophrenia are often comorbid (76)”

    From Predictive coding and neurocomputational psychiatry: a mechanistic framework for understanding mental disorders (2026) · cites this paper as [76]

    Table 1 (page not available in our copy) reports a 4% pooled prevalence of schizophrenia-spectrum and psychotic disorders in the autism population, supporting co-occurrence. The case-definition section shows that this category includes psychotic disorders beyond schizophrenia, so the estimate does not establish how often schizophrenia specifically co-occurs with autism. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

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Authors
Lai, M.-C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H.
Affiliations
  • Centre for Addiction and Mental Health (CA)
  • University College London (GB)
Corresponding author
Lai, Meng-Chuan
ORCID
Venue
The Lancet Psychiatry
Publisher
Elsevier BV
Published
2019-10
Volume
6
Issue
10
Pages
819-829
ISSN
2215-0366 (ISSN-L)
DOI
10.1016/s2215-0366(19)30289-5
OpenAlex
W2936336589
Cited by
1,892
References
67
Citations by year
2026: 401 · 2025: 332 · 2024: 332 · 2023: 286 · 2022: 221 · 2021: 212 · 2020: 103 · 2019: 5
FWCI
17.17
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Explore Bristol Research (submittedVersion)
Funders
Centre for Addiction and Mental Health Foundation
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Down syndrome and intellectual disability research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
Keywords
autism spectrum disorder, co-occurring mental health disorders, psychiatric comorbidity, prevalence, attention deficit hyperactivity disorder, anxiety disorders, sleep-wake disorders, depressive disorders, obsessive-compulsive disorder, bipolar disorder, schizophrenia spectrum disorders, trauma- and stressor-related disorders, substance-related and addictive disorders, gender dysphoria, clinical versus community samples
MeSH terms
Autistic Disorder, Mental Disorders, Humans, Comorbidity, Prevalence

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