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Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis
Open accessAbstract
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 (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
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“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]
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“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)
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“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
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“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]
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“Anxiety and depression are prevalent among autistic adolescents and may be difficult to accurately diagnose and treat given various factors (e.g., diagnostic overshadowing, heterogeneity).”
From The relationship between distress tolerance and behavioral activation on anxiety and depression symptomatology in autistic youth: Leveraging self and caregiver perspectives (2024) · cites this paper as Lai et al., 2019
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“Across studies, 15–50% of adults with ADHD exhibit autistic traits or meet ASD diagnostic thresholds, while 15–35% of adults with ASD also fulfill ADHD”
From ADHD in Adulthood: Clinical Presentation, Comorbidities, and Treatment Perspectives (2025) · cites this paper as [43]
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“have increased vulnerability to mental ill‐health (Lai et al., 2019), including high rates of suicide (Cassidy et al., 2014; Kirby et al., 2019).”
From Annual Research Review: Shifting from ‘normal science’ to neurodiversity in autism science (2022) · cites this paper as Lai et al., 2019
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“Typically, larger sex/gender differences are reported in clinical studies, but infrequently the same patterns emerge in population-based studies78,82–84.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [78]
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“Individuals with autism spectrum disorder often present somatic and/or psychiatric co-morbid disorders.”
From Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review (2021) · cites this paper as [7]
In the citing paper
“Additionally, the new classification may also have contributed to the limitation of capturing the differences in prevalence observed between males and females for ASD and co-morbidities (7).”
From Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review (2021) · cites this paper as [7]
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“In addition, individuals with ASD are more likely to experience somatic co-morbidities such as epilepsy, gastro-intestinal (GI) disorders or sight/hearing impairments (7).”
From Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review (2021) · cites this paper as [7]
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“Our review also gathered evidence that co-morbidities are more frequently observed in ASD individuals compared to typically developed population, which is in accordance with the current literature (7).”
From Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review (2021) · cites this paper as [7]
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“Co-occurrence of neurodevelopmental conditions with psychiatric and medical conditions is high74–79.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [78]
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“In terms of health conditions, autistic females are more likely to have epilepsy and endocrine–reproductive problems79,125, depressive disorders78, and disordered eating and sleep126–128, whereas autistic males are more likely to exhibit hyperactivity in childhood124.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [78]
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Metadata
- 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
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2019-10
- Volume
- 6
- Issue
- 10
- Pages
- 819-829
- ISSN
- 2215-0366 (ISSN-L)
- 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
- green
- discovery.ucl.ac.uk
- 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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