Benefits and harms of interventions to improve anxiety, depression, and other mental health outcomes for autistic people: A systematic review and network meta-analysis of randomised controlled trials
Open accessAbstract
Mental health difficulties are prevalent in autistic people with ~14%–50% having experienced depression and ~40%–80% having experienced anxiety disorders. Identifying interventions that improve autistic people’s mental health is a top priority. However, at present, there is no high-quality network meta-analysis of benefits and harms of different interventions. We conducted a systematic review and network meta-analysis of randomised controlled trials, searching MEDLINE, EMBASE, other databases, and trial registers until 17 October 2020. We included randomised controlled trials reporting anxiety or depression in a suitable format. We calculated effect estimates and 95% credible intervals using Bayesian network meta-analysis. Our search identified 13,794 reports, of which 71 randomised controlled trials (3630 participants) were eligible for inclusion. All trials had high risk of bias. The follow-up period ranged from 1 to 24 months. Evidence indicates uncertainty about the effects of different interventions, with more high-quality evidence needed. Available evidence suggests that some forms of cognitive behavioural therapy may decrease anxiety and depression scores in autistic children and adults; mindfulness therapy may decrease anxiety and depression scores in autistic adults with previous mental health conditions; and behavioural interventions may provide some benefit for depression in autistic children. We recommend that autistic people are given access to mental health interventions available to non-autistic people, following principles of person-centred care. PROSPERO registration ID: CRD42019136093 Lay Abstract Nearly three out of four autistic people experience mental health problems such as stress, anxiety or depression. The research already done does not guide us on how best to prevent or treat mental health problems for autistic people. Our aim was to look at the benefits and harms of different interventions on mental health outcomes in autistic people. We searched all the published randomised controlled trials (RCTs) about interventions for mental health conditions in autistic people until 17 October 2020. We also searched for RCTs that were not published in peer-reviewed journals. These were obtained from registers of clinical trials online. We then combined the information from all these trials using advanced statistical methods to analyse how good the interventions are. Seventy-one studies (3630 participants) provided information for this research. The studies reported how participants were responding to the intervention for only a short period of time. The trials did not report which interventions worked for people with intellectual disability. In people without intellectual disability, some forms of cognitive behavioural therapy and mindfulness therapy may be helpful. However, further research is necessary. Many trials used medications to target core features of autism rather than targeting mental health conditions, but these medications did not help autistic people. Until we have more evidence, treatment of mental health conditions in autistic people should follow the evidence available for non-autistic people. We plan to widely disseminate the findings to healthcare professionals through medical journals and conferences and contact other groups representing autistic people.
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Interventions targeting depression in autistic youth are limited.
“Interventions targeting depression in autistic youth are limited”
From Community-guided, autism-adapted group cognitive behavioral therapy for depression in autistic youth (CBT-DAY): Preliminary feasibility, acceptability, and efficacy (2024) · cites this paper as Linden et al., 2023
The Discussion (Summary; page not provided) says evidence for behavioural interventions for depression is limited, and the Results (Effect estimates, Depression in children; page not provided) say uncertainty prevents recommending one intervention over another. That supports a shortage of established treatments for autistic youth, but not the broader implication that few interventions targeting depression exist; the Introduction lists several types. (LLM, conf=0.82)
Experimental — accuracy not yet measuredIn a review of depression treatments for autistic people, only 20 psychosocial treatments met inclusion criteria, with just 12 studies targeting depressive symptoms.
“In a review of depression treatments for autistic people, only 20 psychosocial treatments met the inclusion criteria for the review, with just 12 studies targeting depressive symptoms (Linden et al., 2023; Menezes et al., 2020).”
From Community-guided, autism-adapted group cognitive behavioral therapy for depression in autistic youth (CBT-DAY): Preliminary feasibility, acceptability, and efficacy (2024) · cites this paper as Linden et al., 2023
The Methods (Criteria for considering studies for this review; page unavailable) confirm that Linden et al. reviewed interventions with depression outcomes in autistic people. But the review also covered anxiety and other interventions, and the Results (Searches and characteristics of included studies; page unavailable) report 71 trials overall. The passages found do not substantiate either 20 psychosocial treatments meeting inclusion criteria or 12 studies targeting depressive symptoms. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAutistic individuals may be less able to report issues due to the nature of their autistic condition.
“autistic individuals may be less able to report issues due to the nature of their autistic condition”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Linden et al., 2023
The Discussion (Summary; page unavailable) says autistic people can have difficulty distinguishing experiences related to autism from those related to mental health. That supports a narrower difficulty identifying mental health issues, but the paper does not say autistic people are generally less able to report issues. Its discussion of inadequate adverse-event reporting concerns researchers, not autistic participants. (LLM, conf=0.76)
Experimental — accuracy not yet measuredPotential adverse effects of standard interventions have rarely been investigated.
“the potential adverse effects of standard interventions have been rarely investigated.”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Linden et al., 2023
In Results > Assessment of reporting biases (page unavailable), the review says only a small proportion of trials reporting mental health outcomes in autistic people adequately reported adverse events. Discussion > Summary likewise says harms are often reported inadequately. This supports a concern about limited adverse-effect evidence, but does not establish that adverse effects of standard interventions generally have rarely been investigated; inadequate reporting is not necessarily a lack of investigation. (LLM, conf=0.84)
Experimental — accuracy not yet measuredInterventions often aim to change the individuals rather than accommodate their needs.
“interventions often aim to change the individuals rather than accommodate their needs”
From Rethinking psychological interventions in autism: Toward a neurodiversity‐affirming approach. (2025) · cites this paper as Linden et al., 2023
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“Therefore, on the basis of currently available evidence, in contrast to existing work (e.g. Chancel et al., 2020), we cannot recommend a specific modality of CBT over another.”
ResultMeta-Review: Network Meta-Analyses in Child and Adolescent Psychiatry
Cortese, S., Tomlinson, A., & Cipriani, A. (2018) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2018.07.891 · Cited by 25 · see citing works
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Bischof, N. L., Rapee, R. M., Hudry, K., & Bayer, J. K. (2018) · Autism Research · doi:10.1002/aur.1963 · Cited by 23 · cited 1× · see citing works
“Only one trial had a follow-up longer than 12 months (Bischof et al., 2018).”
BackgroundGuided self-help for depression in autistic adults: The ADEPT feasibility RCT
Russell, A., Gaunt, D., Cooper, K., Horwood, J., Barton, S., Ensum, I., Ingham, B., Parr, J., Metcalfe, C., Rai, D., et al. (2019) · Health Technology Assessment · doi:10.3310/hta23680 · Cited by 22 · cited 4× · see citing works
“For example, our review showed a common issue in autism research, namely that most trials only included autistic people without ID or included only a small number of autistic participants with ID (G. Russell et al., 2019).”
BackgroundInfluentialSelf-citationSquassante, L., Bolognani, F., Smith, J., Murtagh, L., da Fontoura, P. P., Khwaja, O., Umbricht, D., Sanders, K. B., & Rubido, M. D. V. (2018) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2018.09.308 · Cited by 4 · see citing works
Flagged first, then by citations
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Cited by
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Mental health challenges faced by autistic people
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“Non-pharmacological treatment options for anxiety can include modified CBT [98], psychosocial education, parent training, social recreational programs, and mind-fulness techniques, either alone or in combination, that have been tailored to meet the needs and strengths of the patient [95, 98, 99].”
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MethodPemovska, T., Loizou, S., Appleton, R., Spain, D., Stefanidou, T., Kular, A., Cooper, R. E., Greenburgh, A., Griffiths, J., Barnett, P., et al. (2024) · Psychological Medicine · doi:10.1017/s0033291724001089 · Cited by 20 · see citing works
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“…in larger randomized controlled trials, since depression and anxiety are the most common psychiatric co-occurrences (Hollocks et al., 2019; Linden et al., 2022), and psychiatric comorbidity is an important risk factor for suicidal behaviors in autistic adults (Hirvikoski et al., 2020),…”
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HIDDEN STRUGGLES: SHEDDING LIGHT ON DEPRESSION AND ANXIETY IN ADULTS WITH AUTISM SPECTRUM CONDITION
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Community Newsletter: Novel biosensor, mental health needs, autism research’s sex bias
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Recognising behaviour as distress in practice: a discussion paperPreprint
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Behandlungen von psychischen Störungen bei Autismus
Quante, A. (2023) · PSYCH up2date · doi:10.1055/a-2089-9541
Describing Multidomain Health Outcomes in Autistic Children in the ECHO Program
Kaplan‐Kahn, E. A., Rando, J., Ames, J., Bekelman, T. A., Camargo, C. A., Croen, L., Dager, S. R., Dickerson, A. S., Dunlop, A. L., Elliott, A. J., et al. (2024) · JAACAP Open · doi:10.1016/j.jaacop.2024.05.005
Bolton, M. J. (2025) · doi:10.31234/osf.io/t3kfw_v2
Schwartzman, J. M., Kujawa, A., Jeste, S., Corbett, B. A., Xu, W., Monachino, A. D., Castro, M. A., Quintero, K. C., Dao, A., Durazo-Arvizú, R., et al. (2025) · BMC Psychology · doi:10.1186/s40359-025-02911-w
Mood Stabilizers and Antiepileptics
Deb, S. S., Roy, M., & Limbu, B. (2025) · Oxford University Press eBooks · doi:10.1093/oso/9780197635841.003.0029
Autism Sensitive Mindfulness-Based Programmes
Birtwell, K., Andexer, J. N., & Corsellis, E. (2025) · Springer eBooks · doi:10.1007/978-3-032-00353-9_29
McFarlane, Z., & Wilson, A. C. (2025) · Autism in Adulthood · doi:10.1177/25739581251388228
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Self-citationSuicide prevention interventions and supports for the Autistic community: a scoping review protocol
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C.E.E.G. Framework: A Therapeutic Modality for Enhancing Outcomes in Autistic Adolescent Females
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Conociendo las experiencias de estudiantes universitarios autistas: el impacto de la salud mental
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A Systematic Review of the Risk and Protective Factors for Suicide in Autism Spectrum Disorder
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Special Issue: Discovery of Novel Antidepressants and Anxiolytics
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- Authors
- Linden, A., Best, L., Elise, F., Roberts, D., Branagan, A., Tay, Y. B. E., Crane, L., Cusack, J., Davidson, B., Davidson, I., Hearst, C., Mandy, W., Rai, D., Smith, E., & Gurusamy, K.
- Affiliations
- University College London (GB)
- Autistica (GB)
- Cheshire and Wirral Partnership NHS Foundation Trust (GB)
- AutAngel Community Interest Company, UK
- University of Bristol (GB)
- Corresponding author
- Linden, Audrey
- ORCID
- Venue
- Autism
- Publisher
- SAGE Publications
- Published
- 2022-08-11
- Volume
- 27
- Issue
- 1
- Pages
- 7-30
- ISSN
- 1362-3613 (ISSN-L)
- 1461-7005
- PMC
- PMC9806485
- OpenAlex
- W4291158558
- Cited by
- 78
- References
- 80
- Citations by year
- 2026: 17 · 2025: 20 · 2024: 24 · 2023: 16 · 2022: 1
- FWCI
- 2.13
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Autism (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Birmingham Research Portal (University of Birmingham) (publishedVersion, cc-by)
- UCL Discovery (University College London) (submittedVersion)
- Explore Bristol Research (submittedVersion, cc-by)
- Bristol Research (University of Bristol) (submittedVersion, cc-by)
- OSF Preprints (OSF Preprints) (submittedVersion)
- Funders
- National Institute for Health Research (Research for Patient Benefit Programme (PB-PG-0418)
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Developmental and Educational Psychology › Behavioral and Psychological Studies
- Social Sciences › Psychology › Clinical Psychology › Family and Disability Support Research
- Keywords
- mental health, depression, anxiety disorders, cognitive behavioral therapy, mindfulness therapy, behavioral interventions, children with autism, autistic adults, person-centred care, harms of interventions, intellectual disability, evidence uncertainty
- MeSH terms
- Autism Spectrum Disorder, Network Meta-Analysis, Anxiety, Autistic Disorder, Depression, Humans, Intellectual Disability, Randomized Controlled Trials as Topic, Outcome Assessment, Health Care
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