Comorbid Mood and Anxiety Disorders in ASD

Findings indicate that individuals with autism spectrum disorder (ASD) may have an increased risk of receiving mood and anxiety disorder diagnoses compared with individuals without ASD.

Researchers arrived at their conclusion after conducting a cohort study using data from 31,220 individuals born in Olmsted County, Minnesota, from January 1, 1976, to December 31, 2000. Ultimately, 1014 patients with ASD and 2028 patients without ASD were included in the final analysis. The main outcome of the study was defined as the cumulative incidence of clinically diagnosed depression, anxiety, and bipolar disorder through early adulthood among patients with ASD compared with those without ASD.

Overall, the researchers found that the risks of receiving clinical diagnoses of bipolar disorder, depression, and anxiety were significantly higher in patients with ASD compared with those without ASD (hazard ratios 9.34, 2.81, and 3.45, respectively).

Estimates of cumulative incidence by age 30 years were 7.3% for bipolar disorder, 54.1% for depression, and 50.0% for anxiety among patients with ASD. For their counterparts without ASD, corresponding estimates were 0.9% for bipolar disorder, 28.9% for depression, and 22.2% for anxiety.

Lead study author Alexandra Kirsch, PhD, who is a pediatric neuropsychologist at NorthShore University HealthSystem in Chicago, Illinois, discussed these findings and their clinical implications further.

Consultant360: Was your study able to identify, or have you hypothesized why the risk of developing depression, anxiety, and/or bipolar disorder is greater in individuals with ASD compared with those without ASD?

Dr Kirsch: While we did not directly study the reasons behind the greater prevalence of mood and anxiety disorder comorbidities in individuals with ASD, we were able to hypothesize some potential causes. First, the psychosocial sequelae associated with having ASD may increase the risk for depression and anxiety. These include challenges with making and maintaining friendships and succeeding in academic and vocational roles, as well as the presence of behaviors that may be difficult to manage. There is also the potential that ASD and these comorbidities have shared etiologies that have not yet been fully elucidated. Additionally, a portion of individuals with comorbidities may reflect initial difficulty with diagnostic clarity.

C360: What consequences can occur among individuals with ASD if comorbidities like depression, anxiety, and bipolar disorder are not diagnosed and addressed?

Dr Kirsch: Without treatment, mood and anxiety concerns can have significant negative effects on overall functioning and are related to higher rates of substance abuse and suicide, which we know are salient concerns for individuals with ASD.

C360: How might the findings from your study aid in risk stratification for psychiatric disorders in patients with autism?

Dr Kirsch: This study highlights that for many patients, the experience of having ASD may be only one piece of the puzzle for understanding success and long-term outcomes. As mentioned above, individuals with anxiety, depression, or bipolar disorder can have different functional outcomes, and this becomes even more salient when one already has ASD. There is an additive nature of also having a comorbid condition that may predict other salient outcomes in this community.

C360: In your study, you and your co-authors noted that “although individuals with ASD may receive these diagnoses at younger ages, they may continue to have greater risk in adulthood, when access to specialty care and resources is more limited, which may place a large burden for screening on primary care practitioners providing care to adults with ASD.” What steps are important for primary care practitioners (PCPs) to take to ensure continued access to the right care and resources during adulthood?

Dr Kirsch: First and foremost, PCPs need to feel comfortable working with individuals on the spectrum. We will have more and more individuals aging into adulthood and requiring ongoing care without enough specialty clinics to manage them. Thus, understanding the core features of ASD and being able to differentiate them from other diagnoses will be extremely important. PCPs also need proper screening tools that have been validated for this population and differentiate clinical comorbidities with success. Awareness of and access to referral networks of adult mental health care providers, both therapists and psychiatrists, who work with individuals on the spectrum will be beneficial to establish.

C360: What key clinical takeaways do you hope clinicians learn from your study?

Dr Kirsch: Individuals with ASD are potentially at even greater risk for mood and anxiety concerns than those without ASD, which means it is critical to screen for these comorbidities regularly and at even younger ages. There is sometimes a bias to see people as just one thing (ie, their diagnosis) and not always look for the other areas that may benefit from targeted mental health treatment. It is my hope that providers will have greater awareness for potential comorbidities and ask questions about mental health, opening the door for further discussion.

C360: What are the next steps for future research?

Dr Kirsch: Research is needed to better understand the cause and outcomes of these comorbidities in individuals with ASD. Screening tools that take into account how the core features of ASD (ie, language challenges, problems with labeling and describing emotions, and difficulty engaging socially in a reciprocal manner) that may affect accuracy of screening and are well-validated in this population are vital.

Alexandra Kirsch, PhD, is a pediatric neuropsychologist at Northshore University HealthSystem in Chicago, IL.

—Christina Vogt

Kirsch AC, Huebner ARS, Mehta SQ, et al. Association of comorbid mood and anxiety disorders with autism spectrum disorder [Published online December 2, 2019]. JAMA Pediatr. doi: