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Association of Comorbid Mood and Anxiety Disorders With Autism Spectrum Disorder

Educational Objective
To examine whether individuals with autism spectrum disorder (ASD) are at greater risk for comorbid diagnoses of depression, anxiety, or bipolar disorder.
1 Credit CME
Key Points

Question  What are the rates of comorbid mood and anxiety disorders in individuals with autism spectrum disorder?

Findings  In the cohort study of 31 220 individuals born in Olmsted County, Minnesota, those who were identified as having autism spectrum disorder were significantly more likely to have comorbid depression, anxiety, and bipolar disorder compared with age- and sex-matched referents.

Meaning  The findings suggest that individuals with autism spectrum disorder may be more likely to receive diagnoses of depression, bipolar disorder, and anxiety than those without an autism spectrum disorder diagnosis.

Abstract

Importance  It is critical to evaluate the risk of comorbid psychiatric diagnoses to meet the needs of individuals with autism spectrum disorder (ASD).

Objective  To examine whether individuals with ASD are at greater risk for comorbid diagnoses of depression, anxiety, or bipolar disorder.

Design, Setting, and Participants  This cohort study used data from a population-based birth cohort of 31 220 individuals born in Olmsted County, Minnesota, from January 1, 1976, to December 31, 2000. Patients with research-identified ASD were previously identified using a multistep process that evaluated signs and symptoms abstracted from medical and educational records. For each of the 1014 patients with ASD, 2 age- and sex-matched referents who did not meet criteria for ASD were randomly selected from the birth cohort (n = 2028). Diagnosis codes for anxiety, depression, and bipolar disorders were electronically obtained using the Rochester Epidemiological Project records-linkage system. Data analysis was performed from July 1, 2018, to April 1, 2019.

Main Outcomes and Measures  Cumulative incidence of clinically diagnosed depression, anxiety, and bipolar disorder through early adulthood in individuals with ASD compared with referents.

Results  A total of 1014 patients with ASD (median age at last follow-up, 22.8 years [interquartile range, 18.4-28.0 years]; 747 [73.7%] male; 902 [89.0%] white) and 2028 referents (median age at last follow-up, 22.4 years [interquartile range, 18.8-26.2 years]; 1494 [73.7%] male; 1780 [87.8%] white) participated in the study. Patients with ASD were significantly more likely to have clinically diagnosed bipolar disorder (hazard ratio [HR], 9.34; 95% CI, 4.57-19.06), depression (HR, 2.81; 95% CI, 2.45-3.22), and anxiety (HR, 3.45; 95% CI, 2.96-4.01) compared with referents. Among individuals with ASD, the estimates of cumulative incidence by 30 years of age were 7.3% (95% CI, 4.8%-9.7%) for bipolar disorder, 54.1% (95% CI, 49.8%-58.0%) for depression, and 50.0% (95% CI, 46.0%-53.7%) for anxiety. Among referents, cumulative incidence estimates by 30 years of age were 0.9% (95% CI, 0.1%-1.7%) for bipolar disorder, 28.9% (95% CI, 25.7%-32.0%) for depression, and 22.2% (95% CI, 19.3%-25.0%) for anxiety.

Conclusions and Relevance  The findings suggest that individuals with ASD may be at increased risk for clinically diagnosed depression, anxiety, and bipolar disorder compared with age- and sex-matched referents. This study supports the importance of early, ongoing surveillance and targeted treatments to address the psychiatric needs of individuals with ASD.

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Article Information

Accepted for Publication: July 19, 2019.

Corresponding Author: Alexandra C. Kirsch, PhD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (kirsch.alexandra@mayo.edu).

Published Online: December 2, 2019. doi:10.1001/jamapediatrics.2019.4368

Author Contributions: Dr Kirsch and Ms Weaver had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kirsch, Huebner, Mehta, Weaver, Myers, Voight, Katusic.

Drafting of the manuscript: Kirsch, Huebner, Weaver.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Howie, Weaver.

Obtained funding: Myers, Katusic.

Administrative, technical, or material support: Huebner, Mehta, Voight.

Supervision: Kirsch, Huebner, Mehta, Voight, Katusic.

Conflict of Interest Disclosures: Dr Kirsch reported receiving grants from the National Institutes of Health and the Public Health Service during the conduct of the study. Dr Huebner reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Howie reported receiving grants from the National Institute of Mental Health during the conduct of the study. Dr Katusic reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by research grants MH093522 from the National Institutes of Health and AG034676 from the US Public Health Service (Dr Katusic).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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