Research in Developmental Disabilities 35 (2014) 2003–2007

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review article

Depression and mood disorders among persons with

Autism Spectrum Disorders
Johnny L. Matson, Lindsey W. Williams *
Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States

A R T I C L E I N F O A B S T R A C T

Article history: In the past decade, Autism Spectrum Disorders (ASD) have both risen in prevalence and
Received 6 March 2014 become a critical area of research in the field of developmental disabilities. As the body of
Accepted 21 April 2014 knowledge about ASD has grown, the overlap of ASD with other problems has also become
Available online 24 May 2014
a rapidly emerging area of study. One of the most studied of these topics is comorbid
psychopathology, with depression and mood disorders emerging as one of the more
Keywords:
troublesome of these co-occurring conditions. A great deal of research is still needed to
Autism
determine how best to assess and treat these disorders within the context of ASD. This
Depression
Comorbid manuscript reviews current trends and topics relative to this area of study.
Psychopathology ß 2014 Elsevier Ltd. All rights reserved.

Contents

1. Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004
2. Depression and mood disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004
3. Suicidal ideation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004
4. Comorbid psychopathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005
5. Factors associated with mood disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005
6. Depression and anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005
7. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006
8. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

Autism Spectrum Disorders (ASD) have become a highly visible and frequently studied topic (Kuzniewicz et al., 2014; Lai,
Tseng, & Guo, 2013; Matson & LoVullo, 2009; Sullivan, 2013). This situation is at least in part due to the increasing prevalence
of the condition (Matson & Kozlowski, 2011; Vasa et al., 2013). However, other factors such as better diagnostic methods and
greater public awareness have also influenced this trend. While ASD is heterogeneous in overall presentation, core features
such as communication and social deficits, and stereotypies are routinely present (Fodstad, Matson, Hess, & Neal, 2009;
Horovitz & Matson, 2010; Matson, Dempsey, & Fodstad, 2009a). It is important to evaluate core symptoms across a range of
instruments, and where possible, in various settings since the prevalence and intensity of individual symptoms vary from

* Corresponding author.
E-mail addresses: johnmatson@aol.com (J.L. Matson), lindseywilliswilliams@gmail.com, lwil175@lsu.edu (L.W. Williams).

http://dx.doi.org/10.1016/j.ridd.2014.04.020
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
2004 J.L. Matson, L.W. Williams / Research in Developmental Disabilities 35 (2014) 2003–2007

case to case (Mannion, Leader, & Healy, 2013; Matson & Wilkins, 2009). In addition to these core symptoms, many comorbid
problems are also common. Commonly co-occurring difficulties include challenging behaviours, adaptive behaviour, and
psychopathology (Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009; Smith & Matson, 2010a,b,c).
Comorbid psychopathology has been reported at high rates among persons with ASD. These problems occur very early in
life and across the lifespan (LoVullo & Matson, 2009; Matson et al., 2009a, 2009b; Matson, Hess, & Boisjoli, 2010). Also, some
disorders occur more commonly than others and present at different ages. Several disorders particularly common with
respect to their co-occurrence with ASD include ADHD, anxiety disorders, and obsessive-compulsive behaviours (Chasson
et al., 2011; Gadow, 2012; MacNeil, Lopes, & Minnes, 2009). Another set of common problems that covary with ASD includes
depression and mood disorders (Matson et al., 1999; Matson & Smiroldo, 1997).

1. Assessment

Conventional wisdom is that ASD should be identified as early as possible (Matson, Fodstad, Mahan, & Sevin, 2009;
Matson, Wilkins, & Gonzalez, 2008; Matson et al., 2009f; Narzisi et al., 2013). Similarly, given the high prevalence rates of
comorbid conditions such as challenging behaviours and comorbid psychopathology, they should be assessed earlier rather
than later (Matson, Gonzalez, & Rivet, 2008). In addition to being assessed early, an individual with ASD should also be
evaluated periodically as the individual ages (Matson, Boisjoli, Gonzalez, Smith, & Wilkins, 2007; Matson, Gonzalez, et al.,
2008; Matson, LoVullo, Rivet, & Boisjoli, 2009; Matson & Rivet, 2008; Wachtel & Shorter, 2013).
Assessment involves not only identifying core symptoms of ASD but also commonly co-occurring conditions. These
difficulties are very serious in their own right. Thus, to better understanding them, important areas of research towards
better assessment include how and how often these disorders overlap with ASD, whether problematic behaviours are
occurring, and what factors are maintaining or causing co-occurring problem(s). These approaches can then be applied
systematically to assessment of the individual. This latter approach has become quite popular, particularly with respect to
assessing the challenging behaviours (Matson & Boisjoli, 2007; Matson et al., 2005; Matson, Minshawi, Gonzalez, & Mayville,
2006).
Separate diagnostic instruments are advised given the breadth and complexity of this task. The research on comorbidity
has further underscored the need to develop and use a wide variety of specialized diagnostic instruments. A review of some
of the emerging research on the topic of comorbidity, specifically as applied to the appearance of depression and mood
disorders among persons with ASD, is the topic of the remainder of this paper.

2. Depression and mood disorders

The research on depression and mood disorders can be categorized into at least five general topics. These issues include
mood and depression, suicidal ideation, comorbidity, the relationship of anxiety and mood, and research on treatment. A
review of each topic follows.
Researchers generally recognize that depression is more common among persons with ASD relative to the general
population. One such study was described by Mazzone et al. (2013), who evaluated 20 children and adolescents between 7
and 16 years of age and 10 with High Functioning Autism, 30 males with major depression age 7–27, and 35 typically
developing children from a psychiatric hospital in Italy. A battery of depression measures was used. The major depression
group evinced slightly more symptoms on these scales than the Asperger-autism group. These two groups had many more
symptoms than the typically developing group. Interestingly, depressive symptoms were also more common among parents
of persons with ASD in a study of 95 caregivers (Bekhet & Zauszniewski, 2013).
Pouw, Rieffe, Stockmann, and Gadow (2013) studied 63 people with ASD and compared them to typically developing
peers. In line with previous research, depressive symptoms were correlated with negative factors associated with social
difficulties and victimization (Cappadocia, Weiss, & Pepler, 2012; Kim, Szatmari, Bryson, Steiner, & Wilson, 2000). The
reasons for these findings require considerably more study. This is a very important area for research, and careers can be built
around discovering factors related to this phenomenon.

3. Suicidal ideation

Suicidal thoughts, which of course are related to depression and mood disturbances, have also been studied. A
particularly impressive study was published by Mayes, Gorman, Hillwig-Garcia and Syed (2013). They evaluated 791
children with autism, 1–16 years of age. These children were compared to 186 typically developing children. The dependent
variable was suicidal ideation. Mothers reported that 14% of the ASD group evinced suicidal ideation. This rate was 28 times
greater than what was reported for the typically developing group. Risk factors for suicidal ideation included being 10 years
of age or older, minority ethnic background, lower SES, and male gender.
Kato et al. (2013) looked at clinical features of suicide attempts. They assessed 587 consecutive people who had
attempted suicide. These people were all over age 18 and had been hospitalized in an inpatient psychiatric hospital. From
this sample, 43 had been diagnosed with ASD. Overall length of hospitalization for the ASD group was longer than for the
overall suicidal group. At this point, the factors that lead to these high rates are unknown (Hannon & Taylor, 2013). However,
these papers point to the seriousness of the issue and the need to research this topic more extensively.
 J.L. Matson, L.W. Williams / Research in Developmental Disabilities 35 (2014) 2003–2007 2005

4. Comorbid psychopathologies

A number of papers have been published looking at how psychopathology in general relates to ASD. Often, mood and
depression issues are embedded in a broader comorbidity. For example, La Malfa et al. (2007) evaluated 90 adults with
intellectual disability plus the co-occurrence of ASD and various forms of psychopathology. Their overall finding was that
mental health issues were common in this group, and the co-occurrence of autism and mood disorders was high. In a second
paper, Stahlberg, Soderstrom, Rastam, and Gillberg (2004) reported on 241 consecutive cases of adults referred for ASD or
ADHD. They noted that among the persons with ASD, 7% had comorbid bipolar disorder.
Rosenberg, Kaufmann, Law, and Law (2011) describe a particularly ambitious study of 4343 children with ASD. Comorbid
conditions studied included anxiety, depression, bipolar disorder, and ADHD. These authors found that milder ASD resulted
in higher rates of all forms of comorbid psychopathology. They also found that persons with intellectual disability and ASD
were as likely to evince comorbid psychopathologies as those with ASD but without intellectual disability. The only
exception was depression, which occurred less frequently among persons with intellectual disabilities. Additionally, and in
contrast to the general population, no difference in depression by gender was noted in this group. Worley and Matson (2011)
studied 125 children with ASD and found no gender differences across disorders, replicating the findings of Rosenberg et al.
(2011).
Munesue et al. (2008) studied 44 consecutive outpatients with High Functioning Autism who were assessed for mood
disorders. Of this group, 16 evinced symptoms of this problem. From this group, four were diagnosed with major depression,
two were diagnosed with bipolar I, six had bipolar II, and four met criteria for bipolar disorder not otherwise specified. The
bulk of comorbid disorder cases were of the bipolar variety. This finding would not be expected from the overall population.
However, this was a convenient sample based on clinical cases, which may have affected these findings.

5. Factors associated with mood disorders

While considerably more research is needed regarding mood disorders as they relate to ASD, some efforts have been
made in this regard. For example, Ingersoll and Hambrick (2011) studied the effects of ASD on depressive symptoms on
parental behaviour. Compared to the general population of parents, caregivers of children with ASD reported higher levels of
stress and depression. More severe symptoms of ASD were predictors of more stress and depression among parents. Meltzer
(2011) reported similar findings. Additionally, she reported that decreased sleep quality for parents and decreased sleep
quantity children were predictors of parental depression.

6. Depression and anxiety

To date, one of the largest areas of studies on comorbidity with ASD and depression also involves anxiety. Kim et al. (2000)
report on this co-occurring phenomenon among 9–14 year olds with Asperger Syndrome and High Functioning Autism.
Fifty-nine children with an ASD were compared to a community sample of 1751 children. Greater rates of anxiety and
depression were noted in the ASD sample.
Pine, Guyer, Goldwin, Towbin, and Leibenluft (2008) also studied these comorbidities. They tested 352 participants. This
group included 107 healthy controls, 88 individuals with an anxiety disorder, 32 people with major depression, 62 persons
with bipolar disorder, and 63 individuals with a mood disorder with severe non-episodic irritability. All of the groups scored
higher on ASD symptoms than typically developing controls. They also reported that persons with mood disorders evinced
language and social impairments, behavioural rigidity, and stereotypies. The ASD symptoms, on average, were less severe for
these persons compared to individuals who presented at an ASD clinic.
Kanai et al. (2011) assessed these overlapping comorbidities in adults with Asperger’s Syndrome. One-hundred-nine
individuals were administered the Japanese version of the Hospital Anxiety and Depression Scale and the NEO Five-Factor
Inventory. Neuroticism was higher for the Asperger group compared to the 65 adults with no known psychiatric condition.
The extroversion, agreeableness, and conscientiousness were lower in the Asperger’s group.
Mayes, Calhoun, Murray, Ahuja and Smith (2011) looked at anxiety, depression, and irritability among 1390 children ages
6–16 years old. Two-hundred-thirty-three children evinced High Functioning Autism while 117 children were diagnosed
with Low Functioning Autism. Fifty-four children with High Functioning Autism and 42% of the children with the Low
Functioning Autism reported depression. The symptoms were not as severe as for persons who displayed depression only.
Lugnegard, Hallerback, and Gillberg (2011) studied 26 men and 28 women whose mean age was 27 years. All of these
individuals had a diagnosis of Asperger Syndrome. Among their sample, 70% had experienced at least one episode of major
depression and 50% had recurrent episodes of depression or anxiety.
Strong et al. (2012) studied 95 children with a diagnosis of ASD. These children were assessed for depression and anxiety
symptoms. Forty-four percent of those children and adolescents tested were categorized as borderline or clinically
depressed, while 56% met these criteria for an anxiety disorder. Thirty-seven individuals in the sample met the criteria for
both depression and anxiety.
Russell-Smith, Bayliss, and Maybery (2013) conducted a study that was more conceptual in nature. They tested 284
college undergraduates. These investigators found that ASD symptoms were related to social anxiety while negative
schizotypy was related to anhedonia and depression.
2006 J.L. Matson, L.W. Williams / Research in Developmental Disabilities 35 (2014) 2003–2007

7. Treatment

Treatment research is lagging relative to describing and assessing comorbidity among persons with ASD. This situation is
understandable at present since the problem must be accurately identified before treatment can proceed. Most intervention
to date has been extrapolated from the research on persons without ASD, but more research is urgently needed to improve
and target assessment and treatment for those with ASD, as symptoms may present differently among persons with ASD, or
they may be masked by the ASD symptoms (Giovinazzo, Marciano, Giana, Curatolo, & Porfirio, 2013). Furthermore,
professionals who routinely deal with ASD may not be well versed in diagnosing various forms of concomitant
psychopathology (Frazier, Doyle, Chiu, & Coyle, 2002).

8. Conclusions

Comorbid psychopathology among persons with ASD has begun to receive attention from the scientific community. This
fact is extremely important if the best quality care for persons with ASD is to be realized. The recognition of these
comorbidities has been one of the most significant developments in the field of ASD. These developments have markedly
changed how the disorder is conceptualized. For example, there will be a need to subtype the ASD syndrome, add more axes,
or employ severity and level types, or some combination of these approaches. This notion is not particularly new. Numerous
studies over many years have remarked on the heterogeneity of ASD. However, as researchers develop more knowledge,
clarity is occurring about what heterogeneity means. How symptoms present, what disorders are likely to present based on
age, gender, the effects of core symptom presentation on psychopathology and many other related factors. This knowledge
will impact the future decisions on how best to assess and treat persons with ASD and comorbid depression and mood
disorders.

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