Cognitive behavioral therapy (CBT) is efficacious for reducing anxiety in children and depressive symptoms among adults with autism spectrum disorder (ASD). Social skills training (SST) effectively reduces anxiety in children and adults with ASD and depressive symptoms in children. These are among the systematic review and meta-analysis findings published in Psychological Medicine.

Investigators sought to evaluate the effectiveness of psychotherapy for comorbid symptoms of anxiety, depression, and obsessive-compulsive disorder (OCD) among individuals with ASD.

This systematic review and meta-analysis conducted until February 2022 using EMBASE, PsycINFO, and PubMed databases included 26 random controlled trials (RCTs) for CBT (n=1251) and 11 RCTs for SST (n=475) examining any presentation of psychotherapy for OCD, depression, and anxiety symptoms in individuals with ASD. Articles not in English or Dutch, grey literature, lacking RTC design, studying patients without a primary diagnosis of ASD or without a secondary diagnosis of anxiety and/or depressive disorders, or combining psychotherapy with pharmacological treatments (other than regular use of psychotropic medications) were excluded. Articles were not excluded based on sex, age, publication date, types of control groups, or intelligence of participants. All articles were screened by 2 independent investigators.

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Included trial interventions varied from 6 to 40 weeks (group CBT intervention, 15 studies; individual CBT intervention, 7 studies; combination, 4 studies; family-based CBT intervention, 10 studies; nonfamily-based CBT intervention, 16 studies). Control groups were primarily treatment-as-usual or waitlist control. All interventions were group-based for SST.

Investigators found pooled effect sizes revealed a small but significant reduction of depressive symptoms in adults (g=-0.39) and a moderate reduction in anxiety among children (g=-0.70).

Overall effect sizes for SST showed a small reduction of anxiety in adults (g=-0.34) and children (g=-0.35) and a moderate reduction in depressive symptoms among children (g=-0.50).

Investigators noted the effect of CBT on OCD symptoms to be moderate (g=-0.62) but not significant (P =.06). Combined with different age groups in the 3 included RCTs studying OCD, the current investigators could not conclude CBT as effective treatment for individuals with ASD and comorbid OCD.

Risk for bias was low in 3, moderate in 16, and high in 18 RCTs.

Review and meta-analysis limitations include the review nature of the design, half of included studies show high risk for bias, most of the included studies included only ASD with IQ>70-80 excluding a third of the total ASD population, possible publication bias, using multiple outcome measures and rating scales, and failure to include a number-needed-to-treat analysis.

Investigators concluded, “CBT reduces comorbid symptoms of anxiety in children and depressive symptoms in adults with ASD.” They wrote, “SST is both effective for reducing anxiety in children and adults and depressive symptoms in children with ASD.” They suggest applying an individual, family-based approach for CBT.


Wichers RH, van der Wouw LC, Brouwer ME, Lok A, Bockting CLH. Psychotherapy for co-occurring symptoms of depression, anxiety and obsessive-compulsive disorder in children and adults with autism spectrum disorder: a systematic review and meta-analysisPsychol Med. Published online November 21, 2022. doi:10.1017/S0033291722003415

This article originally appeared on Psychiatry Advisor