Imagine feeling overwhelmed in a world not built for you. For many autistic individuals, this is a daily reality, especially regarding mental health.
Autism is a lifelong developmental disability affecting communication and interaction. Autistic people may find it harder to understand others’ thoughts and feelings, or may feel overwhelmed by bright lights or loud noises (National Health Service, 2022). Over 1 in 100 people are on the autism spectrum, with around 700,000 autistic adults and children in the UK. (National Autistic Society, n.d.).
Autistic people are more likely to experience mental health difficulties than the general population (Lai et al., 2019). Yet accessing effective care is challenging. UK guidelines recommend recognising and treating co-occurring conditions like anxiety or depression, but many autistic individuals face barriers such as long waiting times and services not adapted to their needs.
Addressing these challenges is essential. Researchers conducted a comprehensive review to uncover strategies for improving mental health care for autistic individuals (Loizou et al., 2024), focusing on three key questions:
- What strategies are being used to improve care for autistic people?
- Are these strategies acceptable and feasible for autistic individuals?
- Are these strategies effective in improving mental health outcomes?
Mental health care isn’t built for everyone—autistic individuals face unique barriers to support, despite being at higher risk for mental health difficulties.
Methods
The authors searched Medline, PsycINFO, CINAHL, medRxiv, and PsyArXiv for studies from January 1994 to July 2022. They also reviewed reference lists of relevant systematic reviews and consulted experts for additional papers.
The authors included papers that followed certain criteria such as participants with diagnosed or suspected autism, and clinicians and carers providing views on mental health interventions for autistic individuals.
Outcomes included feasibility, care acceptability, mental health measures, and quality of life. All study designs and service evaluations were included for the first two research questions (above), but only empirical quantitative studies were included for the third. Study selection was conducted using Rayyan software, and full-text screening was done according to the Cochrane guidelines (Higgins & Thomas, 2019).
Quality was assessed with the Mixed Methods Appraisal Tool, and results were presented via narrative synthesis.
Results
Study characteristics
The 30 included studies included five randomised controlled trials (RCTs) or pilot RCTs, three non-RCTs, three qualitative studies, one cross-sectional study, four surveys, four service evaluations, and ten before-after comparison studies. Two of the studies were from the same trial.
The overall quality of the included studies was generally high. Sixteen studies were of high quality (i.e., low risk of bias), seven were of moderate quality, and seven were of low quality.
Main findings
Mental health treatments for autistic people, often based on Cognitive Behavioural Therapy (CBT), are being adapted to address anxiety, depression, and obsessive-compulsive disorder. Adjustments include improving communication, modifying treatment content and structure, and personalising approaches.
Mental health services are also adapting by improving communication for autistic people, aiding clinicians in understanding and identifying autism, and creating more comfortable environments.
Many changes align with autistic adults’ preferences, such as clearer communication, better-trained professionals, and more flexible spaces. While communication improvements are common, environmental adjustments are less frequent, indicating room for further enhancement in mental health care for autistic individuals.
A full list of adaptations is presented in table 2 in the open access review, which is reproduced below.
Table 2: All service-level and intervention-level adaptations (simplified version) (N = 24). [Click to view full-sized figure]
Adapted Cognitive Behavioural Therapy
CBT is one of the most commonly used therapies for mental health conditions, but standard CBT often falls short for autistic people. This review highlighted adaptations like:
- Using plain, direct language and avoiding metaphors.
- Incorporating visual aids and written instructions.
- Allowing more time for sessions or breaking them into smaller parts.
These adaptations were well-received by autistic participants, who found them helpful and practical. Therapists noted the modifications were easy to implement, making adapted CBT promising. Most interventions, including adapted CBT and bespoke therapies, were acceptable to autistic individuals and feasible for therapists. Positive feedback focused on clear communication, sensory accommodations, and tailored pacing of sessions.
Is this effective?
Results were less conclusive. Some studies showed improvements in anxiety and depression, but evidence was insufficient for definitive conclusions. No trials compared adapted and non-adapted interventions, highlighting the need for more robust trials to confirm better outcomes.
Adapting therapies for autistic individuals can enhance inclusivity and accessibility in mental health care. However, challenges remain, such as a lack of diverse populations in studies (e.g., ethnic minorities and intellectual disabilities). Addressing these gaps is crucial to ensure inclusivity for all.
Mental health care should be a safety net, not a hurdle. For autistic individuals, access to understanding and respectful care can be life-changing. This review shows progress, but also highlights the need for continued efforts.
As a society, we must push for inclusive, effective, and compassionate services. Small changes can make a big difference. Together, we can help autistic individuals thrive.
This review suggests that adapted CBT, using clear language, visual aids, and flexible pacing, was well-received by autistic individuals.
Conclusions
Overall, this review highlights the acceptability of many autism-adapted service/interventions, at service and individual levels, that improve autistic individual’s mental health care. The findings of this review suggest that evidence on effectiveness was inconclusive but appears initially promising.
To enhance research, we need larger samples and control groups, a co-produced mental health service improvement package and neurodivergence-informed approaches.
Adapting mental health therapies, like making CBT clearer and more flexible, can improve care for autistic individuals, but more research is needed to confirm the effectiveness.
Strengths and limitations
This is the first systematic review to the authors’ knowledge that examines all attempts to improve mental health care for autistic individuals. The interventions studied were applied within real-world services, enhancing their relevance. The review covered multiple levels—service, intervention, and individual—offering a broad perspective on autism-adapted care. It also addressed diverse mental health conditions, making the findings widely applicable. Notably, two-thirds of the included studies were of moderate to high quality, reinforcing the reliability of the conclusions.
However, bias was a key concern. Many studies had low participation rates and lacked diversity, with most participants being white males. Selection bias may have been introduced due to the novel population assessment method, and confirmation bias was a possibility given the involvement of lived-experience researchers throughout the review process. While efforts were made to mitigate publication bias, it remains a limitation as studies relevant to this review may not have been published, despite efforts to conduct a comprehensive search. This could have influenced the findings by limiting the available evidence. Additionally, only 10% of initial title/abstract screenings underwent dual independent review, and the exclusion of qualitative measures may have overlooked important insights.
Confounding was another issue, as most studies were non-RCTs, making it difficult to rule out other influencing factors. Small sample sizes further increased the risk of chance findings, and the high heterogeneity across studies made meta-analysis unfeasible.
This review provides the first comprehensive look at autism-adapted mental health care, but limitations like bias, small sample sizes, and study diversity gaps remain.
Implications for practice
A key strength of this review was the involvement of lived-experience researchers, highlighting the importance of co-production in mental health service development. Simple adjustments, such as clearer communication and environmental modifications, can be easily implemented without further RCTs. Involving autistic therapists could further enhance services, as autistic professionals bring unique insights into supporting autistic clients, fostering greater understanding and trust.
Personalised approaches are essential, as autistic individuals may not respond to standard treatments in the same way as non-autistic people. A neurodivergence-informed approach can help balance individualised treatment with evidence-based practices. Future research and service improvements should also focus on underrepresented groups, including autistic people with intellectual disabilities, long-term mental health difficulties, and those from ethnic minority backgrounds.
There is also a need for more bespoke interventions tailored to autistic individuals’ unique challenges. Continued research, advocacy, and co-produced solutions are key to ensuring more accessible and effective mental health care.
Co-producing mental health services with autistic individuals can drive meaningful change as simple adjustments and neurodivergence-informed care can improve accessibility and outcomes.
Statement of interests
No conflicts of interest to declare.
Contributors
Thanks to the UCL Mental Health MSc students who wrote this blog from student group 6: Yihong (Sherry) Cao, Isadora Miranda Gonzalez, Kalie Shun Yee Chan and Qanita Fatima. Hannah Gray (Study Group Co-Lead) provided feedback and supported the student group to bring their blog to life.
UCLÂ MSc in Mental Health Studies
This blog has been written by a group of students on the Clinical Mental Health Sciences MSc at University College London. A full list of blogs by UCL MSc students can be found here.
We regularly publish blogs written by individual students or groups of students studying at universities that subscribe to the National Elf Service. Contact us if you’d like to find out more about how this could work for your university.
Links
Primary paper
Loizou, S., Pemovska, T., Stefanidou, T., Foye, U., Cooper, R., Kular, A., Greenburgh, A., Baldwin, H., Griffiths, J., Saunders, K.R., Barnett, P., Minchin, M., Brady, G., Ahmed, N., Parker, J., Chipp, B., Olive, R. R., Jackson, R., Timmerman, A., Sapiets, S., Driskell, E., Parsons, B., Spain, D., Totsika, V., Mandy, W., Pender, R., Clery, P., Trevillion, K., Lloyd-Evans, B., Simpson, A, & Johnson, S. (2024). Approaches to improving mental healthcare for autistic people: systematic review. BJPsych open, 10(4), e128. https://doi.org/10.1192/bjo.2024.707
Other references
Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J., & Welch, V. A. (2019). Cochrane Handbook for Systematic Reviews of Interventions (Second edition). Wiley. https://doi.org/10.1002/9781119536604
Lai, M. C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819-829. https://doi.org/10.1016/S2215-0366(19)30289-5
National Autistic Society.(n.d.). What is autism? https://www.autism.org.uk/advice-and-guidance/what-is-autism
NHS. (2022, September 9). What is autism? https://www.nhs.uk/conditions/autism/what-is-autism/
