Skip to main content Accessibility help

Risk and functional significance of psychotic experiences among individuals with depression in 44 low- and middle-income countries

  • A. Koyanagi (a1) (a2), H. Oh (a3) (a4), A. Stickley (a5), J. M. Haro (a1) (a2) and J. DeVylder (a6)...



Studies on whether the co-occurrence of psychotic experiences (PEs) and depression confers a more pronounced decrement in health status and function compared with depression alone are scarce in the general adult population.


Data on 195 479 adults aged ⩾18 years from the World Health Survey were analysed. Using the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI), depression in the past 12 months was categorized into four groups: depressive episode, brief depressive episode, subsyndromal depression, and no depression. Past 12-month psychotic symptoms were assessed using four questions on positive symptoms from the CIDI. Health status across seven domains (cognition, interpersonal activities, sleep/energy, self-care, mobility, pain/discomfort, vision) and interviewer-rated presence of a mental health problem were assessed. Multivariable logistic and linear regression analyses were performed to assess the associations.


When compared with those with no depression, individuals with depression had higher odds of reporting at least one PE, and this was seen across all levels of depression severity: subsyndromal depression [odds ratio (OR) 2.38, 95% confidence interval (CI) 2.02–2.81], brief depressive episode (OR 3.84, 95% CI 3.31–4.46) and depressive episode (OR 3.75, 95% CI 3.24–4.33). Having coexisting PEs and depression was associated with a higher risk for observable illness behavior and a significant decline in health status in the cognition, interpersonal activities and sleep/energy domains, compared with those with depression alone.


This coexistence of depression and PEs is associated with more severe social, cognitive and sleep disturbances, and more outwardly apparent illness behavior. Detecting this co-occurrence may be important for treatment planning.


Corresponding author

*Address for correspondence: A. Koyanagi, M.D., M.Sc., Ph.D., Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, Barcelona, Spain. (Email:


Hide All
Armando, M, Nelson, B, Yung, AR, Ross, M, Birchwood, M, Girardi, P, Fiori Nastro, P (2010). Psychotic-like experiences and correlation with distress and depressive symptoms in a community sample of adolescents and young adults. Schizophrenia Research 119, 258265.
Ayuso-Mateos, JL, Nuevo, R, Verdes, E, Naidoo, N, Chatterji, S (2010). From depressive symptoms to depressive disorders: the relevance of thresholds. British Journal of Psychiatry 196, 365371.
Barragan, M, Laurens, KR, Navarro, JB, Obiols, JE (2011). Psychotic-like experiences and depressive symptoms in a community sample of adolescents. European Psychiatry 26, 396401.
Breslau, N, Roth, T, Rosenthal, L, Andreski, P (1996). Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biological Psychiatry 39, 411418.
Cooper, L, Peters, L, Andrews, G (1998). Validity of the Composite International Diagnostic Interview (CIDI) psychosis module in a psychiatric setting. Journal of Psychiatric Research 32, 361368.
DeVylder, JE, Burnette, D, Yang, LH (2014). Co-occurrence of psychotic experiences and common mental health conditions across four racially and ethnically diverse population samples. Psychological Medicine 44, 35033513.
DeVylder, JE, Koyanagi, A, Unick, J, Oh, H, Nam, B, Stickley, A (2016). Stress sensitivity and psychotic experiences in 39 low- and middle-income countries. Schizophrenia Bulletin. Published online 24 April 2016. doi:10.1093/schbul/sbw044.
Feeny, D, Furlong, W, Boyle, M, Torrance, GW (1995). Multi-attribute health status classification systems. Health Utilities Index. Pharmacoeconomics 7, 490502.
Fisher, HL, Lereya, ST, Thompson, A, Lewis, G, Zammit, S, Wolke, D (2014). Childhood parasomnias and psychotic experiences at age 12 years in a United Kingdom birth cohort. Sleep 37, 475482.
Freeman, D, Sheaves, B, Goodwin, GM, Yu, LM, Harrison, PJ, Emsley, R, Bostock, S, Foster, RG, Wadekar, V, Hinds, C, Espie, CA (2015). Effects of cognitive behavioural therapy for insomnia on the mental health of university students: study protocol for a randomized controlled trial. Trials 16, 236.
Grant, BF, Chou, SP, Goldstein, RB, Huang, B, Stinson, FS, Saha, TD, Smith, SM, Dawson, DA, Pulay, AJ, Pickering, RP, Ruan, WJ (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry 69, 533545.
Katz, KA (2006). The (relative) risks of using odds ratios. Archives of Dermatology 142, 761764.
Kelleher, I, Keeley, H, Corcoran, P, Lynch, F, Fitzpatrick, C, Devlin, N, Molloy, C, Roddy, S, Clarke, MC, Harley, M, Arseneault, L, Wasserman, C, Carli, V, Sarchiapone, M, Hoven, C, Wasserman, D, Cannon, M (2012). Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. British Journal of Psychiatry 201, 2632.
Kessler, RC, Ustun, TB (2004). The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research 13, 93121.
Kind, P (1996). The EuroQol instrument: an index of health related quality of life. In Quality of Life and PharmacoEconomics in Clinical Trials (ed. Spiker, B.), pp. 191201. Lippincott-Raven Publishers: Philadelphia, PA.
Kobayashi, H, Nemoto, T, Murakami, M, Kashima, H, Mizuno, M (2011). Lack of association between psychosis-like experiences and seeking help from professionals: a case-controlled study. Schizophrenia Research 132, 208212.
Koyanagi, A, Stickley, A (2015). The association between sleep problems and psychotic symptoms in the general population: a global perspective. Sleep 38, 18751885.
Kurtz, MM, Mueser, KT (2008). A meta-analysis of controlled research on social skills training for schizophrenia. Journal of Consulting and Clinical Psychology 76, 491504.
Linscott, RJ, van Os, J (2010). Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual Review of Clinical Psychology 6, 391419.
Moreno, C, Nuevo, R, Chatterji, S, Verdes, E, Arango, C, Ayuso-Mateos, JL (2013). Psychotic symptoms are associated with physical health problems independently of a mental disorder diagnosis: results from the WHO World Health Survey. World Psychiatry 12, 251257.
Moussavi, S, Chatterji, S, Verdes, E, Tandon, A, Patel, V, Ustun, B (2007). Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 370, 851858.
Nuevo, R, Chatterji, S, Verdes, E, Naidoo, N, Arango, C, Ayuso-Mateos, JL (2012). The continuum of psychotic symptoms in the general population: a cross-national study. Schizophrenia Bulletin 38, 475485.
Nuevo, R, Van Os, J, Arango, C, Chatterji, S, Ayuso-Mateos, JL (2013). Evidence for the early clinical relevance of hallucinatory–delusional states in the general population. Acta Psychiatrica Scandinavica 127, 482493.
Oh, H, DeVylder, J (2015). Psychotic symptoms predict health outcomes even after adjusting for substance use, smoking and co-occurring psychiatric disorders: findings from the NCS-R and NLAAS. World Psychiatry 14, 101102.
Ohayon, MM, Schatzberg, AF (2002). Prevalence of depressive episodes with psychotic features in the general population. American Journal of Psychiatry 159, 18551861.
Royston, P (2004). Multiple imputation of missing values. Stata Journal 4, 227241.
Saha, S, Chant, D, Welham, J, McGrath, J (2005). A systematic review of the prevalence of schizophrenia. PLoS Medicine 2, e141.
Saha, S, Scott, J, Varghese, D, McGrath, J (2012). Anxiety and depressive disorders are associated with delusional-like experiences: a replication study based on a National Survey of Mental Health and Wellbeing. BMJ Open 2, e001001.
Schroeder, K, Fisher, HL, Schafer, I (2013). Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management. Current Opinion in Psychiatry 26, 113119.
Stochl, J, Khandaker, GM, Lewis, G, Perez, J, Goodyer, IM, Zammit, S, Sullivan, S, Croudace, TJ, Jones, PB (2015). Mood, anxiety and psychotic phenomena measure a common psychopathological factor. Psychological Medicine 45, 14831493.
Ustun, TB, Chatterji, S, Mechbal, A, Murray, CJL, WHS Collaborating Groups (2003). The World Health Surveys. In Health Systems Performance Assessment: Debates, Methods and Empiricism (ed. Murray, CJL and Evans, DB), pp. 797808. World Health Organization: Geneva.
Varghese, D, Scott, J, Welham, J, Bor, W, Najman, J, O'Callaghan, M, Williams, G, McGrath, J (2011). Psychotic-like experiences in major depression and anxiety disorders: a population-based survey in young adults. Schizophrenia Bulletin 37, 389393.
Ware, J Jr, Kosinski, M, Keller, SD (1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34, 220233.
Weiser, M, van Os, J, Davidson, M (2005). Time for a shift in focus in schizophrenia: from narrow phenotypes to broad endophenotypes. British Journal of Psychiatry 187, 203205.
Werbeloff, N, Drukker, M, Dohrenwend, BP, Levav, I, Yoffe, R, van Os, J, Davidson, M, Weiser, M (2012). Self-reported attenuated psychotic symptoms as forerunners of severe mental disorders later in life. Archives of General Psychiatry 69, 467475.
Wigman, JT, van Nierop, M, Vollebergh, WA, Lieb, R, Beesdo-Baum, K, Wittchen, HU, van Os, J (2012). Evidence that psychotic symptoms are prevalent in disorders of anxiety and depression, impacting on illness onset, risk, and severity – implications for diagnosis and ultra-high risk research. Schizophrenia Bulletin 38, 247257.
World Health Organization (1993). The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. World Health Organization: Geneva.
Wykes, T, Huddy, V, Cellard, C, McGurk, SR, Czobor, P (2011). A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. American Journal of Psychiatry 168, 472485.
Yung, AR, Buckby, JA, Cosgrave, EM, Killackey, EJ, Baker, K, Cotton, SM, McGorry, PD (2007). Association between psychotic experiences and depression in a clinical sample over 6 months. Schizophrenia Research 91, 246253.


Type Description Title
Supplementary materials

Koyanagi supplementary material
Tables S1-S2

 Word (53 KB)
53 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed