Skip to main content
    • Aa
    • Aa

Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy

  • J. T. W. Wigman (a1), J. van Os (a1) (a2), L. Abidi (a1), M. J. H. Huibers (a3) (a4), J. Roelofs (a3), A. Arntz (a3), I. Kelleher (a5) and F. P. M. L. Peeters (a1)...

Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.


In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.


Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).


In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.

Corresponding author
*Address for correspondence: J. T. W. Wigman, Department of Psychiatry and Psychology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, PO Box 616 (DRT 10), 6200 MD Maastricht, The Netherlands. (Email:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

J Allardyce , T Suppes , J van Os (2007). Dimensions and the psychosis phenotype. International Journal of Methods in Psychiatric Research 16 (Suppl. 1), S34S40.

J Angst , L Cui , JJ Swendsen , S Rothen , A Cravchik , R Kessler , K Merikangas (2010). Major depressive disorder with sub-threshold bipolarity in the National Comorbidity Survey Replication. American Journal of Psychiatry 167, 11941201.

U Barahmand , A Abolghasemi , S Jahanmohammadi (2008). Using metacognitions to identify emotionally vulnerable college students. American Journal of Health Behavior 32, 604613.

A Beck , RA Steer (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment 67, 236247.

RP Bentall , G Rowse , N Shryane , P Kinderman , R Howard , N Blackwood , R Moore , R Corcoran (2009). The cognitive and affective structure of paranoid delusions: a transdiagnostic investigation of patients with schizophrenia spectrum disorders and depression. Archives of General Psychiatry 66, 236247.

MM Blanchard , S Jacobson , MC Clarke , D Connor , I Kelleher , H Garavan , M Harley , M Cannon (2010). Language, motor and speed of processing deficits in adolescents with subclinical psychotic symptoms. Schizophrenia Research 123, 7176.

PF Buckley , BJ Miller , DS Lehrer , DJ Castle (2009). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin 35, 383402.

P Chadwick , P Trower , TM Juusti-Butler , N Maguire (2005). Phenomenological evidence for two types of paranoia. Psychopathology 38, 327333.

N Craddock , M O'Donovan , M Owen (2009). Psychosis genetics: modeling the relationship between schizophrenia, bipolar disorder, and mixed (or ‘schizoaffective’) psychoses. Schizophrenia Bulletin 35, 482490.

L Degenhardt , W Hall , M Lynskey (2003). Exploring the association between cannabis use and depression. Addiction 98, 14931504.

D Dudek , JK Rybakowski , M Siwek , T Pawłowski , D Lojko , R Roczeń , A Kiejna (2010). Risk factors of treatment resistance in major depression: association with bipolarity. Journal of Affective Disorders 126, 268271.

A Farahani , CU Correll (2012). Are antipsychotics or antidepressants needed for psychotic depression? A systematic review and meta-analysis of trials comparing antidepressant or antipsychotic monotherapy with combination treatment. Journal of Clinical Psychiatry 73, 486496.

M Hanssen , F Peeters , L Krabbendam , S Radstake , H Verdoux , J van Os (2003). How psychotic are individuals with non-psychotic disorders? Social Psychiatry and Psychiatric Epidemiology 38, 149154.

S Hetrick , A Parker , I Hickie , R Purcell , A Yung , P McGorry (2008). Early identification and intervention in depressive disorders: towards a clinical staging model. Psychotherapy and Psychosomatics 77, 263270.

SK Hill , JL Reilly , MSH Harris , C Rosen , RW Marvin , O DeLeon , JA Sweeny (2009). A comparison of neuropsychological dysfunction in first-episode psychosis patients with unipolar depression, bipolar disorder, and schizophrenia. Schizophrenia Research 113, 167.

RMA Hirschfeld , JBW Williams , RL Spitzer , JR Calabrese , L Flynn , PE Keck , L Lewis , L McElroy , RM Post , DJ Rapport (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. American Journal of Psychiatry 157, 18731875.

NS Jacobson , P Truax (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59, 1219.

J Johnson , E Horwath , MM Weissman (1991). The validity of major depression with psychotic features based on a community study. Archives of General Psychiatry 48, 10751081.

N Kaymaz , J van Os (2009). Murray et al. (2004) revisited: is bipolar disorder identical to schizophrenia without developmental impairment? Acta Psychiatrica Scandinavica 120, 249252.

I Kelleher , MC Clarke , C Rawdon , J Murphy , M Cannon (2012 a). Neurocognition in the extended psychosis phenotype: performance of a community sample of adolescents with psychotic symptoms on the MATRICS neurocognitive battery. Schizophrenia Bulletin. Published online 4 09 2012 . doi:10.1093/schbul/sbs086.

I Kelleher , H Keeley , P Corcoran , F Lynch , C Fitzpatrick , N Devlin , C Molloy , S Roddy , MC Clarke , M Harley (2012 b). Clinicopathological significance of psychotic experiences in non-psychotic young people: evidence from four population-based studies. British Journal of Psychiatry 201, 2632.

R Kendell , A Jablensky (2003). Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry 160, 412.

RC Kessler , KA McLaughlin , JG Green , MJ Gruber , NA Sampson , AM Zaslavsky , S Aguilar-Gaxiola , AO Alhamzawi , J Alonso , M Angermeyer (2010). Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. British Journal of Psychiatry 197, 378385.

M Konings , M Bak , M Hanssen , J van Os , L Krabbendam (2006). Validity and reliability of the CAPE: a self-report instrument for the measurement of psychotic experiences in the general population. Acta Psychiatrica Scandinavica 114, 5561.

S Moritz , A Kerstan , R Veckenstedt , S Randjbar , F Vitzthum , C Schmidt , M Heise , TS Woodward (2011). Further evidence for the efficacy of a metacognitive group training in schizophrenia. Behavior Research Therapy 49, 151157.

R Nusslock , E Frank (2011). Subthreshold bipolarity: diagnostic issues and challenges. Bipolar Disorders 13, 587603.

M Olfson , R Lewis-Fernández , MM Weissman , A Feder , MJ Gameroff , D Pilowsky , M Fuentes (2002). Psychotic symptoms in an urban general medicine practice. American Journal of Psychiatry 159, 14121419.

G Parker , G Malhi , J Crawford , M Thase (2005). Identifying ‘paradigm failures’ contributing to treatment-resistant depression. Journal of Affective Disorders 87, 185191.

F Peeters , M Huibers , J Roelofs , G van Breukelen , SD Hollon , JC Markowitz , J van Os , A Arntz (2013). The clinical effectiveness of evidence-based interventions for depression: a pragmatic trial in routine practice. Journal of Affective Disorders 145, 349355.

RH Perlis , R Uher , M Ostacher , JF Goldberg , MH Trivedi , AJ Rush , M Fava (2011). Association between bipolar spectrum features and treatment outcomes in outpatients with major depressive disorder. Archives of General Psychiatry 68, 351360.

ER Peters , SA Joseph , PA Garety (1999). Measurement of delusional ideation in the normal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophrenia Bulletin 25, 553576.

DM Semple , AM McIntosh , SM Lawrie (2005). Cannabis as a risk factor for psychosis: systematic review. Journal of Psychopharmacology 19, 187194.

V Sharma , M Khan , A Smith (2005). A closer look at treatment resistant depression: is it due to a bipolar diathesis? Journal of Affective Disorders 84, 251257.

C Simons , N Jacobs , J Jolles , J van Os , L Krabbendam (2007). Subclinical psychotic experiences and cognitive functioning as a bivariate phenotype for genetic studies in the general population. Schizophrenia Research 92, 2431.

C Simonsen , K Sundet , A Vaskinn , AB Birkenaes , JA Engh , A Færden , H Jónsdóttir , PA Ringen , S Opjordsmoen , I Melle (2011). Neurocognitive dysfunction in bipolar and schizophrenia spectrum disorders depends on history of psychosis rather than diagnostic group. Schizophrenia Bulletin 37, 7383.

AR Singer , KS Dobson (2007). An experimental investigation of the cognitive vulnerability to depression. Behavior Research Therapy 45, 563575.

D Smith , L Forty , E Russell , S Caesar , J Walters , C Cooper , I Jones , L Jones , N Craddock (2009). Sub-threshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome. Acta Psychiatrica Scandinavica 119, 325329.

C Stetler , GE Miller (2011). Depression and hypothalamic–pituitary–adrenal activation: a quantitative summary of four decades of research. Psychosomatic Medicine 73, 114126.

B van den Berg , BWJH Penninx , FG Zitman , WA Nolen (2010). Manic symptoms in patients with depressive and/or anxiety disorders. Journal of Affective Disorders 126, 252256.

M van der Gaag , DH Nieman , J Rietdijk , S Dragt , HK Ising , RM Klaassen , M Koeter , P Cuijpers , L Wunderink , DH Linszen (2012). Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: a randomized controlled clinical trial. Schizophrenia Bulletin 38, 11801188.

J van Os , RM Murray (2013). Can we identify and treat ‘schizophrenia light’ to prevent true psychotic illness? British Medical Journal 346, f304.

J van Os , H Verdoux , S Maurice-Tison , B Gay , F Liraud , R Salamon , M Bourgeois (1999). Self-reported psychosis-like symptoms and the continuum of psychosis. Social Psychiatry and Psychiatric Epidemiology 34, 459463.

I van Rossum , MD Dominguez , R Lieb , HU Wittchen , J van Os (2011). Affective dysregulation and reality distortion: a 10-year prospective study of their association and clinical relevance. Schizophrenia Bulletin 37, 561571.

F Varese , F Smeets , M Drukker , R Lieverse , T Lataster , W Viechtbauer , J Read , J van Os , RP Bentall (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient–control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin 38, 661671.

D Varghese , J Scott , J Welham , W Bor , J Najman , M O'Callaghan , G Williams , J McGrath (2011). Psychotic-like experiences in major depression and anxiety disorders: a population-based survey in young adults. Schizophrenia Bulletin 37, 389393.

JE Ware Jr, CD Sherbourne (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care 30, 473483.

M Weiser , J van Os , M Davidson (2005). Time for a shift in focus in schizophrenia: from narrow phenotypes to broad endophenotypes. British Journal of Psychiatry 187, 203205.

JTW Wigman , M van Nierop , WAM Vollebergh , R Lieb , K Beesdo-Baum , HU Wittchen , J van Os (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.

M Zimmerman (2012). Misuse of the Mood Disorders Questionnaire as a case-finding measure and a critique of the concept of using a screening scale for bipolar disorder in psychiatric practice. Bipolar Disorders 14, 127134.

M Zimmerman , JN Galione , CJ Ruggero , I Chelminski , D Young , K Dalrymple , JB McGlinchey (2010 a). Screening for bipolar disorder and finding borderline personality disorder. Journal of Clinical Psychiatry 71, 12121217.

M Zimmerman , CJ Ruggero , I Chelminski , D Young (2010 b). Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder. Journal of Clinical Psychiatry 71, 2631.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 4
Total number of PDF views: 27 *
Loading metrics...

Abstract views

Total abstract views: 323 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd June 2017. This data will be updated every 24 hours.