The General Health Questionnaire (GHQ)

The English version of the General Health Questionnaire (GHQ) and a translated Indian version were administered to a sample of hundred bilingual college students. Both the versions of the GHQ showed adequate internal consistency and reliability. There was a high concordance between the two versions on high scorers and low scorers. These results were also applicable to GHQ-30 and GHQ-12. Item analysis revealed certain differences between the two versions attributable to semantic and technical problems. Validity of the GHQ in the Indian setting are discussed.     

Detection of the anxio-depressive disorders in liaison psychiatry. Contribution of the General Health Questionnaire

Among self-report inventories of psychopathology for adults, the General Health Questionnaire (GHQ) is one of the prominent instruments developed for the screening of minor psychiatric morbidity. Four versions of the GHQ were provided from the original 60 items (GHQ-30, 28, 20, 12) and three different scorings have been suggested. A large number of validity studies, mostly favourable, have been performed and are reviewed in this paper. Recent work has suggested that the sensitivity of the GHQ to clinical change was fair, compared to the Present State Examination. The most recent version, the GHQ-28, was built from factor analyses of the 60-item version and covered four dimensions, with seven items each: anxiety and insomnia, severe depression, social impairment, somatic complaints, but their subscores were not independent. Several international extensive studies have confirmed that the GHQ was an interesting tool in Community as well as in General Practice. But, as it falls short from detecting all the chronic cases, research aimed at improving its quality in this direction is still in progress. The use of the French version of the GHQ-28 is expected to be encouraged.     

The factor structure of the General Health Questionnaire (GHQ): a scaled version for general practice in Spain.

BACKGROUND: The 28-item version of the General Health Questionnaire (GHQ-28) developed by Goldberg and Hillier in 1979 is constructed on the basis of a principal components analysis of the GHQ-60. When used on a Spanish population, a translation of the GHQ-28 developed for an English population may lead to worse predictive values. METHODS: We used our Spanish sample to replicate the entire process of construction of the GHQ-28 administered in a primary-care setting. RESULTS: Two shorter versions were proposed: one with six scales and 30 items, and the other with four scales and 28 items. CONCLUSIONS: The resulting GHQ-28 was a successful adaptation for use on the Spanish sample. When compared with the original version, only 21 items were the same. Moreover, contrary to the English version, which groups sleep problems and anxiety in the same scale, a scale with items related exclusively to 'Sleep disturbances' was found.     

Reliability and validity of the Cambodian version of the 28-item General Health Questionnaire

This study confirmed the reliability and validity of a Cambodian version of the 28-item General Health Questionnaire (GHQ-28). The GHQ-28 was tested on 223 adult Cambodians living in Dunedin, New Zealand, who were examined independently by a psychiatrist (P.C.) using the short Present State Examination (PSE). There were satisfactory internal consistencies for the whole scale and the subscales except the C scale. It corectly identified 84.4% of cases with a 3/4 cut-off (sensitivity 87.5%, specificity 82.8%), suggesting a discriminative power as good as its English version when used among Caucasian women in Dunedin. The four subscales were by no means independent, and concurrent validity tests with the PSE suggested that they provided additional information regarding somatic symptoms and anxiety, but not about social dysfunction and depression.     

The evaluation of an Urdu version of the GHQ-28

The Urdu and English versions of the GHQ-28 were administered in Pakistan to bilingual students using a crossover design, in order to evaluate the equivalence and reliability of the translation in relation to the original, and to determine convergent validity using the Hospital Anxiety and Depression Scale (HADS) as a comparison measure. Satisfactory findings at each of level of analysis indicated that the Urdu GHQ-28 was comparable to the original English version.     

Mental illness in Greek and Turkish adolescents

Summary Samples of 867 Greek adolescents in Munich, 2,702 Greek adolescents in Greece and 2,780 Turkish adolescents in Turkey were assessed concerning mental health in a two-stage procedure. In the first stage the General Health Questionnaire (GHQ) was used for screening. Significant age differences in the GHQ 28-item scale and most of its subscales were observed mainly for the samples in the homeland. Male adolescents had lower scores than female adolescents in the GHQ 28-item scale and its sub-scales while social class appeared to be of little influence. Significantly higher GHQ-28 scores were obtained for Greeks and Turks in their homelands as compared to Greeks in Munich. The GHQ-28 correlations with the Anorexia Nervosa Inventory for Self-Rating were fairly high. A principal component analysis with Varimax rotation showed fairly consistent results for this age group when compared with the results of Goldberg and Hillier (1979). With the exception of the GHQ factor social dysfunction Greek adolescents in their homeland had significantly higher scores in the total GHQ-28 and its sub-scales than Greeks in Germany. Thus, our data do not confirm the acculturation-stress hypothesis. The data would be consistent with the hypothesis of selective migration which states that Greek adolescents in Germany constitute a positive selection with respect to risk for mental illness.     

Validity of the GHQ-28 in New Zealand women

The GHQ-28 was validated against the short PSE in a New Zealand community study of female psychiatric morbidity. The GHQ-28 total scores were significantly correlated with the PSE scores. Higher coefficients were obtained using the scoring method of Goodchild and Duncan-Jones than with the standard scoring method. In this data set, the 3/4 cutoff had the best sensitivity and specificity. The correlations of the GHQ-28 subscales with ICD diagnostic classes and ad hoc PSE sub-scores were also statistically significant. Because the distribution of the GHQ-28 scores is positively skewed, non-parametric statistics may be preferable to the traditional Pearson's correlation coefficient. Overall, the results from this study confirm the GHQ-28 to be a valid and practical screen for presence or absence of psychiatric disorder in New Zealand women.     

Discriminant validity of the 12-item version of the general health questionnaire in a Swedish case-control study

Background: The 12-item version of the General Health Questionnaire (GHQ-12) is widely used as a proxy for Affective Disorders in public health surveys, although the cut-off points for distress vary considerably between studies. The agreement between the GHQ-12 score and having a clinical disorder in the study population is usually unknown.

Aims: This study aimed to assess the criterion validity and to determine the sensitivity and specificity of the GHQ-12 in the Swedish population.

Methods: This study used 556 patient cases surveyed in specialized psychiatric care outpatient age- and sex-matched with 556 controls from the Stockholm Health Survey. Criterion validity for two scoring methods of GHQ-12 was tested using Receiver Operating Characteristics (ROC) analyses with Area Under the Curve (AUC) as a measure of agreement. Reference standard was (1) specialized psychiatric care and (2) current depression, anxiety or adjustment disorder.

Results: Both the Likert and Standard GHQ-12 scoring method discriminated excellently between individuals using specialized psychiatric services and healthy controls (Likert index AUC?=?0.86, GHQ index AUC?=?0.83), and between individuals with current disorder from healthy controls (Likert index AUC?=?0.90, GHQ index AUC?=?0.88). The best cut-off point for the GHQ index was ≥4 (sensitivity?=?81.7 and specificity?=?85.4), and for the Likert index ≥14 (sensitivity?=?85.5 and specificity?=?83.2).

Conclusions: The GHQ-12 has excellent discriminant validity and is well suited as a non-specific measure of affective disorders in public mental health surveys.     

The Beck Depression Inventory and General Health Questionnaire as measures of depression in the general population: a validation study using the Composite International Diagnostic Interview as the gold standard

The Beck Depression Inventory (BDI) and the General Health Questionnaire (GHQ) are commonly used in population studies as measures of depression. We examined in a population sample the validity of four scales for depressive symptoms, the GHQ-12, the 21- and 13-item versions of the BDI, and a new 6-item version of the BDI developed for this study. A total of 5561 participants in the "Health 2000" survey (30-79 years) completed the four scales and were assessed with the Composite International Diagnostic Interview (CIDI), which was used as the validation criterion. We selected items for the BDI-6 through an exploratory factor analysis for the BDI-21. The accuracy of the scales, including the BDI-6, was satisfactory (c-statistics 0.88-0.92 for depression within the past 2 weeks and 0.80-0.83 within the past 12 months) and slightly better for men (0.92-0.96 and 0.85-0.87) than for women (0.86-0.88 and 0.78-0.79). Higher scores in all the scales were associated with more severe depression and more recent depressive episodes. This study suggests that various versions of the BDI and the GHQ-12 are useful in detecting depressive disorders in the general population. Even the 6-item version of the BDI showed acceptable criterion validity, although replication in an independent dataset is needed to confirm its validity.     

Psychiatric morbidity in the clients of social workers

Newly referred clients (N = 141) in two inner city Social Service department settings were interviewed using the Present State Examination and the Social Maladjustment Schedule and screened by social workers using the GHQ and the Case Review Form. 73% of cases were GHQ positive, using the 4/5 cut off on the GHQ-28. Receiver Operating Characteristic analysis showed that the GHQ cut-off point which maximised sensitivity and specificity in the present sample was 10/11. PSE/ID/CATEGO analysis identified 25% of the sample as "cases" (ID 6-8) and 28% as "threshold disorders" (ID 5). Using a straightforward "present/absent" assessment of "caseness" social workers misclassified more than a third of the PSE cases and correctly identified half of the non-cases. The results are discussed.     

Psychiatric morbidity in general practice in Italy

Summary Psychiatric morbidity among 505 attenders on a single day at 32 general practices in South Verona was assessed using the General Health Questionnaire (GHQ-30) and recordings of practitioners' evaluations. The usual GHQ scoring system with a cut-off point of 5/6 resulted in 52% of high-scorers while the scoring system for longstanding psychological distress conditions (C-GHQ) yielded 37% of high-scorers (cut-off point 11/12). General practitioners identified 28% of attenders as cases. One-day population based prevalence estimates for the GHQ-30 and practitioners' assessment gave values of 6.6 and 4.5 per 1000 at risk. Among several possible risk factors, only presence of previous psychiatric illness increased significantly the relative risk of being a case in terms of GHQ, C-GHQ scores and practitioners' assessments. These findings are discussed in relation to the results of other surveys in the same area and other general practice studies.     

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.     

The GHQ-12 as a screening tool in a primary care setting

Summary The performance of the 12-item General Health Questionnaire (GHQ) was tested against a modified version of a structured diagnostic interview for making DSM III-4 diagnoses, the Composite International Diagnostic Interview (CIDI), in a population of 787 primary care patients, 214 of whom were interviewed. The Yoruba versions of both instruments were found to be feasible in this setting and the inter-rater reliability of the CIDI was good. The GHQ-12 showed a sensitivity of 68% and a specificity of 70% when only cases meeting the criteria for specific DSM III-R disorders were considered. The sensitivity was better for certain individual disorders and the overall performance was marginally improved when scoring was made according to the revised method proposed by Goodchild and Duncan-Jones.     

A review of the validity of the General Health Questionnaire in adolescent populations

OBJECTIVE: To comprehensively review the validity of the General Health Questionnaire (GHQ) [1] with adolescents (aged 12-19). Although the GHQ has been extensively used and validated with adults and has been frequently used with adolescents, the validity data for this group are sporadic. METHOD: Systematic review of the English language peer-reviewed literature. RESULTS: Eight studies were identified validating the GHQ with young people of which four included only adolescents and four studies involved young adults and adolescents. Of these eight studies, four used an English language version of the GHQ and four used a translated version. CONCLUSION: The GHQ has demonstrated validity with older adolescents (17 + years) from the UK and Hong Kong (Chinese translation) and with girls aged 15 in the UK, but there are few data for either gender, aged less than 15 years. Studies in Australia and Italy reported a high proportion of misclassified cases while the studies in Spain and Yugoslavia included some older subjects (20 + years). Therefore, the validity of the GHQ for adolescents in populations other than the UK and Hong Kong remains to be demonstrated. IMPLICATIONS: Psychiatrists and other mental health professionals need to be aware of the above limitations when using the GHQ as a screening instrument with adolescents. Further studies are required to: (i) determine the minimum age at which it can be employed, (ii) compare the use of adult versus adolescent criterion interviews, (iii) assemble relevant normative data, and (iv) establish the validity of translated versions.     

Validity of General Health Questionnaire (GHQ-36/GHQ-12) in the psychiatric O.P.D. of a general hospital--a pilot study

Two shorter versions of the General Health Questionnaire (GHQ) viz. GHQ-36 physical illness items removed (GHQ-36-P) and GHQ-12 were validated in the psychiatric OPD of a teaching hospital in Calcutta among known patients and controls. It was found that a higher cut-off point than that originally recommended yielded satisfactory validation indices for both the versions.     

Cross-cultural validity of the Amritsar Depression Inventory and the General Health Questionnaire amongst English and Punjabi primary care attenders

  Background: In order to estimate the health needs of cultural groups, the cross-cultural validity of instruments requires investigation in distinct cultural rather than ethnic or racial groups. Method: We screened `Punjabi' and `English' primary care attenders in South London (UK), using the General Health Questionnaire (GHQ-12), an English origin instrument, and the Amritsar Depression Inventory (ADI), which was developed in the Punjab in India. The criterion measure was the Clinical Interview Schedule (CIS-R). We calculated the validity coefficients, optimal thresholds and the area under the `Receive Operating Characteristic' curve to compare cross-cultural performance. We identified items on each questionnaire that contribute to performance of the instruments. Results: The GHQ-12 has high validity coefficients in both cultural groups. The ADI performs as well amongst English subjects, but among Punjabis it is poorer than the GHQ-12. Among Punjabis who have been resident in the UK for over 30 years, the ADI performs no better than chance. Few items on the ADI or the GHQ are strongly predictive of case status. Conclusions: The GHQ-12 shows good validity in both cultures. Expressions of distress may change due to acculturation. `Culturally sensitive' screening instruments need to reflect this. Further work might attend to the changing expressions of distress following migration. Accepted: 21 January 2000     

The criterion validity of different versions of the General Health Questionnaire among non-psychiatric inpatients

Purpose  

While the General Health Questionnaire (GHQ) has an excellent screening performance among outpatients and in the community, its accuracy to detect mental disorders among non-psychiatric inpatients was reported to be lower. The aim of the present study was to compare the criterion validity of different scoring methods, i.e. the Bimodal scoring, Likert scoring, Modified Likert scoring and Chronic scoring, of the 30-, 20- and 12-item version of the GHQ.     

Which version of the General Health Questionnaire should be used in community studies?

Literature pertinent to the use of the various versions of the General Health Questionnaire (GHQ) is briefly surveyed. The literature indicates that the 60-item version has the highest reliability and validity coefficients, the lowest misclassification rate, and the highest sensitivity and specificity. Using data from a previously published community survey in Perth using the 60-item GHQ, comparisons are made between use of the 60-, 30-, 20- and 12-item versions, including community prevalence rates, simultaneous identification of cases, disagreement rates and patterns of community rates with age. The 60-item version gives the lowest prevalence rates. It is argued that the 60-item GHQ is probably the best as it gives the lowest misclassification rates, the smallest standard error of estimated prevalence rates and allows measurement of certain subscales not contained within the shorter versions.     

Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians

BACKGROUND: The object of this study was to develop an Iranian version of the General Health Questionnaire-28 (GHQ-28) for use with elderly subjects. METHODS: The GHQ-28 Farsi version was evaluated for face validity among 204 elderly subjects aged 59 years or older, chosen randomly from residents of Tehran. The Composite International Diagnostic Interview (CIDI) was used to establish a gold standard diagnosis of mental disorders. RESULTS: The GHQ-28 was an internally consistent measure. Cronbach's alpha, split-half coefficients and test-retest reliability were 0.9, 0.89 and 0.58 respectively. Four factors were extracted using factor analysis: "depression," "psychosocial activity," "anxiety," and "somatic." Using receiver operating curve (ROC) analysis, the optimum cutoff score for the GHQ-28 in this group was 19/20 (sensitivity 0.83, specificity 0.76). Using a loading of 0.6 or greater, a short form of the instrument (GHQ-15) (alpha=0.9) was derived and correlated well with the longer form of the scale (r=0.97). Using ROC analysis, the optimum cutoff score was 10/11 (sensitivity 0.83, specificity 0.69). CONCLUSIONS: The short and long forms of the GHQ-28 are suitable screening instruments for elderly Iranian residents, particularly those living in urban areas.     

Psychological disorders and symptoms in primary care

Background Psychological symptoms that do not reach the threshold for formal diagnosis are disregarded in prevalence rates and are apparently assumed to be transient and of little clinical importance. Method Consecutive primary care attenders (n = 2379) were screened using the 12-item General Health Questionnaire (GHQ-12) and a stratified random sample (n = 704) completed baseline structured diagnostic interview, disability assessment, and the 28-item version of the GHQ (GHQ-28). Subjects with significant psychiatric symptoms and a random sample of those without (n = 263) were evaluated with the same measures 12 months later. Results While 25 % of the baseline sample scored 5 or more on the GHQ-28, only 10 % met the ICD-10 criteria for one or more disorders. At baseline, caseness on either the GHQ or ICD-10 was associated with poor self-rated overall health, interviewer-rated occupational disability and with more disability days in prior month. At 12-month follow-up, being a case on the GHQ at baseline, but not on ICD-10, was associated with disability, poor health perception and high health service utilization. Conclusion Psychological symptoms that may not reach diagnostic threshold are associated with impaired functioning over 12 months. Individuals with such symptoms may be identified using self-report questionnaires for dimensional symptoms, such as the GHQ-28. Accepted: 8 February 2002