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Rehab Measures: General Health Questionnaire-28

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Available for purchase from MAPI Research Trust 

Title of Assessment

General Health Questionnaire-28 

Acronym

GHQ-28

Instrument Reviewer(s)

Summary Date

 

Purpose

Used to indicate psychological well-being and detect possible cases of psychiatric disorders (psychiatric morbidity).

Description

  • A 28-item self-report questionnaire designed to assess four aspects of distress (McDowell and Newell, 1996)
    • Depression
    • Anxiety 
    • Social impairment
    • Hypochondriasis
  • Respondents rate each question using options provided
    • "Better than usual”
    • "Same as usual”
    • “Worse than usual”
    • “Much worse than usual”
  • Choice of scoring method may impact diagnosis (Richard et al, 2004, n = 1145, general medicine patients)
    • GHQ (Acute) scoring methods (traditional method); scores of:
      • 0 for choices 1 and 2
      • 1 for choices 3 and 4
    • cGHQ (Chronic) scoring has been suggested for patients with persistent complaints  
      • For the 18 negatively valanced items:
        • 0 for choice 1 and score of 1 for choices 2, 3, and 4
      • 7 positively valanced items:
        • 0 for choices 1 and 2
        • 1 for choices 3 and 4
  • Interpreting Results:
    • GHQ method; average score = 6.28 (Median = 4; SD = 6.38)
    • cGHQ method; average score = 11.45 (Median = 11; SD = 6.73)
  • Prior research has not found a significant difference between gender, age, language or educational level (Goldberg et al, 1997)
  • Provides an indication of ‘psychological distress’ rather than depression, it may be more sensitive to the issues faced by stroke survivors.

Area of Assessment

Depression; General Health 

Body Part

Not Applicable 

ICF Domain

Body Function 

Domain

Emotion; General Health 

Assessment Type

Patient Reported Outcomes 

Length of Test

05 Minutes or Less 

Time to Administer

3-4 minutes

Number of Items

28- items 

Equipment Required

None required

Training Required

Read manual

Type of training required

Reading an Article/Manual 

Cost

Not Free 

Actual Cost

Contact information and permission to use:
 
MAPI Research Trust, Lyon, France:
Email:  PROinformation@mapi-trust.org
Internet: www.mapi-trust.org

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Cardiac Conditions; Geriatrics; Stroke; Traumatic Brain Injury 

Populations Tested

  • Stroke
  • Traumatic Brain Injury
  • Geriatrics
  • Cardiac Conditions

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Chronic and Acute stroke patients: (Lincoln et al, 2003; n = 143; mean age = 66 (13.5) years; time since onset not specified)

  • The optimum cut-score for the GHQ-28 in relation to DSM-III-R criteria was 11/12 (sensitivity 81%, specificity 68%).
  • However, no cut scores on the GHQ-28 demonstrated satisfactory sensitivity (for details see responsiveness section)
  • Patients diagnosed as depressed based on ICD-10 or DSM-III-R scores also had significantly higher scores on the GHQ-28. 
  • Goldberg (1978) suggests that participants with total scores of 23 or below should classified as
    non-psychiatric, while participants with scores > 24 may be classified as psychiatric

Normative Data

Chronic Stroke: (Robinson & Price, 1982; n = 103; mean age = 60 (11) years)

  • GHQ Score = 5
    • Initially depressed = 29%
    • Depressed at 6 months = 68%
  • GHQ Score = 6
    • Initially depressed = 23%
    • Depressed at 6 months = 60%
  • GHQ Score = 8
    • Initially depressed = 17%
    • Depressed at 6 months = 46%

Test-retest Reliability

Chronic Stroke: (Robinson & Price, 1982)

  • Excellent test re-test reliability (r = 0.90, within two months)

Interrater/Intrarater Reliability

Ischaemic Heart Disease: (Failde et al, 2000; n = 185; mean age = 60.2 (10.4); Spanish sample)
  • Excellent, Cronbach's alpha = .95
Elderly population: (Malakouti et al, 2007; n = 204; mean age >59 years; Iranian (Farsi) sample)
  • Excellent, Cronbach's alpha = .90

Internal Consistency

Ischaemic heart disease: (Failde et al, 2000)
  • Excellent Internal Consistency (Cronbach's alpha = 0.95)

Criterion Validity (Predictive/Concurrent)

Chronic and Acute stroke patients: (Lincoln et al, 2003)

ICD-10
DSM-III-R

Not Depressed

Depressed

 

Not Depressed

Depressed

74 (52%)

(42%)

Kappa

112 (77%)

21 (15%)

Kappa

GHQ-28
Not depressed
31
1
0.40
32
0
0.12
Depressed
40
59
77
21
BDI
Not depressed
17
4
0.16
20
1
0.05
Depressed
54
56
89
20
WDI
Not depressed
32
5
0.36
36
1
0.12
Depressed
38
55
72
20
 
DSM-III-R = Diagnostic and Statistical Manual-III-R
ICD-10 = International Classification of Mental and Behavioral Disorders 10
BDI = Beck Depression Inventory
WDI = Wakefeld Depression Inventory

Chronic Stroke: (O'Rourke, 1998; n = 105; median age = 68; assessed > 6 months post stroke)

  • No difference between the GHQ-30 and the Hospital Anxiety and Depression (HAD) Scale was found for:
    • Any DSM-IV diagnosis (p = 0.95)
    • Grouped depression (p = 0.56)
    • Anxiety (p = 0.25)

Chronic Stroke: (Robinson & Price, 1982)

  • Excellent correlations with other measures of depression
    • PSE (r = 0.88)
    • Hamilton (r = .88)
    • Zung (r = .86)

Construct Validity (Convergent/Discriminant)

Acute Stroke: (Thomas & Lincoln, 2006; n = 123 stroke patients; assessed at 1 and 6 months post-stroke)
 
BDI scores at Recruitment:
  • Mildly Depressed (BDI 11–18)
    • GHQ-28: Median Score = 27.0 (IQR = 21.5 to 36.0)
  • Severely Depressed (BDI > 19)
    • GHQ-28: Median Score = 44.0 (IQR = 32.0 to 54.5)

BDI scores 6 Months Post Stroke:

  • Mildly Depressed (BDI 11–18)
    • GHQ-28: Median Score = 28.0 (IQR = 22.0 to 37.0)
  • Severely Depressed (BDI > 19)
    • GHQ-28: Median Score = 48.0 (IQR = 35.0 to 55.0)
IQR = Inter Quartile Range; e.g. the distance between the 75th percentile and the 25th percentile, also called the "mid-spread" or "middle fifty".

Content Validity

The GHQ-28 is a scaled version of the original 60-item measure.  523 completed CHQ-60's were factor analyzed to produce the four 7 items subscales found in the current GHQ-28

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Chronic and Acute stroke patients: (Lincoln et al, 2003)
 

GHQ Sensitivity and specificity of cut-off scores:

 
ICD-10 diagnosis
DSM-III-R diagnosis
GHQ cut-off
Sensitivity
Specificity
Sensitivity
Specificity
5
0.98
0.35
1.00
0.24
6
0.98
0.44
1.00
0.29
7
0.88
0.55
0.95
0.41
8
0.85
0.61
0.95
0.47
9
0.78
0.63
0.95
0.52
10
0.72
0.68
0.86
0.57
11
0.63
0.72
0.81
0.63
12
0.57
0.73
0.81
0.68
13
0.48
0.76
0.76
0.73
14
0.47
0.80
0.71
0.76
15
0.43
0.84
0.67
0.80

Professional Association Recommendations

Considerations

  • The GHQ-28 is designed to screen not diagnose
  • Total scores can be used an index of severity
  • Scoring method may impact interpretation: There are currently three different scoring methods:
    • Conventional scoring; the first 2 response options are scored as 0; the last 2 as 1
    • Likert scoring: uses weights based on
      the frequency of the symptom.
    • Corrected GHQ; similar to the conventional methods. For items that indicate an illness or health problem, responses of “same as usual” are scored as 1 rather than 0. Scoring is unchanged for other items.
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Bibliography

Failde, I., I. Ramos, et al. (2000). "Comparison between the GHQ-28 and SF-36 (MH 1-5) for the assessment of the mental health in patients with ischaemic heart disease." Eur J Epidemiol 16(4): 311-316. Find it on PubMed

Li, G. Y., H. Ueki, et al. (2006). "Association between the scores on the general health questionnaire-28 and the saliva levels of 3-methoxy-4-hydroxyphenylglycol in normal volunteers." Biol Psychol 73(2): 209-211. Find it on PubMed

Lincoln, N. B., C. R. Nicholl, et al. (2003). "The validity of questionnaire measures for assessing depression after stroke." Clin Rehabil 17(8): 840-846. Find it on PubMed

McDowell, I. and C. Newell (2006). "The general health questionnaire." Measuring Health: A Guide to Rating Scales and Questionnaires: 225–237.

O'Rourke, S., S. MacHale, et al. (1998). "Detecting psychiatric morbidity after stroke: comparison of the GHQ and the HAD Scale." Stroke 29(5): 980-985. Find it on PubMed

Richard, C., M. T. Lussier, et al. (2004). "GHQ-28 and cGHQ-28: implications of two scoring methods for the GHQ in a primary care setting." Soc Psychiatry Psychiatr Epidemiol 39(3): 235-243. Find it on PubMed

Robinson, R. G. and T. R. Price (1982). "Post-stroke depressive disorders: a follow-up study of 103 patients." Stroke 13(5): 635-641. Find it on PubMed

Thomas, S. A. and N. B. Lincoln (2006). "Factors relating to depression after stroke." Br J Clin Psychol 45(Pt 1): 49-61. Find it on PubMed

Year published

1972 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 12/4/2013 5:33 PM  by Jason Raad