RehabMeasures Instrument
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  2. General Health Questionnaire-28

General Health Questionnaire-28

Purpose

The GHQ-28 is used to indicate psychological well-being and detect possible cases of psychiatric disorders (psychiatric morbidity).

Link to Instrument

Acronym GHQ-28

Area of Assessment

Depression
General Health

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Not Free

Cost Description

For contact information and permission to, see Description.

Diagnosis/Conditions

  • Brain Injury Recovery
  • Cardiac Dysfunction
  • Stroke Recovery

Populations

Stroke
Older Adults and Geriatric Care
Non-Specific Patient Population

Key Descriptions

  • A 28-item self-report questionnaire designed to assess four aspects of distress (McDowell and Newell, 1996):
    1) Depression
    2) Anxiety
    3) Social impairment
    4) Hypochondriasis
  • Respondents rate each question using options provided
    1) "Better than usual”
    2) "Same as usual”
    3) “Worse than usual”
    4) “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:
    1) 0 for choices 1 and 2
    2) 1 for choices 3 and 4
  • cGHQ (Chronic) scoring has been suggested for patients with persistent complaints:
    1) For the 18 negatively valanced items: 0 for choice 1 and score of 1 for choices 2, 3, and 4
    2) 7 positively valanced items: 0 for choices 1 and 2 and 1 for choices 3 and 4
  • Interpreting Results:
    1) GHQ method; average score = 6.28 (Median = 4; SD = 6.38)
    2) 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.
  • Contact information and permission to use:
    MAPI Research Trust, Lyon, France:
    Email: PROinformation@mapi-trust.org
    Internet: www.mapi-trust.org

Number of Items

28

Time to Administer

3-4 minutes

Required Training

Reading an Article/Manual

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

ICF Domain

Body Function

Measurement Domain

Emotion
General Health

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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Stroke

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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)

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

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

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

Older Adults and Geriatric Care

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Interrater/Intrarater Reliability

Elderly population: (Malakouti et al, 2007; n = 204; mean age >59 years; Iranian (Farsi) sample) 

  • Excellent, Cronbach's alpha = .90

Non-Specific Patient Population

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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

Internal Consistency

Ischaemic heart disease: (Failde et al, 2000)

  • Excellent Internal Consistency (Cronbach's alpha = 0.95)

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. 

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. 

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. 

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. 

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. 

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

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

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