CHAPTER 66: GENERAL HEALTH QUESTIONNAIRE (GHQ-12)

Description

The General Health Questionnaire (GHQ-12) by Goldberg (1976) is a self-administered questionnaire designed to detect persons that are symptomatic or at risk of developing the common, non-psychotic mental health problems associated with depression, anxiety, somatic symptoms, and social dysfunction (Jackson, 2007). Designed for the general population, available versions include the 60-, 30-, 28-, and the 12-item (GHQ-12) versions. The GHQ-12 was introduced in 1988 and is now considered one of the most extensively used outcome measures across a number of health professions (del Pilar Sánchez-López & Dresch, 2008). The GHQ-12 covers several domains associated with a person’s psychological well-being and is worded in such a way as to comprise six positive and six negative items concerning the past few weeks of a person’s life and includes such items as “Have you recently felt capable of making decisions about things?” while, negative items include “Have you recently felt constantly under strain?” (Hu, Stewart-Brown, Twigg, & Weich, 2007). Positively worded items have responses of “better than usual,” “same as usual,” “less than usual,” and “much less than usual,” while responses to negatively worded items are “not at all,” “no more than usual,” “rather more than usual,” and “much more than usual.” Scoring is along a 4-point ordinal scale (0 to 3) with higher scores suggestive of more distress. The GHQ-12 can be completed in less than 10 minutes.

Psychometrics

A study of 897 men and 911 women (59% ≥ 50 years old) determined that Cronbach’s alpha coefficients (estimates of reliability) were 0.83 for men and 0.85 for women (Doi & Minowa, 2003). Whereas Kihc et al. (1997) determined that the internal consistency of the GHQ-12 was α = 0.76, which compared to results of the GHQ-30 at 0.92 in their study of a stratified sample of 400 cases (15 to 65 years old). Although the GHQ-12 is often regarded as measuring only a single dimension of psychological health, a confirmatory factory analysis using a cohort of 9000 (mean age: 41 years; n = 2077 ≥ 56 years of age), suggested that 2 factors best described as symptoms of mental disorder (encompassing negative affect, anxiety, and impaired mental functioning) and positive mental health (covering positive mental functioning and positive affect) (Hu et al., 2007). A similar study by Gao et al. (2004) that compared six factor models relative to the measure, found that the one proposed by Graetz (1991) to be the best fit, as strong correlations between the 3 factors of anxiety and depression (4 items), social dysfunction (6 items), and loss of confidence (2 items) were found (range = 0.83-0.90), suggesting that even if there were 3 different factors, it would be difficult to differentiate them. Examples of other factor models compared in the study were general dysphoria, social, and the cope, stress, and depress model. A study comparing the level of agreement between the GHQ-12 and the Geriatric Depression Scale (GDS-30) using 1172 subjects (≥ 60 years old) found median scores to be 2.7 for the GHQ-12 and 11.7 for the GDS-30 with the prevalence of depressive symptoms based on the GHQ-12 at 40% and 33% using cutoff points of 2/3 and 3/4, whereas 50% and 38% were classified as depressed at cutoff points of 10/11 and 13/14 according to the GDS-30 (Costa, Barreto, Uchoa, & Lima-Costa, 2003). Agreement between the scales ranged from 0.50 to 0.60 with depressive symptoms significantly higher for woman and those individuals ≥ 75 years of age (Costa et al., 2003). A study by del Pilar Sánchez-López and Dresch (2008) of 1001 subjects (50% between 45 and 65 years old) generally concurred with those findings where they too established statistically significant differences between women and men’s scores at 7.34 and 9.30, respectively. The study by Hu et al. (2007) discussed previously, however, found that positive mental health was most strongly associated with younger age, being in work, being single, not having any financial strain, and having no or few physical health problems.

Advantages

There is a significant amount of research in support of the GHQ-12 as well as its other versions for use in clinical practice and it is arguably a gold standard measure of the symptoms of psychological distress in the general population. Several alternative scoring methodologies have also been proposed expanding its usefulness, and since its introduction in 1976, the GHQ has been translated into 38 different languages, highlighting its relevance as a cross-cultural assessment (Jackson, 2007). Finally, in certain populations the 28-item version may be considered as it is a more multidimensional outcome measure comprising 4 distinct subscales (somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression) of 7 items each (Gao et al., 2004).

Disadvantages

Some have argued that aspects of the negative and positive wording used by the measure has a latent effect on answer selection and thus on scoring. Also, the GHQ-12 is designed to only give a general indication of psychological distress and should not be considered a replacement for more thorough and accepted psychological assessments.

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