General Health Questionnaire – 28 (GHQ-28)

Purpose

The General Health Questionnaire – 28 (GHQ-28) is a self-report questionnaire that is used as a screeningTesting for disease in people without symptoms.
tool for psychological wellbeing.

In-Depth Review

Purpose of the measure

The General Health Questionnaire – 28 (GHQ-28) is self-report screeningTesting for disease in people without symptoms.
measure used to detect possible psychological disorder. The GHQ-28 identifies two main concerns: (1) the inability to carry out normal functions; and (2) the appearance of new and distressing phenomena (Goldberg & Hillier, 1979).

Available versions

The GHQ-28 is derived from the original 60-item General Health Questionnaire. There is also a 30-item version (GHQ-30) and a 12-item version (GHQ-12).

Features of the measure

Items:
The GHQ-28 consists of 28 questions designed to identify whether an individual’s current mental state differs from his/her typical state. Questions include:

Have you recently been feeling perfectly well and in good health?
Have you recently lost much sleep over worry?
Have you recently been managing to keep yourself busy and occupied?
Have you recently felt constantly under strain?
Have you recently felt that life is entirely hopeless?

Factor analysis of the GHQ-28 identified four 7-item subscales:
Somatic symptoms (items 1-7)
Anxiety/insomnia (items 8-14)
Social dysfunction (items 15-21)
Severe depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(items 22-28).

There is a high correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the anxiety subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
and the total score, showing that anxiety is a common symptom of psychiatric disorders (Goldberg & Hillier, 1979). Accordingly, subscales are not independent of each other and subscores should not be used to indicate specific psychological diagnoses. Rather, the measure is used to identify the presence of symptoms compared to what is normal for the individual (Salter et al., 2013).

Scoring:
The individual is asked to rate how he/she feels in relation to each question, according to the following criteria:

• Better than usual
• Same as usual
• Worse than usual
• Much worse than usual

Different scoring methods have been reported. One scoring method adopts a Likert scaleLikert scaling is one type of response to items in a questionnaire or tool. For example, Likert scaling would have you rate an item such as “I am satisfied with the care I received” on a scale using a 1-to-5 response scale where:
• 1 = strongly disagree
• 2 = disagree
• 3 = undecided
• 4 = agree
• 5 = strongly agree
You will find various options and scaling methods for the number of response choices (1-to-7, 1-to-9, 0-to-4). Odd-numbered scales usually have a middle value that is labelled Neutral or Undecided. Some tools used forced-choice Likert scaling with an even number of responses and no middle neutral or undecided choice. of 0 to 3, resulting in a total possible score range of 0 to 84. This Likert scoring system was used with the original 60-item GHQ (Goldberg & Hillier, 1979).

An alternative and more common method attributes a binary score system of 0 to the first and second response options (better than usual, same as usual) and a score of 1 to the third and fourth response options (worse than usual, much worse than usual).

Some note that this scoring system is not sensitive to individuals with chronic conditions, where the individual may have experienced a symptom for a prolonged period of time (O’Rourke et al., 1998). Accordingly, the chronic scoring method attributes a score of 0 to the first item (better than usual) and a score of 1 to the third and fourth items, as per the traditional scoring method. The second item (‘same as usual’) receives a score of 0 for negative items and a score of 1 for positive items.

Response option	Traditional (acute) scoring method	Chronic scoring method	Likert scoring method
Better than usual	0	0 (all items)	0
Same as usual	0	0 (negative items)1 (positive items)	1
Worse than usual	1	1	2
Much worse than usual	1	1	3

Higher scores indicate a greater possibility of psychological distress. A score ≥5 has been reported to indicate probable cases of psychiatric disorder (Anderson et al., 1996), however this has not been validated as the most appropriate score for the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population (Salter et al., 2013).

What to consider before beginning:
The choice of scoring method may impact diagnosis.
The GHQ-28 is not designed to detect chronic mental health conditions.

Time:
The GHQ-28 takes approximately 5 minutes to administer.

Training requirements
No training requirements have been specified for the GHQ-28, however it is advised that clinicians read the assessment manual prior to use.

Equipment
The GHQ-28 is a self-report questionnaire that does not require specific equipment.

Client suitability

Can be used with:

• Individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.
• Individuals with cardiac conditions
• Individuals with spinal cord injury
• Individuals with musculoskeletal conditions
• The elderly (Rehabilitation Measures Database, 2010)

Should not be used with:

• The GHQ-28 has not been reported to be unsuitable for use with any particular population.

In what languages is the measure available?

• The GHQ-28 is available in 38 languages (Sterling, 2011) and has cross-cultural applicability (Kilic et al., 1997).

Summary

What does the tool measure?	Psychological wellbeing.
What types of clients can the tool be used for?	The GHQ-28 can be used with, but is not limited to, patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Five minutes.
ICF Domain	Body Function.
Versions	GHQ (original 60-item version) GHQ-30 GHQ-28 GHQ-12
Other Languages	The GHQ is available in 38 languages
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have reported on internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Test-retest: One study reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the GHQ-28 in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specified). Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Inter-rater: No studies have reported on the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: – One study reported excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” between the GHQ-28 total score and the Zung Self-Rating DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Scale, Hamilton DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Scale and the Present State Examination. – One study reported no difference between the GHQ-30 and HAD Scale total scores when identifying any DSM-IV diagnosis, anxiety or depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. . Predictive: One study reported that patients with acute to chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. who were diagnosed as depressed according to ICD-10 or DSM-IIIR criteria achieved a significantly higher GHQ-28 total score than patients who were not diagnosed as depressed; a score >4 on the GHQ-28 correlated with depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. among participants. Construct: Convergent/Discriminant: – One study reported adequate correlations between the GHQ-12 and the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and AphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) Quality of Life scale (SAQOL) and SAQOL-39 mean scores; adequate correlations between the GHQ-12 and SAQOL subtests; and adequate to excellent correlations between the GHQ-12 and SAQOL-39 subtests. – One study reported that individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. with a Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Inventory (BDI) score of 11-18 (mild depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. ) demonstrated GHQ-28 median scores of 27.0 and 28.0 at 1 and 6 months post-stroke respectively; individuals with a BDI score ≥19 (severe depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. ) demonstrated GHQ-28 median scores of 44.0 and 48.0 at 1 and 6 months post-stroke respectively. – No studies have reported on cross-diagnostic validityThe degree to which an assessment measures what it is supposed to measure. of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Known Groups: No studies have reported on known-group validityThe degree to which an assessment measures what it is supposed to measure. of the GHQ in a sample of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Floor/Ceiling Effects	No studies have reported on floor/ceiling effects of the GHQ within a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Does the tool detect change in patients?	The GHQ-28 is intended for use as a screeningTesting for disease in people without symptoms. instrument and therefore is not designed to measure change over time. – One study reported 81% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” and 68% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the GHQ-28 when using cutoff scores of 11/12 (optimal in relation to DSM-IIIR criteria), or 85% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” and 61% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). when using cutoff scores of 7/8 (optimal in relation to ICD-10 criteria). – One study examined reported 80% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” and 76% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the GHQ-30 when using a cutoff score of 8/9.
Acceptability	The GHQ-28 is non-invasive and quick to administer. Caution should be exercised with scoring.
Feasibility	The GHQ-28 is suitable for administration in various settings. The assessment is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool?	https://www.gl-assessment.co.uk/products/general-health-questionnaire-ghq/

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the GHQ relevant to the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population. Five studies were identified. Please note that three of these studies use the GHQ-28 (Lincoln et al., 2003; Robinson & Price, 1982; Thomas & Lincoln, 2006); one study that used the GHQ-30 (O’Rourke et al., 1998) and one study that used the GHQ-12 (Hilari et al., 2003) were also included.

Floor and ceiling effect

No studies have reported on the floor or ceiling effects of the GHQ in a sample of individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have reported on internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Test-retest:
Robinson and Price (1982) examined test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the GHQ-28 with a sample of 20 individuals (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specified) and reported excellent 2-month test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r=0.90).

Intra-rater:
No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the GHQ in a sample of individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Inter-rater:
No studies have reported on the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the GHQ in a sample of individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Validity

Content:

The GHQ-28 is a scaled version of the original 60-item GHQ developed by Goldberg in 1978. Factor analysis of the original GHQ was conducted in a sample of 523 individuals who attended a primary care setting, resulting in the 28-item version with four 7-item subscales (Goldberg & Hillier, 1979).

Criterion:

Concurrent:
Robinson and Price (1982) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the GHQ-28 in a sample of 103 individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (time since strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. not specific) by comparison with other psychopathology scales. The authors reported excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
between the GHQ-28 total score and the Zung Self-Rating DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (r=0.86), Hamilton DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (r=0.88) and the Present State Examination (r=0.94).

O’Rourke et al. (1998) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the GHQ-30 in a sample of 105 individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. by comparison with the Hospital Anxiety and DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(HAD) Scale. There was no difference between the GHQ-30 and HAD Scale total scores when identifying any DSM-IV diagnosis (p=0.95), anxiety (p=0.25) or depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(p=0.56), using ROC curves.
Note: The study used the conventional 0-0-1-1 format to score the GHQ-30; this version of the GHQ is not split into subscales for depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and anxiety.

Predictive:
Lincoln et al. (2003) examined predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the GHQ-28 in a mixed sample of 143 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients with acute to chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Patients who were diagnosed as depressed according to the ICD-10 or DSM-IIIR achieved a significantly higher (p≤0.01) GHQ-28 total score than patients who were not diagnosed as depressed (ICD-10: kappa=0.40, IQR depressed 9-19/not depressed 3-12; DSM-IIIR: kappa=0.12, IQR depressed 12-21/not depressed 5-13). A score >4 on the GHQ-28 correlated with depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
among participants.

GHQ-28	ICD-10		DSM-IIIR
	Depressed (42%)	Not depressed (52%)	Depressed (15%)	Not depressed (77%)
IQR	9-19	3-12	12-21	5-13
Kappa	0.40		0.12

Construct:

Convergent/Discriminant :
Hilari et al. (2003) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the GHQ-12 in a sample of 83 individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada), by comparison with the StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and AphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) Quality of Life scale (SAQOL) and the SAQOL-39. The study yielded an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the GHQ-12 and SAQOL mean (r=0.58, p<0.01) and between the GHQ-12 and the SAQOL-39 mean (0.53, p<0.01). Correlations between the GHQ-12 and SAQOL subtests were adequate (mood r=0.57, thinking r=0.41, personality r=0.57, energy r=0.32, family roles r=0.41, social roles r=0.41, work r=0.34, p<0.01). Correlations between the GHQ-12 and SAQOL-39 subtests were adequate (physical r=0.39, energy r=0.32, p<0.01) to excellent (psychosocial r=0.62, p<0.01).

Thomas and Lincoln (2006) reported on convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the GHQ-28 in a sample of 123 individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
, by comparison with the Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory (BDI). Measures were taken at 1 month and 6 months post-stroke. Individuals who were diagnosed with mild depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(BDI score of 11-18) demonstrated GHQ-28 median scores of 27.0 (IQR=21.5-36.0) and 28.0 (IQR=22.0-37.0) at 1 and 6 months post-stroke respectively. Individuals with severe depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
(BDI score ≥19) demonstrated GHQ-28 median scores of 44.0 (IQR=32.0-54.5) and 48.0 (IQR=35.0-55.0) at 1 and 6 months post-stroke respectively.

Known Group:
No studies have reported on known-group validityThe degree to which an assessment measures what it is supposed to measure.
of the GHQ in a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Responsiveness

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
& SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
Lincoln et al. (2003) examined sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the GHQ-28 in a mixed sample of 143 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients with acute to chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The study found that optimal cutoff scores for the GHQ-28 in relation to DSM-IIIR and ICD-10 criteria were 11/12 (sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
81%, specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
68%) and 7/8 (sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
85%, specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
61%) respectively.

GHQ-28 cutoff score	ICD-10 diagnosis		DSM-IIIR diagnosis
	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
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

O’Rourke et al. (1998) examined sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the GHQ-30 in a sample of 105 individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Using previously recommended cutoff scores of 4/5 yielded sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
scores of 0.9 and 0.47 (respectively). The authors recommended a cutoff score of 8/9, which achieved sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
scores of 0.8 and 0.76 (respectively).

References

Anderson, C., Laubscher, S., & Burns, R. (1996). Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients. Stroke, 27, 1812-6.

Goldberg, D.P. & Hillier, V.F. (1979). A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-45.

Hilari, K., Byng, S., Lamping, D.L., & Smith, S.C. (2003). Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39): Evaluation of acceptability, reliability and validity. Stroke, 34, 1944-50.

Kilic, C., Rezaki, M., Rezaki, B., Kaplan, I., Ozgen, C., Sagduyu, A., & Ozturk, M.O. (1997). General Health Questionnaire (GHQ12 & GHQ28): psychometric properties and factor structure of the scales in a Turkish primary care sample. Social Psychiatry and Psychiatric Epidemiology, 32, 327-31.

Lincoln, N.B., Nicholl, C.R., Flannaghan, T., Leonard, M., & Van der Gucht, E. (2003). The validity of questionnaire measures for assessing depression after stroke. Clinical Rehabilitation, 17, 840-6.

Malakouti, S.M., Fatollahi, P., Mirabzadeh, A., & Zandi, T. (2007). Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians. International Psychogeriatrics, 19(4), 623-34.

O’Rourke, S., MacHale, S., Signorini, D., & Dennis, M. (1998). Detecting psychiatric morbidity after stroke: Comparison of the GHQ and HAD Scale. Stroke, 29, 980-5.

Rehabiliation Measures Database. (2010). General Health Questionnaire-28. Retrieved from http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=909

Robinson, R.G. & Price, T.R. (1982). Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke, 13(5), 635-40.

Salter, K., Campbell, N., Richardson, M., Mehta, S., Jutai, J., Zettler, L., Moses, M., McClure, A., Mays, R., Foley, N., & Teasell, R. (2013). Outcome Measures in Stroke Rehabilitation. Retrieved from http://www.ebrsr.com/sites/default/files/Chapter21_Outcome-Measures_FINAL_16ed.pdf

Sterling, M. (2011). General Health Questionnaire – 28 (GHQ-28). Journal of Physiotherapy, 57, 259.

Thomas, S.A. & Lincoln, N.B. (2006). Factors relating to depression after stroke. British Journal of Clinical Psychology, 45, 49-61.

Werneke, U., Goldberg, D.P., Yalcin, I., & Ustun, B.T. (2000). The stability of the factor structure of the General Health Questionnaire. Psychological Medicine, 30, 823-9.

Willmott, S.A., Boardman, J.A.P., Henshaw, C.A., & Jones, P.W. (2004). Understanding General Health Questionnaire (GHQ-28) score and its threshold. Social Psychiatry and Psychiatric Epidemiology, 39, 613-7.

See the measure

How to obtain theGeneral Health Questionnaire – 28 (GHQ-28)?

https://www.gl-assessment.co.uk/products/general-health-questionnaire-ghq/