Psychological Medicine, 1997, 27, 191–197.

Copyright # 1997 Cambridge University Press

The validity of two versions of the GHQ in the

WHO study of mental illness in general health care
D. P. G O L D B E RG," R. G A T E R, N. S A R T O R I US, T. B. U S T U N, M. P I C C I N E L LI,
O. G U R E J E    C. R U T T ER
From the Institute of Psychiatry, London ; and the Division of Mental Health of the World Health
Organization, Geneva, Switzerland

ABSTRACT
Background. In recent years the 12-item General Health Questionnaire (GHQ-12) has been exten-
sively used as a short screening instrument, producing results that are comparable to longer
versions of the GHQ.
Methods. The validity of the GHQ-12 was compared with the GHQ-28 in a World Health
Organization study of psychological disorders in general health care. Results are presented for
5438 patients interviewed in 15 centres using the primary care version of the Composite Inter-
national Diagnostic Instrument, or CIDI-PC.
Results. Results were uniformly good, with the average area under the ROC curve 88, range
from 83 to 95. Minor variations in the criteria used for defining a case made little difference to
the validity of the GHQ, and complex scoring methods offered no advantages over simpler
ones. The GHQ was translated into 10 other languages for the purposes of this study, and
validity coefficients were almost as high as in the original language. There was no tendency for
the GHQ to work less efficiently in developing countries. Finally gender, age and educational
level are shown to have no significant effect on the validity of the GHQ.
Conclusions. If investigators wish to use a screening instrument as a case detector, the shorter
GHQ is remarkably robust and works as well as the longer instrument. The latter should only
be preferred if there is an interest in the scaled scores provided in addition to the total score.

brevity of the GHQ-12 makes it attractive for

INTRODUCTION
The World Health Organization’s study of
psychological disorders in general medical
settings provided an opportunity to evaluate the
performance of two versions of the GHQ against
a research interview that generates diagnoses
using either the ICD-10 or the DSM-IV systems
in 15 different centres. The fact that there was
common training of research workers and that
identical methodology was used at all centres
increases the value of making comparisons
between centres, since an important cause of
variation has been greatly reduced.
This study compares the shortest GHQ, or
GHQ-12, with the longer scaled GHQ-28. The
" Address for correspondence : Professor Sir David Goldberg,
Institute of Psychiatry, De Crespigny Park, London SE5 8AF.
191
use in busy clinical settings, as well as in settings
where some patients may be illiterate and require
the questionnaire read out to them. Early studies
disembedded this short GHQ from longer
versions – it is contained within in 30, 36 and 60
item questionnaire ; but it shares only six items
with the scaled GHQ, or GHQ-28. More recent
studies have used the questionnaire on its own.
Since relatively little has been published on
the validity of the GHQ-12, all previous studies
known to the authors have been summarized in
Table 1, even including two studies that did not
use standardized assessments. However, results
of these studies were within the range of variation
of the others reported. It can be seen that
validity studies have been reported in nine
countries, and that the median values for
sensitivity and specificity are high, although the
192 D. P. Goldberg and others

Table 1. Previous validity studies using the GHQ-12

2nd stage interview Threshold Sensitivity Specificity
Authors, date Country ; Setting numbers Score GHQ-12 (%) (%)

Goldberg, 1972* England ; Primary care CIS ; N ¯ 200 1}2 93±5 78±5
Tennant, 1977* Australia ; Community PSE ; N ¯ 120 — 87±0 91±0
Banks 1983* England ; Community PSE ; N ¯ 200 2}3 71±4 79±8
adolescents
Radanovic & Eric, Yugoslavia ; Students CIS ; N ¯ 151 1}2 91±3 75±8
1983*
Mari & Williams, 1985 Brazil ; Primary care CIS ; N ¯ 260 3}4 85±0 79±0
Shamasundar et al. India ; Primary care IPSS ; N ¯ 144 1}2 87±0 93±0
1986
Bellantuono et al. Italy ; Primary care CIS ; N ¯ 90 2}3 75±0 71±0
1987
Bandyopadhyay et al. India ; Referrals to Unstandardized ; 2}3 77±4 89±7
1988 psychiatry N ¯ 111
Wilkinson & Markus, England ; Primary care CIS-PROQSY; 1}2 75±0 91±0
1989* N ¯ 256
Gureje & Obikoya, Nigeria ; Primary care CIDI ; N ¯ 214 0}1 67±0 74±0
1990
Pan & Goldberg, 1991 England ; Chinese CIS ; N ¯ 223 2}3 67±5 76±6
primary care
Araya et al. 1992 Chile ; Primary care CIS-R ; N ¯ 77 4}5 76±0 73±0
Picinelli et al. 1993 Italy ; Primary care CIS ; N ¯ 94 3}4 75±0 74±0
(13}14 Likert) (71±0) (76±0)
Abiodun, 1993 Nigeria ; Primary care PSE ; N ¯ 272 3}4 83±7 79±8
Abiodun, 1994 Nigeria ; Medical and PSE ; N ¯ 263 2}3 88±7 83±3
surgical
Gynaecology, PSE ; N ¯ 233 2}3 91±4 77±5
Antenatal, PSE ; N ¯ 240 2}3 83±3 81±4
Community PSE ; N ¯ 330 2}3 84±1 81±2
Politi et al. 1994 Italy ; Conscripts, Unstandardized ; 8}9 68±0 59±0
18 year-old males N ¯ 363 (Likert)
van Hemert et al. 1995 Holland ; MOPD, PSE
disembedded GHQ-12 N ¯ 112 2}3 77±0 79±0
free standing GHQ-12 N ¯ 78 5}6 72±0 75±0
Summary 9 countries Various Mode : 2}3 Median : 83±7 % Median : 79±0 %
4031 interviews

* Disembedded version of GHQ used. CIS ¯ Clinical Interview Schedule ; PSE ¯ Present State Examination ; CIDI ¯ Composite
International Psychiatric Interview ; IPSS ¯ Indian Psychiatric Survey Schedule ; PROQSY ¯ Computer administered CIS.

range is very wide. The various studies used a
range of different second stage research inter-
views, and it was not clear to what extent the
wide range of validity coefficients reflected
variation in the clinical standard against which
the GHQ-12 was being compared. This may
have accounted for the range of best thresholds
reported in the literature previously, shown in
Table 1. However, it can be seen from Table 1
that the best threshold for the Clinical Interview
Schedule (CIS : eight studies, mean threshold
3±13) is almost identical to that for the Present
State Examination (PSE : six studies, mean
threshold 3±17). There has also been doubt
about the best method for scoring available :
various studies (Gureje & Obikoye, 1990 ; Pan &
Goldberg, 1990 ; Piccinelli et al. 1993) have not
shown that C-GHQ scoring has much to offer,
but there is doubt about the value of Likert
scoring (0–1–2–3) against the more usual GHQ
scoring (0–0–1–1) (Piccinelli et al. 1993 ; Politi et
al. 1994). Cronbach’s alpha is reported in several
studies, and is between ­0±82 and ­0±86 (Sriram
et al. 1989 ; Winefield et al. 1989 ; Politi et al.
1994). van Hemert and his colleagues (1995)
have suggested that the threshold score for the
disembedded questionnaire is much lower than
that for the free-standing questionnaire, and this
receives partial confirmation from the table
(disembedded, seven studies, mean threshold
2±57 ; free standing, 12 studies, mean threshold
3±42). However, this cannot be the whole story,
since there is considerable overlap between the
two distributions.
The validity of the GHQ-28 has also been
questioned by van Hemert and his colleagues on
 Validity of the GHQ across cultures
the grounds that the inclusion of items from the
somatic subscale, where a positive response can
be produced either by physical disease or by
psychological disorder, can only reduce the
discriminatory ability of the questionnaire. In
support of his argument, van Hemert et al. show
that the validity coefficients of the somatic
subscale are less than those of the other three
subscales. However, merely because one scale
has coefficients that are less good does not mean
that the overall instrument lacks validity ; indeed,
satisfactory coefficients have been reported by
others (Bolognini et al. 1989 ; Romans Clarkson
et al. 1989 ; Benjamin et al. 1991 ; Aderibighe &
Gureje, 1992 ; Cheung & Spears, 1994) since the
last review by Goldberg & Williams (1988).
In addition to providing data on the com-
parative validity of the GHQ in the 15 centres,
the present study investigates the performance
of the GHQ-12 as a case detector against the
longer GHQ-28. Results are reported for various
definitions of ‘ caseness ’, whether ICD-10 or
DSM-IV, with or without current anxiety, and
with and without alcohol dependence. The
questionnaire was administered in 11 different
languages, and we consider whether translation
from its original language is associated with
lowered validity. Since the questionnaire was
designed in the developed world, we compare
the performance of the questionnaire in Europe
and North America with its performance in the
developing world. Finally, we examine the effects
of gender, age or educational level on the
screening performance of the instrument.
METHOD
The study involved 15 centres round the world,
in which a total of 11 languages were spoken
(Ustun & Sartorius 1995). Both GHQ and the
primary care version of the Composite In-
ternational Diagnostic Interview (CIDI-PC)
were translated and back-translated in each of
these languages. Consecutive patients attending
clinics at participating centres were approached
providing that they were older than 17, were not
too ill to participate ; were able to communicate
and had a fixed address. The latter requirement
was because the study used a longitudinal design.
A pilot study in each centre indicated that the
GHQ score distributions were very different
across centres. In each centre the scores were
193
divided into three strata, so that the first one
contained 60 % of the patients, the second one
20 %, and the third one the top 20 %. To achieve
these proportions, the following scores defined
medium and high scorers in each centre : Ankara
(2,4), Athens (3,5), Bangalore (3,7), Berlin (2,5),
Groningen (2,5), Ibadan (2,5), Mainz (2,5),
Manchester (2,4), Nagasaki (2,4), Paris (4,7),
Rio de Janeiro (3,5), Santiago (5,7), Seattle
(3,5), Shanghai (0,1 in one centre, 2,4 in the
other) and Verona (4,6). The adoption of these
varying sampling fractions meant that it was
possible to complete the study in each centre by
screening approximately similar numbers of
patients. The GHQs were printed with a com-
puter generated code indicating the score which
a patient should exceed if they were to be
selected for interview : in this way a complex
stratified sampling method was used smoothly
across the 15 centres.
The CIDI-PC can generate diagnoses using
either the International Classification of Disease,
10th Edition (ICD-10) system (WHO, 1993), or
the Diagnostic and Statistical Manual of the
American Psychiatric Association, 4th edition
(DSM-IV) system (American Psychiatric As-
sociation, 1984). For the present purposes,
‘ lifetime ’ diagnoses were ignored, and only
current mental status was considered. The
following diagnoses were included : current
depression, dysthymia, agoraphobia, panic dis-
order, generalized anxiety disorder, somatiza-
tion disorder, neurasthenia (chronic fatigue)
and hypochondriasis. We examined the effects
of including current anxiety symptoms (not
requiring a 6-month duration) and alcohol
dependence, but harmful use of alcohol was not
included in the present analysis.
Sample size was determined in order to
provide adequate statistical power for com-
parisons both between and within centres. It was
projected that 1500 patients needed to be
screened in each centre in order to detect 60
current cases of depression, and to have adequate
numbers to allow a centre to compare the course
of depression relative to other disorders that
were common at that centre. If selected for
interview, patients were usually seen within a
day or so of the GHQ being completed, although
at Verona the time was within 2 weeks. At the
time of the interview each subject completed a
34-item version of the GHQ, containing both
194 D. P. Goldberg and others

the GHQ-12 and the GHQ-28. The present
study has used results from this GHQ to compute
validity measures.
The research worker administering the CIDI-
PC was blind to the results of this questionnaire.
Selection of centres was dependent upon the
existence of experienced investigators, and
ability to raise funds for the study in the
developed countries. The detailed methodology
is described elsewhere (Ustun & Sartorius 1995).
RESULTS
In the first stage of the study 25 916 patients
(96±5 % of those approached) completed the
GHQ-12. Co-operation with the second stage
interview varied between centres, but was found
to be 64±9 % across centres. A total of 5438
patients completed the second stage interview.
Before validity coefficients were computed,
results were weighted back to the original
populations of patients who had been screened.
Receiver Operating Characteristic (ROC) curves
were calculated using the ROCFIT programme
(Metz et al. 1984). Best thresholds were calcu-
lated using the optimal trade-off between sen-
sitivity and specificity : where two thresholds
gave similar trade-offs, that with higher sen-
sitivity was preferred.
Validity coefficients for the GHQ-12
These were generally high, with the mean area
under the ROC curves being 0±88, with a fairly
narrow range : Berlin and Mainz at the lower
end with 0±83, and Manchester and Bangalore at
the top with 0±95 and 0±93 respectively (see Table
2). The overall sensitivity was 83±4 %, and the
specificity 76±3 %. At each centre, optimal figures
were achieved with rather different thresholds :
many centres with 1}2, but Manchester high
with 3}4, and Bangalore with a surprising 6}7.
Most of the patients at the Bangalore centre
were illiterate, and had the questionnaire read
out to them. The mean prevalence of ICD-10
diagnoses across the 15 centres was 24 %, and
data from each centre were standardized to this
prevalence in order to calculate the positive
predictive values (PPVs) and allow comparison
between centres.
Validity coefficients for the GHQ-28
There were also found to be high, but no higher
than those for the GHQ-12 (see Table 3). The
positive predictive values were generally slightly
better, and there was less variation in the best
thresholds between centres.
Altering the gold standard
Values for DSM-IV diagnoses are comparable,
but slightly lower, than those for ICD-10
diagnoses. We also tried the effects of adding
‘ current anxiety ’ to the ICD-10 diagnoses, but
found that it made little differences to the
validity coefficients – the reduced sensitivity was
compensated for by the improved specificity,
and the area under the curve stayed the same.
Adding alcohol dependence to the list of ICD-10

Table 2. Validity coefficients for the GHQ-12 in 15 centres

Sensitivity Specificity PPV GHQ-12
#%
Centre Threshold (%) (%) (%) ROC

Ankara 1}2 70±6 82±3 55±7 0±85

Athens 2}3 80±6 84±7 62±4 0±93
Bangalore 6}7 86±7 88±9 71±2 0±94
Berlin 2}3 72±6 75±0 47±8 0±83
Groningen 2}3 80±3 86±4 65±1 0±90
Ibadan 1}2 77±8 79±4 54±4 0±89
Mainz 2}3 73±5 81±2 55±2 0±83
Manchester 3}4 84±6 89±3 71±4 0±95
Nagasaki 1}2 76±2 85±9 63±1 0±86
Paris 1}2 78±2 79±4 54±3 0±85
Rio de Janeiro 1}2 70±2 77±3 49±4 0±84
Santiago 2}3 84±8 82±2 60±0 0±89
Seattle 1}2 82±1 76±5 52±4 0±86
Shanghai 1}2 86±1 79±9 57±5 0±90
Verona 1}2 75±8 65±3 40±6 0±85
All centres 2}3 76±3 83±4 52±9 0±88
 Validity of the GHQ across cultures 195

Table 3. Validity coefficients for the GHQ-28 in 15 centres

Sensitivity Specificity PPV GHQ-28
#%
Centre Threshold (%) (%) (%) ROC

Ankara 3}4 74±6 77±1 50±7 0±86

Athens 5}6 89±5 82±8 62±2 0±92
Bangalore 8}9 93±4 85±0 66±4 0±94
Berlin 5}6 81±9 72±9 48±8 0±84
Groningen 5}6 84±9 81±9 59±8 0±93
Ibadan 4}5 80±8 75±6 51±2 0±87
Mainz 5}6 80±7 72±9 48±5 0±84
Manchester 6}7 84±4 86±2 65±8 0±93
Nagasaki 3}4 76±7 77±6 51±9 0±85
Paris 3}4 79±3 74±9 49±9 0±82
Rio de Janeiro 3}4 82±0 71±8 47±9 0±86
Santiago 6}7 89±0 85±8 66±4 0±94
Seattle 3}4 80±5 74±8 50±2 0±84
Shanghai 7}8 84±6 85±5 64±8 0±92
Verona 5}6 70±8 72±9 45±2 0±84
All centres 5}6 79±7 79±2 54±7 0±88

Table 4. Effects of varying the scoring system on the validity coefficients of the GHQ in 15 centres :
GHQ scoring assigns weights of 0, 0, 1, 1 ; Likert weights of 0, 1, 2, 3 ; and C-GHQ assigns weights
of 0, 1, 1, 1 to items indicating illness, and 0, 0, 1, 1 for items indicating health
Area under Best Sensitivity Specificity
GHQ Scoring method curve threshold (%) (%)

GHQ-12 GHQ-scoring 0±88 1}2 83±5 75±1

C-GHQ 0±86 4}5 78±9 74±5
Likert 0±85 11}12 78±9 77±4
GHQ-28 GHQ-scoring 0±87 5}6 79±2 79±6
C-GHQ 0±85 12}13 77±2 77±2
Likert 0±87 23}24 79±8 78±5

Table 5. Effects of varying the diagnostic system on the validity coefficients of the GHQ
in 15 centres
GHQ Area under Best Sensitivity Specificity
Gold Standard version curve threshold (%) (%)

ICD-10 system GHQ-12 0±88 1}2 83±5 75±1

GHQ-28 0±88 5}6 79±2 79±6
DSM-4 system GHQ-12 0±87 1}2 81±6 76±4
GHQ-28 0±87 5}6 76±7 81±0

diagnoses reduced the coefficients (see Tables 4
and 5).
Different scoring methods
The questionnaires were scored by the usual
method (0–0–1–1), as well as Likert (0–1–2–3)
and the C-GHQ method, in which items that
measure health are scored as usual, but items
reflecting illness are scored 0–1–1–1. For the
GHQ-12, the Likert method was worse than the
GHQ method, but it was about the same for the
GHQ-28. The C-GHQ was slightly less good
than the GHQ method for both questionnaires
(see Tables 4 and 5).
Effect of translation from English
For this analysis, the pooled results for
Manchester and Seattle were compared with
results for the 13 other centres. The area under
the ROC curve is slightly less for the GHQ-12
196 D. P. Goldberg and others
given in English, but about the same for the
GHQ-28. The differences are not significant.
Developed versus developing country
For this analysis, the nine centres in developed
countries were compared with Ibadan and
Bangalore as representatives of developing
countries. Four other countries formed an
intermediate group. There is no tendency for
countries in the developing world to have lower
coefficients.
Effects of gender, age and educational level
If the GHQ is to be used as a screening
instrument in surveys, it is essential that its
validity characteristics are not influenced by
gender, age of subject, or educational level, as
this would bias the results. ROC curves were
computed by gender, by age group, and by
educational level, and were not found to be
significantly different from one another. Where
there were more than two groups (i.e. age and
educational level) pairwise comparisons were
made between each pair : none were significant.
DISCUSSION
There are a number of possible explanations for
the differences in validity coefficients between
centres besides local cultural differences in the
expression of distress. These include differing
degrees of defensiveness, effects of translation
into a particular language, differing degrees of
expertise in administering the second stage
interview, and varying degrees of collaboration
with the survey. It is not possible to determine
which of these was responsible for the differences
reported, although the differences are probably
best accounted for in terms of differences in the
preparedness of patients to report symptoms on
a pencil and paper test.
Mari & Williams (1986) found that those with
more than four years education had better ROC
curves than those with less education than this :
the poorly educated were more likely to give
positive replies to the questionnaire that were
not confirmed by interview, while Hobbs and his
colleagues (1984) showed that the GHQ worked
better with women (sensitivity 88 %, specificity
83 %) than with men (sensitivity 72 %, specificity
87 %). Neither of these results were confirmed
on this relatively large data-set.
However, the difference between the best and
the worst centre is not that great. It would
appear that if a researcher wishes to use the
GHQ as a case detector, that the shorter
questionnaire, scored in the simplest manner, is
as good as longer versions and more involved
methods. The Likert scoring method will pro-
duce a wider and smoother score distribution if
a researcher wishes to assess severity and the C-
GHQ method is more normally distributed than
the GHQ scoring method. Finally, the GHQ-28
should only be used if a researcher wishes to
have scaled scores in addition to a total score.
The similarity between the validity coefficients
for the two diagnostic systems probably reflects
the fact that they are fast converging upon each
other. The GHQ works as well in the developing
world as the developed world and loses only a
small amount by translation into other
languages.
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