Using the GHQ-12 to screen for mental health problems among primary care patients: psychometrics and practical considerations

Abstract

Background: This study explores the factor structure of the Indonesian version of the GHQ-12 based on several theoretical perspectives and determines the threshold for optimum sensitivity and specificity. Through a focus group discussion, we evaluate the practicality of the GHQ-12 as a screening tool for mental health problems among adult primary care patients in Indonesia. Methods: This is a prospective study exploring the construct validity, criterion validity and reliability of the GHQ-12, conducted with 676 primary care patients attending 28 primary care clinics randomised for participation in the study. Participants' GHQ-12 scores were compared with their psychiatric diagnosis based on face-to-face clinical interviews with GPs using the CIS-R. Exploratory and Confirmatory Factor Analyses determined the construct validity of the GHQ-12 in this population. The appropriate threshold score of the GHQ-12 as a screening tool in primary care was determined using the receiver operating curve. Prior to data collection, a focus group discussion was held with research assistants who piloted the screening procedure, GPs, and a psychiatrist, to evaluate the practicality of embedding screening within the routine clinic procedures. Results: Of all primary care patients attending the clinics during the recruitment period, 26.7% agreed to participate (676/2532 consecutive patients approached). Their median age was 46 (range 18-82 years); 67% were women. The median GHQ-12 score for our primary care sample was 2, with an interquartile range of 4. The internal consistency of the GHQ-12 was good (Cronbach's α = 0.76). Four factor structures were fitted on the data. The GHQ-12 was found to best fit a one-dimensional model, when response bias is taken into consideration. Results from the ROC curve indicated that the GHQ-12 is 'fairly accurate' when discriminating primary care patients with indication of mental disorders from those without, with average AUC of 0.78. The optimal threshold of the GHQ-12 was either 1/2 or 2/3 point depending on the intended utility, with a Positive Predictive Value of 0.68 to 0.73 respectively. The screening procedure was successfully embedded into routine patient flow in the 28 clinics. Conclusions: The Indonesian version of the GHQ-12 could be used to screen primary care patients at high risk of mental disorders although with significant false positives if reasonable sensitivity is to be achieved. While it involves additional administrative burden, screening may help identify future users of mental health services in primary care that the country is currently expanding.

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“…Each item was graded on a 4-point Likert scale such as "much more than usual", "more than usual", "not more than usual", and "not at all". Although several procedures to sum up the GHQ-12 scores are available [32,36], we employed the 0-0-1-1 scoring method which yield a total of 12 scores ranging between 0 and 12, with a higher score indicating greater psychological distress [37]. In the current study, the index showed a very good internal consistency with a Cronbach's alpha of 0.84.…”

“…The primary outcome variable in this study was psychological distress which we assessed by the 12-item General Health Questionnaire (GHQ-12) [30]. The GHQ-12 is a widely employed and well-validated screening instrument [31,32] to measure common mental disorders (e.g., depression, anxiety, and stress) that disrupt the performance of an individual's daily activities [33][34][35]. The GHQ-12 includes both positively and negatively worded items, e.g., "In the past two weeks, have you been able to enjoy your normal day to day activities?…”

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“…This issue of pertains to both the items and answer options themselves, but even more importantly to the thresholds used to categorize respondents into severity of illness categories. Studies comparing self-reported screening tools to clinical interviews have clearly shown that appropriate thresholds vary substantially between different study populations [43][44][45]. Of note, while cultural differences might be most important, there might well be differences in measurement properties between different sub-population within a de ned cultural context, for instance between generally well-educated health workers and the likely less educated general or patient population.…”

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“…We used dichotomous or bimodal scoring of 0 or 1, and the possible total score ranged from 0 to 12. Distress was defined as a GHQ-12 score of 3 or higher [18].…”