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Diagnosing mental disorders in primary care: the General Health

Questionnaire (GHQ) and the Symptom Check List (SCL-90-R) as screening
instruments

Article  in  Social Psychiatry and Psychiatric Epidemiology · August 1999

DOI: 10.1007/s001270050156 · Source: PubMed

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Soc Psychiatry Psychiatr Epidemiol (1999) 34: 360±366
ORIGINAL PAPER
N. Schmitz á J. Kruse á C. Heckrath
L. Alberti á W. Tress
Diagnosing mental disorders in primary care:
the General Health Questionnaire (GHQ) and the
Symptom Check List (SCL-90-R) as screening instruments*
Accepted: 16 February 1999
Abstract Background: The treatment of mental disor-
ders in Germany is mainly done by primary care phy-
sicians. Several studies have shown that primary care
physicians have diculty in diagnosing these disorders.
Recently, several self-report questionnaires have been
developed that can be used as screening instruments to
identify psychopathology in primary care settings and in
the community. The aim of this paper was to investigate
the screening properties of the General Health Ques-
tionnaire (GHQ-12) and the Symptom Check-List (SCL-
90-R) in a primary care setting in Germany. Method: A
randomly selected sample (n = 408) of adult outpatients
from 18 primary care oces in DuÈsseldorf was screened
using the German versions of the GHQ-12 and the SCL-
90-R. A structured diagnostic interview (SCID) and an
impairment rating (IS) were used as a gold standard to
which both questionnaires were compared. Test perfor-
mance was evaluated by receiver operating characteristic
(ROC) analysis. Results: We found no di€erence in the
performance of the general scores of the two question-
naires. Both instruments were able to detect cases.
Complex scoring methods o€ered no advantages over
simpler ones for the GHQ-12. ROC analysis con®rmed
that the SCL-90-R subscales ``anxiety'' and ``depres-
sion'' showed acceptable concurrent validity for the
diagnostic groups anxiety and depression (according to
DSM-III-R). Conclusions: GHQ-12 and SCL-90-R ap-
peared to be useful tools for identifying mental disorders
N. Schmitz (&) á J. Kruse á C. Heckrath á L. Alberti á W. Tress
Clinic for Psychosomatic Medicine and Psychotherapy,
Heinrich-Heine University,
Bergische Landstrasse 2, H19,
D-40605 DuÈsseldorf,
Germany
e-mail: schmitzn@uni-duesseldorf.de,
Tel.: +49-211-9224723,
Fax: +49-211-9224709
* Grant support for this investigation was given by the German
Federal Ministry for Research and Technology (BMFT).
Ó Steinkop€ Verlag 1999
in primary care practice and research. The use of GHQ-
12 or SCL-90-R, employed as a ®rst step, supplemented
by a second-stage interview, may enhance the detection
rate of mental disorder in primary care settings.
Introduction
The problem of identifying mental disorders is increas-
ingly recognised as an important health care issue.
Mental disorders result in substantial patient su€ering
and health care cost and are present in primary care in at
least 20±36% of primary care outpatients (Spitzer et al.
1994; Tress et al. 1997). In fact, more patients with
mental disorders are cared for in the primary care sector
than in the mental health sector (e.g. Manderscheid
et al. 1993). However, several studies have shown that
primary care physicians have diculty in diagnosing
these disorders in the majority of patients, who usually
present with somatic symptoms suggestive of a medical
condition, while volunteering few psychological com-
plaints. As Spitzer et al. (1994) pointed out, major ob-
stacles to the recognition of mental disorders by primary
care physicians include inadequate knowledge of the
diagnostic criteria, uncertainty about the best question
to ask for evaluating whether those criteria are met, and
time limitations inherent in a busy oce setting.
Katzelnick et al. (1997) have shown that identi®cation
and treatment of mental disorders in primary care can
reduce disability and health care utilisation and improve
quality of life.
Recently, several self-report questionnaires have been
developed that can be used as screening instruments to
identify psychopathology in primary care settings and in
the community. Examples are the General Health
Questionnaire (GHQ, Goldberg 1972) and the Symptom
Check-List (SCL-90-R, Derogatis 1977; Franke 1995).
Both SCL-90-R and GHQ are well-researched instru-
ments and are frequently used for case identi®cation
(e.g. Gureje and Obikoye 1990; Koeter 1992; Witnitzer
et al. 1992; Lykouras et al. 1996). Once an appropriate

cut-o€ point has been chosen, the questionnaires can be
used as screening devices for the detection of psycho-
logical distress.
A valid comparison between the German version of
the GHQ-12 and the SCL-90-R cannot be made because
to date the two instruments have not been examined
simultaneously using the same case criterion and the
same population.
The aim of the present paper was to compare the
criterion validity of SCL-90-R (90 items) with the cri-
terion validity of a short form of GHQ (GHQ-12, 12
items) in a primary care setting, while the external cri-
terion is the presence or absence of psychopathology as
indicated by an experienced psychotherapist. Receiver
operating characteristic (ROC) analysis was used as an
evaluation technique for these two tests, using data from
an epidemiological investigation in primary care (Tress
et al. 1997).
Subjects and methods
Instruments
The GHQ and SCL-90-R are self-report questionnaires for the
detection and measurement of psychopathology. An overall index
based on all items is generally considered to be a measure of psy-
chological (dys)function. On the basis of speci®c cut-o€ points,
respondents can be assigned to a group with or a group without
substantial psychopathology. Schmitz and Davies-Osterkamp
(1997) and Davies-Osterkamp et al. (1996) discussed several cut-o€
points for the SCL in clinical practice. GHQ and SCL have been
used as screening instruments in primary care in several studies (e.g.
Mari and Williams 1985; Witznitzer et al. 1992; Joukamaa et al.
1995; Linden et al. 1996; Tiemens et al. 1996).
General Health Questionnaire
The GHQ-12 is a self-report instrument for the detection of mental
disorders in the community and among primary care patients.
Accordingly, the GHQ has a four-point response scale, which is
usually scored in a bimodal fashion ± symptom present: ``not at all''
(0); ``same as usual'' (0); ``rather more than usual'' (1); and ``much
more than usual'' (1). The response scale is simply ``yes'' or ``no''.
For psychometric analysis it is possible to use a simple Likert scale
(0-1-2-3), although there are only small di€erences from the point
of view of case identi®cation between results produced by the dif-
ferent scoring methods. The total score, obtained by summing up
the scores of the individual items, is a measure for severity of ill-
ness, as described by Goldberg and Williams (1991).
Symptom Check List SCL-90-R
The SCL-90-R is a 90-item self-report symptom inventory designed
to screen for a broad range of psychological problems. Each of the
90 items is rated on a ®ve-point Likert scale of distress, ranging
from ``not at all'' (0) to ``extremely'' (4). Subsequently the answers
are combined in nine primary symptom dimensions: Somatization,
Obsessive-Compulsive, Interpersonal Sensitivity, Hostility, De-
pression, Anxiety, Paranoid Ideation, Phobic Anxiety and Psy-
choticism. In addition, three global indices provide measures of
overall psychological distress: the Global Severity Index (GSI), the
Positive Symptom Total (PST) and the Positive Symptom Distress
Index (PSDI).
361
Impairment Score
The Impairment Score (IS, German: BSS, Schepank 1995; Franz
et al. 1997) is a standardised instrument which allows trained and
clinically experienced interviewers to assess the severity ± ranging
from ``not at all'' (0) to ``extremely'' (4) ± of clinically present
psychological impairment on three subscales: physical, psychic, and
socio-communicative (behaviour) impairment due only to mental
disorders (not caused by somatic reasons). The total range of the
sum-score is from 0 (no impairment) up to the maximum value 12
(extreme impairment); patients with a sum-score of 4, 5 or 6 can be
described as medium symptomatic while patients with a score
above 7 can be described as severely symptomatic.
Structured Clinical Interview
The Structured Clinical Interview (SCID, Wittchen et al. 1990) for
the Diagnostic and Statistical Manual of Mental Disorders (DSM-
III-R) is a diagnostic instrument that is widely used by researchers
and clinicians in order to guide the diagnostic evaluation process.
SCID ascertains the presence and severity of psychological signs
and symptoms in the 4 weeks prior to the interview.
Settings and population sample
The study was an epidemiological observational study. Prevalence
of mental disorders in primary care was assessed in a sample of 572
German adult outpatients from 18 randomly selected primary care
clinics in DuÈsseldorf (Germany). Data collection took place from
January 1995 to December 1995. In each practice, patient recruit-
ment was carried out over a 2-week period during oce hours.
Consecutive attenders of the clinics who were aged between 18 and
70 were asked to participate within a 2-week period. Subjects were
informed about the general purposes of the study and asked to give
their informed consent.
After the general practitioner's consultation, the patients ®lled
in symptom checklists (SCL-90-R, GHQ-12) and were examined
and diagnosed by a mental health professional (among others, IS,
DSM-III-R classi®cation). This interview was conducted blind (i.e.
without knowledge of the questionnaire results), using the SCID
(Wittchen et al. 1990). Patients who ful®lled the following two
criteria were de®ned as cases of mental disorders: (a) a total score
of 5 or more on the IS (i.e. considerable psychological impairment)
and (b) any speci®c DSM-III-R diagnosis made according to the
SCID. Therefore, non-cases were patients who were physically ill
and had no or mild psychological impairment.
The reasons for consultation were classi®ed using the Reason
for Visit Classi®cation (RVC, Schneider et al. 1979). The most
frequently mentioned reasons for visit were respiratory symptoms
(22.2%), symptoms of the musculoskeletal system and connective
tissue (14.0%), and symptoms of the digestive system (9.7%), while
only 3.5% mentioned psychological problems. These results are
consistent with a large epidemiological survey of primary care
providers in Germany, where RVC was evaluated in a sample of
12,000 subjects (Schach et al. 1989). Detailed study methodology is
reported by Tress et al. (1997). The sample comprised 179 men
(31.3%) and 393 women (68.7%), mainly aged between 23 and 65
(mean = 42.7, SD = 15.7). The main diagnoses are summarised
in Table 1.
Of the 572 persons in the sample, 408 ®lled in SCL-90-R and
GHQ-12 completely.
Receiver operating characteristic curve
The performance of screening questionnaires is usually expressed in
terms of sensitivity, speci®city, and positive and negative predictive
power. These parameters are quantitative expressions of the rela-
tions of questionnaire scores to some external case criterion. The
SCID interview and the IS served as the gold standard against
which both SCL-90-R and GHQ were compared.
362

Table 1 Frequencies of DSM-

III-R diagnoses for cases and Cases % of total sample Non-cases % of total sample
non-cases (n = 572) (n = 572)

Total Female Male Total Female Male

(n = 393) (n = 179) (n = 393) (n = 179)

Adjustment disordersa 11.3 12.4 8.8 4.9 5.6 3.5

Alcohol dependencya 4.0 1.3 9.9 2.9 0.6 8.2
Anxiety disordersa 5.2 5.6 5.1 3.3 3.6 2.8
Depressive disordersa 5.2 3.4 6.1 1.5 0.5 2.0
Eating disordersa 3.8 4.2 2.9 2.0 1.9 2.4
Psychological factors 6.6 6.9 5.8 9.1 8.4 10.6
a€ecting physical conditiona
Somatoform disordersa 17.1 19.3 12.3 13.6 13.3 13.4
Other disordersa 2.2 2.1 2.3 0.3 0.0 1.2
Multiple disorders 16.9 17.4 15.8 7.2 6.8 7.9
a
Some of the individuals are listed in category Multiple disorders

Sensitivity is de®ned as the number of true cases of a disorder
detected by the test (true-positives) divided by the number of all
diseased subjects. Conversely speci®city is de®ned as the number of
true-negatives (nondiseased subjects who were considered negative
by the test), divided by the number of all nondiseased subjects.
Positive predictive value is de®ned as the proportion of true cases
who are correctly diagnosed, while negative predictive value is
de®ned as the proportion of nondiseased subjects who are correctly
diagnosed. The predictive values are clinically useful but depend
very strongly on prevalence.
With the introduction of receiver operating characteristic
(ROC) analysis, an innovative method has become available for the
graphic description of the relationship between sensitivity and
speci®city and their relationship to di€erent cut-o€ points. A ROC
curve is obtained by combining sensitivity and speci®city data over
all cut-o€ points. At each cut-o€ point, sensitivity is plotted as a
function of 1 ) speci®city (or false positive rate). The points can be
connected by a smooth curve. For a perfectly accurate test (sensi-
tivity = 1, speci®city = 1), the ROC curve is a horizontal line
connecting the points (0, 1) and (1, 1). For a random test whose
discriminatory ability is no better than chance, the ROC curve will
be a diagonal line connecting the points (0, 0) and (1, 1). This has
been referred to as the ``line of no information''. Most actual tests
will produce curves lying between these two extremes. The higher
the sensitivity and speci®city at various cut-o€ points, the more
closely the curve approaches the upper left corner of the graph. A
measure used for the overall performance of an instrument is the
area under the curve (AUC). Parametric and nonparametric
methods exist that allow the calculation of the AUC and the
comparison of tests. In this study, we used a computer program
(ROCFIT, Metz et al. 1993), which ®ts a curve by a maximum
likelihood technique.
Results
Preliminary analysis showed that there was a linear re-
lationship between the GHQ-12 and the SCL-90-R. The
correlation was 0.64 for the total scores, suggesting that
a general factor for the two instruments may be present.
Figure 1 shows the distribution of the Global Severity
Index (GSI) for the cases and non-cases. As expected,
there are large overlapping parts of the empirical distri-
butions, although the distributions are di€erent for the
®rst and second moments. As shown in Fig. 2, similar
results can be found for the GHS General Score.
Di€erences in the total scores can be found for the
cases regarding gender: women are characterised by
higher scores for the global indices (SCL-90-R: female
mean = 0.94 (SD = 0.65), male mean = 0.71
(SD = 0.44), t = 2.01, df = 140, P = 0.037; GHQ:
female mean = 5.07 (SD = 4.12), male mean = 3.68
(SD = 3.42) t = 1.91, df = 140, P = 0.059), while
there are no signi®cant di€erences for the population of
non-cases.
The most prevalent items of the SCL-90-R and the
GHQ are shown in Table 2. To make the prevalence of
the items comparable, the items of the SCL-90-R were
dichotomised according to the scaling of the GHQ.
Somatic symptoms seemed to be common in this sample,
but were not more prevalent than psychological symp-
toms. Similar results were found by Araya et al. (1992)
in a primary care sample in Chile.
Figure 3 presents the performance of the SCL-90-R
and GHQ-12 total scores as screening instruments for
mental disorders in primary care. The curves were ob-
tained by plotting sensitivity against false-positive rate
for all cut-o€ points of the two screening tests and ®tting
a smooth likelihood curve. Both scores show acceptable
concurrent validity (i.e. ROC curves well above the di-

Table 2 The ®ve most pre-

valent items of the SCL-90-R SCL-90-R Prevalence GHQ-12 Prevalence
and the GHQ-12 % (n = 142) % (n = 142)

3 ± unpleasant thoughts 52.5 2 ± constantly under strain 52.8

31 ± worry 50.0 8 ± not reasonably happy, all 50.0
things considered
27 ± lower back pains 50.0 10 ± unhappy and depressed 47.9
2 ± nervousness 47.5 1 ± lost sleep over worry 45.8
66 ± restless sleep 46.5 9 ± not able to enjoy day-to-day 45.1
activity
 363

Fig. 1 Histogram of the Global

Severity Index (GSI) of the
SCL-90-R for cases and non-
cases

agonal line of no information). Moreover, the ROC
curve for the SCL-90-R total score (GSI) is nearly
identical to that of the GHQ total score.
A numerical presentation for sensitivity, speci®city and
predictive values is provided in Table 3 and Table 4. The
di€erences between SCL-90-R and GHQ were small in this
German primary care sample. A two-sample Z-test (two-
tailed) was applied to test the di€erence for statistical
signi®cance (Erdreich and Lee 1981). There was no signi-
®cant di€erence between the areas under the curves [SCL-
90-R: mean AUC = 0.75 (SD = 0.026); GHQ: mean
AUC = 0.73 (SD = 0.028); Z = 0.73, P = 0.464]. No
signi®cant di€erence was found between ROC curves for
GHQ bimodal and Likert scaling procedure.
Di€erences between the performance of the two
questionnaires were, therefore, probably due to chance.
In a second step we examined validity of the SCL-90-
R anxiety and depression subscales. Validity was es-

Fig. 2 Histogram of the GHQ

General Score for diseased and
nondiseased individuals
364
tablished with the DSM-III-R diagnosis for anxiety
(300.00±02; 300.21±23; 300.29±30; 309.89) and depres-
sion (296.20±23; 296.29; 300.40; 311.00) disorders. Both
scales show acceptable concurrent validity for the two
diagnostic groups (i.e. ROC curves well above the main
diagonal). Results are shown in Table 5. In comparison,
the GHQ-12 was not designed to screen for di€erent
diagnostic groups. Although several studies have found
a two-factor structure of the GHQ-12 (e.g. Gureje 1991),
it is more appropriate to use the GHQ-12 as a global
screening instrument. Alternatively, another version of
the GHQ (GHQ-28; 28 items with anxiety and depres-
sion subscales) can be used to screen for depression and
anxiety.
Discussion
This is the ®rst study reporting on the comparative
performance of the GHQ-12 and the SCL-90-R in a
German primary care setting, using identical external
criteria.
The major ®nding is that the GHQ-12 and the SCL-
90-R general scores performed equally well in detecting
Fig. 3 Receiver Operating
Characteristic (ROC) curve for
cases and non-cases using SCL-
90-R GSI and GHQ-12 General
Score
mental disorders in a sample of 18 randomly selected
primary care clinics in DuÈsseldorf, Germany. The small
di€erence between the questionnaires in their ability to
detect cases of psychological morbidity was not statis-
tically signi®cant. The two screening instruments were
found to be easy to administer, although there was a
di€erence in the time spent by patients to complete them
(roughly 2±5 min for the GHQ-12 and 10±20 min for the
SCL-90-R). The questions in both questionnaires were
well understood by the respondents.
In our opinion, the SCL-90-R compared to the GHQ-
12 has some de®nite advantages. The SCL-90-R covers a
broad range of psychological problems and symptoms of
psychopathology. A global index as a measure for gen-
eral distress and nine primary symptom dimensions can
be computed. The analysis of the anxiety and depression
subgroups indicated that the subscales can be used as
screening instruments, too. In contrast, the GHQ-12
contains only 12 items. As a consequence, only a general
distress factor can be computed from the items.
On the other hand, there is often a time limitation in
primary care clinics. Administration and evaluation of
the SCL-90-R needs much more time than the applica-
tion of the GHQ-12.
 365

Table 3 Validity coecients for the SCL-90-R at di€erent classi®cation may occur due to inaccuracy of diagnoses
thresholds for all screened individuals and the denying of symptoms in questionnaires.
Threshold 0.4 0.5 0.6 0.7 0.8 0.9 Some restrictions must be kept in mind regarding the
measurement of mental disorders with the GHQ-12 and
Sensitivity 0.75 0.64 0.57 0.52 0.46 0.39 the SCL-90-R in the present study. First, the present
Speci®city 0.59 0.74 0.78 0.82 0.85 0.95 study was not designed to assess validity of the two
Positive predictive value 0.51 0.58 0.60 0.62 0.63 0.77
Negative predictive value 0.81 0.77 0.76 0.75 0.73 0.70 instruments in a primary care setting. No further self-
report measures (e.g. Inventory of Interpersonal Prob-
lems, Beck Depression Inventory, Spielberg Anxiety
Inventory, etc.) were used to study construct validity of
Table 4 Validity coecients for the GHQ at di€erent thresholds the instruments.
for all screened individuals
Second, interviewing, diagnosing and rating was done
Threshold 1.5 2.5 3.5 4.5 5.5 6.5 by one mental health professional. Although this mental
health professional was supervised by a team of re-
Sensitivity 0.68 0.60 0.51 0.46 0.39 0.32 searchers (physicians and psychologists), the single in-
Speci®city 0.65 0.74 0.81 0.85 0.89 0.93
Positive predictive value 0.53 0.57 0.60 0.64 0.67 0.72 terviewer design may lack reliability and validity of the
Negative predictive value 0.78 0.76 0.74 0.73 0.72 0.71 diagnostic data (e.g. Horowitz et al. 1979).
Third, the study was conducted at 18 primary care
clinics located in DuÈsseldorf, Germany. Although the
If a primary care physician is only interested in gen- primary care physicians were selected randomly, the
eral psychological distress, the GHQ-12 questionnaire present study does not comprise a nationally represen-
can be used as a screening instrument in the primary tative sample. Di€erences across cities and countries
care sector. However, if there is a need for more detailed may occur due to di€erences in sociodemographics. The
information concerning depression and anxiety, the high prevalence rate of mental disorder (36.8%) needs to
GHQ-28 may be used. A more detailed diagnosis is at- be replicated in further studies.
tained by using the SCL-90-R. Nevertheless, some lim- Fourth, there was a small sample size in the diagnostic
itations of the screening instruments must be recognised. groups anxiety and depression. Comorbidity appeared in
GHQ-12 and SCL-90-R focus on breaks in normal both groups. However, our ®ndings are consistent with
function, rather than upon lifelong traits. Additionally, other studies. Sandanger et al. (1998) used the Hopkins
both questionnaires are not able to detect personality Symptom Checklist-25 (HSCL-25) in a Norwegian pop-
and adjustment disorders (e.g. Goldberg and Williams ulation survey as a screening instrument for mental dis-
1991). As a result, misclass®cation may occur. Figures 1 orders. They found a better performance for the subscales
and 2 show great overlaps of the symptom scores be- depression and anxiety than for the general score.
tween cases and non-cases. There are several cases with Despite these limitations, the goals for the ®eld testing
low scores on GHQ-12 and SCL-90-R, indicating low of the German version of the SCL-90-R and the GHQ-12
levels of psychological distress. Further analysis of these in a primary care setting were achieved. The instruments
subjects indicated that more than half of the cases with showed acceptable qualities for diagnosing mental health
diagnoses of ``adjustment disorders'' and ``psychological disorders in the primary care sector. The use of GHQ-12
factors a€ecting physical condition'' have GHQ sum or SCL-90-R, employed as ®rst step, supplemented by a
scores of less than 2 and GSI scores of less than 0.5. In second-stage interview, may enhance the detection rate of
fact, these diagnostic groups are not well identi®ed by mental disorder in primary care settings.
the two screening instruments. On the other hand, all There is a need for future research in this ®eld. Due to
subjects in this study were physically ill, which may re- time limitation in primary care clinics, a computerised
sult in a general distress factor (high scores on both administration of the self-report measures could be used
scales) for the non-cases, too. Further sources of mis- in primary care.

Table 5 Relationship between

DSM-III-R diagnostic group DSM-III-R diagnostic DSM-III-R diagnostic
and SCL-90-R subscales group ``Depression'' group ``Anxiety''

Screening tool: Screening tool:

SCL-90-R SCL-90-R
Subscale ``Depression'' Subscale ``Phobic anxiety''
Cases n = 33 n = 36
(according to DSM-III-R) Mean = 1.21 SD = 0.87 Mean = 0.94 SD = 0.90
Non-cases n = 128 n = 128
(according to DSM-III-R) Mean = 0.37 SD = 0.39 Mean = 0.16 SD = 0.22
Area under the curve AUC = 0.81 AUC = 0.86
SD = 0.044 SD = 0.038
366
References
Araya R, Wynn R, Lewis G (1992) Comparison of two self ad-
ministered psychiatric questionnaires (GHQ-12 and SRQ-20) in
primary care in Chile. Soc Psychiatry Psychiatr Epidemiol 27:
168±173
Davies-Osterkamp S, Strauss BM, Schmitz N (1996) Interpersonal
problems as predictors of symptom related treatment outcome
in long-term psychotherapy. Psychother Res 6: 164±176
Derogatis LR (1977) SCL-90-R, administration, scoring, and
procedures manual for the R(evised) version. Johns Hopkins
University, School of Medicine, Baltimore
Erdreich LS, Lee ET (1981) Use of Relative Operating Charac-
teristic analysis in epidemiology. Am J Epidemiol 114: 649±662
Franke GH (1995) SCL-90-R: Die Symptom-Check-Liste von De-
rogatis ± Deutsche Version. Beltz Test Gesellschaft, GoÈttingen
Franz M, Schmitz N, Tress W (1997) MoÈglichkeiten zur emp-
irischen Erfassung des Schweregrades psychogener Erkran-
kungen. Prax Klin Verhaltensmed Rehabil 37: 7±12
Goldberg D (1972) Detecting psychiatric illness by questionnaire.
Oxford University Press, Oxford
Goldberg D, Williams P (1991) A user's guide to the General
Health Questionnaire. NFER-Nelson, Windsor
Gureje O, Obikoye B (1990) The GHQ as a screening tool in a
primary care setting. Soc Psychiatry Psychiatr Epidemiol 25:
276±280
Gureje O (1991) Reliability and the factor structure of the Yoruba
version of the 12-item General Health Questionnaire. Acta
Psychiatr Scand 84: 125±129
Horowitz LM, Inouye D, Seigelman EY (1979) On averaging
judges' rating to increase their correlation with an external
criterion. J Consult Clin Psychol 47: 453±458
Joukamaa M, Lethinen V, Karlsson H (1995) The ability of general
practitioners to detect mental disorders in primary health care.
Acta Psychiatr Scand 91: 52±56
Katzelnick DJ, Kobak KA, Greist JH, Je€erson JW, Henk HJ
(1997) Depression among high utilization patients: e€ect of
identi®cation and primary care treatment on service utilization,
disability, and quality of life. Psychiatr Serv 48: 59±64
Koeter MWJ (1992) Validity of the GHQ and SCL anxiety and de-
pression scales: a comparative study. J A€ect Disord 24: 271±280
Linden M, Maier W, Achberger M, Herr R, Helmchen H, Benkert
O (1996) Psychological disorders and their treatment in general
praxis in Germany. Results of a World Health Organization
(WHO) study. Nervenarzt 67: 205±215
Lykouras L, Adrachta D, Kalfakis N, et al (1996) GHQ-28 as an
aid to detect mental disorders in neurological inpatients. Acta
Psychiatr Scand 93: 212±216
View publication stats
Manderscheid RW, Rae DS, Narrow WE, Locke BZ, Regier DA
(1993) Congruence of service utilization estimates from the
epidemiologic catchment area project and other sources. Arch
Gen Psychiatry 50: 108±114
Mari JJ, Williams P (1985) A comparison of the validity of two
psychiatric screening questionnaires (GHQ-12 and SRQ-20) in
Brazil, using Relative Operating Characteristic (ROC) analysis.
Psychol Med 15: 651±659
Metz CE, Wang PL, Kronman HB (1993) ROCFIT. Department
of Radiology and the Franklin McLean Memorial Research
Institute, University of Chicago
Sandanger I, Moum T, Ingebrigsten G, Dalgard OS, Sorensen T,
Bruusgaard D (1998) Concordance between symptom screening
and diagnostic procedure: the Hopkins Symptom Checklist-25
and the Composite International Diagnostic Interview I. Soc
Psychiatry Psychiatr Epidemiol 33: 345±354
Schach E, Schwartz FW, Kerek-Bodden HE (1989) EVaS-Studie-
Eine Erhebung uÈber die ambulante medizinische Versorgung in
der Bundesrepublik Deutschland. Deutscher AÈrzte Verlag,
Cologne
Schepank H (1995) Der BeeintraÈchtigungsschwerescore (BSS). Ein
Instrument zur Bestimmung der Schwere einer psychogenen
Erkrankung. Beltz Test Gesellschaft, GoÈttingen
Schmitz N, Davies-Osterkamp S (1997) Klinische und Statistische
Signi®kanz ± diskutiert am Beispiel der Symtom Check Liste
(SCL-90-R). Diagnostica 43: 80±96
Schneider D, Appleton L, Mdemore T (1979) A Reason for Visit
classi®cation for ambulatory care. Data evaluation and Meth-
ods Research 2 (78), National Center for Health Statistics,
Public Health Service. US Government Printing Oce, Wash-
ington D.C.
Spitzer RL, Williams JBW, Kroenke K, et al (1994) Utility of a
new procedure for diagnosing mental disorders in primary care.
JAMA 272: 1749±1756
Tiemens BG, Ormel J, Simon GE (1996) Occurence, recognition,
and outcome of psychological disorders in primary care. Am J
Psychiatry 153: 636±644
Tress W, Kruse J, Heckrath C, Schmitz N, Alberti L (1997) Psy-
chogene Erkrankungen in hausaÈrztlichen Praxen. Z Psychosom
Med 43: 211±232
Wittchen HU, Schramm E, Zaudig M, Spengler P, Rummler R,
Mombour W (1990) SKID-Strukturiertes Klinisches Interview
fuÈr DSM-III-R. Beltz, Weinheim
Witznitzer M, Verhulst FC, van den Brink W, et al (1992) De-
tecting psychopathology in young adults: the Young Adult Self
Report, the General Health Questionnaire and the Symptom
Checklist as screening instruments. Acta Psychiatr Scand 86:
32±37