General Health Questionnaire-28 (GHQ-28)

Abstract

The General Health Questionnaire-28 (GHQ-28) is a widely utilized, self-administered screening instrument designed to detect non-psychotic psychiatric morbidity or psychological distress in the general population, primary care settings, and various epidemiological studies. Developed by David P. Goldberg, the GHQ-28 is a reduced, factor-analytically derived version of the original 60-item scale (GHQ-60). It measures the recent deterioration of mental health status over the preceding few weeks, focusing on the respondent’s current condition rather than long-standing traits. Its brevity and established psychometric properties make it an invaluable screening tool for identifying individuals who may require further clinical assessment.

Keywords

General Health Questionnaire, GHQ-28, psychological distress, non-psychotic morbidity, screening tool, primary care, mental health, David Goldberg, somatic symptoms, depression.

Authors

David P. Goldberg, Paul Williams

Purpose

The primary purpose of the GHQ-28 is to act as an initial screen for transient but clinically significant psychological distress. Unlike diagnostic tools, the GHQ-28 aims to identify individuals who are currently suffering from a mental disorder that is likely to be treatable and recognizable by healthcare professionals. It specifically measures the extent to which the respondent has experienced symptoms that deviate from their normal state of functioning within the past few weeks, making it highly sensitive to recent changes in mental well-being.

It is extensively used in large-scale epidemiological surveys to estimate the prevalence of minor psychiatric disorders and in general practice settings to flag patients whose physical complaints may mask underlying emotional or mental health issues. The instrument’s effectiveness stems from its focus on the inability to successfully carry out normal functions and the emergence of distressing symptoms.

Construct

The GHQ-28 measures general psychological well-being and distress, specifically targeting four main dimensions of psychological distress that constitute non-psychotic psychiatric morbidity. These dimensions were identified through factor analysis and represent distinct symptom clusters. The scale is designed to quantify the severity of these symptoms and the degree of associated functional impairment experienced by the individual.

The four underlying constructs measured by the GHQ-28 are:

• Somatic Symptoms: Measures physical complaints often associated with anxiety or stress (e.g., headaches, feeling run down).
• Anxiety and Insomnia: Captures feelings of tension, worry, panic, and sleep disturbances.
• Social Dysfunction: Assesses difficulties in coping with daily activities and loss of confidence or ability to enjoy normal life.
• Severe Depression: Focuses on depressive cognitions, feelings of worthlessness, hopelessness, and suicidal ideation.

Validity

The validity of the GHQ-28 has been robustly established across numerous cross-cultural studies. It demonstrates strong criterion validity, showing high correlation with clinical psychiatric diagnoses established via structured interviews. Studies, including those conducted as part of the World Health Organization (WHO) investigations into mental illness in general health care, have confirmed its ability to accurately distinguish between clinical cases and non-cases in primary care settings.

The instrument possesses excellent concurrent validity, consistently correlating highly with other established measures of psychological distress and anxiety. Its structure, derived through factor analysis, supports its construct validity by demonstrating that the items reliably group into the intended four subscales, reflecting distinct, though often co-occurring, dimensions of psychiatric morbidity.

Reliability

The GHQ-28 is known for its high internal consistency, with Cronbach’s alpha coefficients typically ranging from 0.85 to 0.95 across various populations, indicating that the items reliably measure a shared underlying construct of psychological distress. The internal reliability holds strong both for the total score and for the individual factor subscales, although the reliability of the Social Dysfunction subscale is sometimes reported to be slightly lower.

Furthermore, the scale exhibits acceptable test-retest reliability over short intervals (e.g., 2–4 weeks), confirming its stability as a measure of current mental state. However, as it is designed to measure transient, current distress, lower test-retest reliability over longer periods is expected, reflecting genuine changes in the respondent’s psychological condition over time.

Factor Analysis

Factor analysis of the 28 items consistently supports a four-factor structure, which was the basis for its derivation from the longer GHQ versions. This structure provides subscale scores that are clinically meaningful and allow researchers to pinpoint specific areas of distress beyond a single global score.

The four factors, each consisting of seven items, are organized as follows:

• Factor I: Somatic Symptoms (Items 1–7): Focuses on physical manifestations of distress.
• Factor II: Anxiety and Insomnia (Items 8–14): Captures generalized anxiety and sleep difficulties.
• Factor III: Social Dysfunction (Items 15–21): Relates to difficulties in personal functioning and daily coping.
• Factor IV: Severe Depression (Items 22–28): Addresses symptoms characteristic of more profound depressive states, including suicidal thoughts.

Instrument

Test Type: Self-report screening instrument for non-psychotic psychiatric morbidity.

Format: 28 items, typically scored using a 4-point Likert scale, resulting in a total score ranging from 0 to 28 (GHQ method 0-0-1-1) or 0 to 84 (standard Likert 0-1-2-3). The GHQ method is preferred for screening cutoff determination.

Language Available: Widely translated and validated in dozens of languages globally, reflecting its use in WHO studies.

Population Group: General population, patients in primary care and general medical settings, and adolescents/adults in epidemiological research.

Age Group: Typically utilized for adolescents (16+) and adults.

Population Details: Suitable for use across various cultural and socioeconomic backgrounds, though specific cutoff points may need adjustment based on population prevalence rates.

Test Methodology: Administered via paper-and-pencil or digital formats; completion time is usually 5–10 minutes. Scoring involves summing the values assigned to the chosen responses, with higher scores indicating greater psychological distress.

Keywords

Psychometric scale, epidemiological tool, mental health screening, somatic symptoms, anxiety, social dysfunction, depression, Goldberg, primary care.

Authors

Author ORCID Identifier: Not provided in source content.

Affiliation Email addresses: Not provided in source content.

Correspondence Address: Not provided in source content.

Permissions & Fee and Test Year

The GHQ scales are proprietary, and permissions for use, especially in large-scale commercial or academic research, are typically managed by the original publishers (e.g., NFER-Nelson Publishing Company Ltd. or distributed through various test agencies). Fees usually apply for professional use. The original GHQ was developed in the early 1970s, and the GHQ-28 form was established and widely published thereafter, with key validation work continuing through the 1990s.

Reference’s

• Goldberg DP, Williams P. A User’s Guide to the General Health Questionnaire. Berkshire: NFER-Nelson Publishing Company Ltd.; 1991.
• Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureye O, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997; 27: 191–7.
• The instrument was utilized in the study, “RESILIENCE AGAINST DEATH ANXIETY IN RELATIONSHIP TO POST-TRAUMATIC STRESS DISORDER AND PSYCHIATRIC CO-MORBIDITY.” The original PDF can be downloaded here: http://pearl.plymouth.ac.uk/pearl_jspui/bitstream/10026.1/306/4/Hoelterhoff%20M%20E_2010.pdf

Items of the General Health Questionnaire-28 (GHQ-28)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

HAVE YOU RECENTLY:

1. Been feeling perfectly well and in good health?
2. Been feeling in need of a good tonic?
3. Been feeling run down and out of sorts?
4. Felt that you are ill?
5. Been getting any pains in your head?
6. Been getting a feeling of tightness or pressure in your head?
7. Been ha‎ving hot or cold spells?
8. Lost much sleep over worry?
9. Had difficulty in staying asleep once you are off?
10. Felt constantly under strain?
11. Been getting edgy and bad-tempered?
12. Been getting scared or panicky for no good reason?
13. Found everything getting on top of you?
14. Been feeling nervous and strung-up all the time?
15. Been managing to keep yourself busy and occupied?
16. Been taking longer over the things you do?
17. Felt on the whole you were doing things well?
18. Been satisfied with the way you’ve carried out your task?
19. Felt that you are playing a useful part in things?
20. Felt capable of making decisions about things?
21. Been able to enjoy your normal day-to-day activities?
22. Been thinking of yourself as a worthless person?
23. Felt that life is entirely hopeless?
24. Felt that life isn’t worth living?
25. Thought of the possibility that you might make away with yourself?
26. Found at times you couldn’t do anything because your nerves were too bad?
27. Found yourself wishing you were dead and away from it all?
28. Found that the idea of taking your own life kept coming into your mind?

Response Format: 1-not at all‚ 2-no more than usual‚ 3-rather more than usual‚ 4- much more than usual