Richard Gater

The validity of two versions of the GHQ in the WHO study of mental illness in general health care

BACKGROUND In recent years the 12-item General Health Questionnaire (GHQ-12) has been extensively 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 International 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.

Somatic Symptoms of Distress: An International Primary Care Study

The objective of this study was to examine cross-national differences in somatic symptoms associated with psychological distress. Data from the World Health Organization (WHO) collaborative study of psychological problems in general health care (5438 patients at 15 sites) were used to examine somatic symptoms associated with psychological distress. At each site, a stratified random sample of consecutive primary care patients completed the 28-item General Health Questionnaire (GHQ) and the Composite International Diagnostic Interview (CIDI). At all sites, the number of current CIDI somatic symptoms (whether medically explained or not) was strongly associated with current psychological distress (measured by selected GHQ-28 items). Pearson correlation of somatic symptom count with psychological distress score was.42 for all sites and ranged from.20 to.58 (p <.0001 at all sites). Across all sites, anxiety and depressive symptoms showed roughly the same association with somatic symptom counts, and specific somatic symptoms or symptom clusters did not show differential association with anxiety or depression. Although somatic symptoms did cluster into meaningful groups (gastrointestinal, neurological/conversion, autonomic, and musculoskeletal), these symptom groups did not show differential association with psychological distress. Examination of individual somatic symptoms and symptom clusters across sites did not reveal clear patterns of association according to geography or level of economic development. These data show a strong association between somatic symptoms and psychological distress, which did not vary across disparate cultures and levels of economic development. Cultural factors, however, may influence the meaning attached to symptoms or the likelihood of presentation for health care.

Determinants of subjective quality of life in patients attending community-based mental health services. The South-Verona Outcome Project 5

Objective: Investigate the relationship of various domains of quality of life (QoL) with socio‐demographics, clinical and social characteristics, service use and satisfaction in a representative sample of patients in contact with the South‐Verona community mental health service.

Is the lifetime risk of depression actually increasing

Data from an international study of psychological problems in primary care were examined for evidence of increasing depression risk. At 15 sites, patients aged 15-65 (n = 26,421) were screened with the GHQ-12 and a stratified random sample (n = 5603) selected for psychiatric assessment (Composite International Diagnostic Interview). Initial analyses agreed with earlier cross-sectional studies, finding higher depression risk and earlier onset in recent birth cohorts. Additional analyses suggested that methods effects may explain these findings. First, apparent prevalence increases were nonspecific with similar trends seen across all study sites and for all disorders examined. Second, reporting patterns suggested significant under-counting of past depressive episodes. Respondents of all ages typically reported first onset of depression during the last 5 years. Reported lifetime prevalence was only 2.02 times current prevalence. These findings suggest that depression risk is not rapidly increasing and that true lifetime prevalence is much higher than estimated by cross-sectional surveys.

Social factors associated with chronic depression among a population-based sample of women in rural Pakistan.

Previous studies have reported a high prevalence of depression in women in Pakistan. This paper investigates whether risk factors for chronic depression established in studies performed in Western countries can explain this high prevalence. A two–phase survey using the self–rating questionnaire (SRQ) for common mental disorders and the Psychiatric Assessment Schedule was performed on a general population sample in rural Pakistan. Demographic data and results of the Life Events and Difficulties Schedule were analysed in relation to SRQ score and psychiatric disorder. A total of 145 women were screened. High SRQ score was associated with low educational status, not having a confidant, having four or more children, being older, not being married and living in a house with more than three people per room. Regression analysis demonstrated that the first three of these independently contributed to SRQ score. In the interviewed sample (74 women), only educational level independently contributed to the presence of depression. In addition, the least educated group experienced the greatest number of marked difficulties: 67% of them had experienced both marked housing and financial difficulties compared to 28% and 25% of the other educational groups (p = 0.005). Experiencing both housing and financial difficulties was a significant risk factor for depression in women with secondary education, but not for those without secondary education. This study suggests that high levels of social adversity and low levels of education are strongly associated with depression in women in Pakistan. The other vulnerability factors found in the West (such as lack of a confidant, the presence of three or more young children at home, or loss of mother during childhood) may be of lesser importance in this population.

The treatment of common mental disorders by a community team based in primary care: a cost-effectiveness study

Thirty patients suffering from new episodes of depression or anxiety disorders seen by a hospital-based psychiatric service were matched for severity of illness with 30 patients seen by a community mental health team based upon primary care. These patients were drawn from a total of 108 such patients seen in the community and 57 seen by the hospital service. Clinical and social outcomes were similar in both groups, and neither was clearly superior in terms of quality of clinical information recorded. However, patients treated in the community were seen more quickly, had more continuity of care and were more satisfied with the service. Health services costs were less for those patients treated in the community, because patients were less likely to be admitted. With one atypical patient excluded, treatment by the community team is more cost effective. The greater number of patients seen by the primary-care-based service means that there is no overall cost saving to the NHS.

Pathways to psychiatric care in Ankara

This paper describes the pathways that patients take to reach psychiatric services in Ankara. A total of 582 patients were seen in a calendar month in seven centres, two of them being child psychiatric clinics. The pathway in Ankara, unlike many other centres in Europe, is dominated by direct referrals. Only 4% of patients in our sample contacted their general practitioner (GP) first, compared with 42% who first saw hospital doctors and 53% who came direct. Religious healers appeared in the pathway of only 1% of patients, and the delay associated with them was longer. Male patients had longer delays than female patients, and delays were also longer for patients presenting with somatic symptoms. Although the availability of psychiatric services is limited, the median time taken to be seen by the psychiatric services after contacting any carer was only 1 week. The results showed that the referral system for the mental health services is still far from a GP-based system. The patients presenting with somatic symptoms consulted hospital doctors more frequently and were delayed more, pointing to the need for the training of hospital doctors, in addition to GPs, in the recognition and management of common psychiatric disorders.

Social intervention for British Pakistani women with depression: randomised controlled trial.

BACKGROUND British Pakistani women have a high prevalence of depression. There are no reported psychosocial interventions for depression in ethnic minorities in the UK. AIMS To determine the efficacy of a social group intervention compared with antidepressants, and whether the combination of the two is more efficacious than either alone. METHOD A total of 123 women with depression participated in the primary care-based cluster randomised controlled trial (ISRCTN19172148). Outcome measures were severity of depression (Hamilton Rating Scale for Depression), social functioning and satisfaction at 3 and 9 months. RESULTS Greater improvement in depression in the social intervention group and the combined treatment group compared with those receiving antidepressants alone fell short of significance. There was significantly greater improvement in social functioning in the social intervention and combined treatment groups than in the antidepressant group at both 3 and 9 months. CONCLUSIONS Pakistani women with depression found the social groups acceptable and their social function and satisfaction improved if they received social treatment compared with the receipt of antidepressants alone.

Matching resources to care: the acceptability, validity and inter-rater reliability of a new instrument to assess severe mental illness (MARC-1).

Background: Most definitions of severe mental illness (SMI) are categorical and assign the patient to either SMI or not-SMI status. While this is useful for some purposes, it is a rather limited approach. The purpose of the present study is to develop a new method of addressing the issue of ‘severity’, and to develop a dimensional rather than a categorical approach. The paper reports on the acceptability, reliability and validity of a method developed to collect a standard set of data covering the majority of items specified in the academic and policy literature as characterising SMI. Method: A single page form, Matching Resources to Care (MARC-1), containing most of the items used in definitions of SMI was used to collect data from community mental health staff about their current open caseload, in four co-terminous health and social services settings during a census week (n = 2139). In addition to the data from the four pilot sites, we conducted a sub-study (n = 91), in which two raters rated the same cases during the same week. Results: The MARC-1 scores were able to distinguish between patients in receipt, and those not in receipt, of specific types of community care (level of care, eligibility for care and statutory aftercare) (P < 0.001). The MARC-1 score was modestly but significantly correlated (r = 0.28) with the Global Assessment Scale (P < 0.001). The mean percentage inter-rater agreement for the MARC-1 score items was 87%. Conclusion: It is possible to use a simple census form in both health and social services agencies. The completion rates were good in both services. The levels of reliability were good, and concurrent validity was established with specific types of care in the community.

The role of engagement with services in compulsory admission of African/Caribbean patients.

High rates of compulsory admission of African/Caribbean patients have been reported. Several factors have been associated with this finding. The roles of some factors related to engagement with services have not been empirically evaluated. The aim of this study was to assess the role of engagement factors in compulsory admission of African/Caribbean patients. A systematic case-note review was made of the admission process of 100 compulsorily and 100 voluntarily admitted patients; each group containing 50 randomly selected African/Caribbean and White British patients. Information about socio-demographic and engagement factors was collected and the findings compared. Compulsorily admitted African/Caribbean patients had more factors indicative of poor engagement with services than patients in the other groups. Prior to admission, they were less likely to keep their appointments, comply with their medication, contact their GPs and were more likely to present late. Furthermore, they had more history of multiple compulsory admissions. The compulsorily admitted patients, irrespective of ethnicity, also engaged poorly with services. Poor engagement with primary care and secondary mental health services of African Caribbean patients appears to be contributing to their high rates of compulsory admission. This aspect of ethnic factors and compulsory admission requires further studies.