Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard
Introduction
Screening for mental health is often required in clinical practice and research. Physicians are in an outstanding role to detect and manage psychiatric disorders; however, recognition of mental disorders by primary care providers is often unsatisfying (Borus et al., 1988, Ormel et al., 1991). Therefore, screening instruments are needed to improve detection rates. In addition, screening questionnaires can be used for research purposes to identify individuals with mental disorders whenever comprehensive interviews are too time consuming. Short tools serve as case finding instruments (Sartorius et al., 1993) or are used to control for mental health as an important variable or confounder.
The MHI-5 (Berwick et al., 1991) is a very brief questionnaire to assess mental health and consists of five items. This short instrument was derived from the 38-item Mental Health Inventory and is included in both versions of the Medical Outcome Study (MOS) questionnaires: MOS Short Form 20 (SF-20; Stewart et al., 1988) and MOS Short Form 36 (SF-36; Ware and Sherbourne, 1992). Extensive data on validity and reliability of the SF-36 are available, e.g. from the IQOLA (International Quality of Life Assessment) project (Ware and Gandek, 1998), but only a few studies have assessed the potential diagnostic properties of the MHI-5. In the original study, the MHI-5 proved to be as good as the more comprehensive and widely used General Health Questionnaire (GHQ; Goldberg and Blackwell, 1970) in detecting any DIS (Diagnostic Interview Schedule; Robins et al., 1985) disorder (Berwick et al., 1991). However, this study is restricted by a rather small final sample size (N=213) and the use of meanwhile superseded DSM-III (American Psychiatric Association, 1980) criteria. McCabe et al. (1996) compared the performance of the MHI-5 and the GHQ-12 (Goldberg and Williams, 1988) and found a high correlation between both instruments; however, no standardized psychiatric interview was used as a gold standard. Only one study has recommended a cut-off point for the MHI-5, which is essential for using the instrument in everyday routine in primary care: In HIV-seropositive outpatients, the MHI-5 performed best with a cut-off of 52 in detecting major depression (Holmes, 1998).
The aim of the present study was to test the validity of the MHI-5 for different DSM-IV (American Psychiatric Association, 1994) Axis I diagnoses in a general population sample. Because two items of the MHI-5 focus on symptoms of anxiety and the remainder on symptoms of mood disorders, it is hypothesized that the MHI-5 is less sensitive in diagnoses other than mood or anxiety disorders. Furthermore, different cut-off values will be tested.
Section snippets
Procedure
The general population sample consisted of individuals with German nationality, born between 1932 and 1978, representing the age group from 18 to 64, and not living in institutions. Participants were recruited from a random sample of the resident registration office files in Lübeck and 46 surrounding communities representing an area of approximately 50 km in diameter. In Germany, individuals are bound by law to be registered in these files within 4 weeks when moving to another place. Therefore,
Results
From 6447 addresses drawn from the office files, 618 (9.6%) were invalid because of various reasons: individual moved away or was not known in the household (506); unoccupied household (36); individual deceased (12); lived in an institution (19); did not have German nationality (23); or did not fulfill inclusion criteria for miscellaneous reasons (22). Of the remaining 5829 valid addresses, 665 (11.4%) individuals were not reachable during the study period, 83 (1.4%) did not participate because
Discussion
This is the first study examining the validity of the MHI-5 in a general population sample and providing DSM-IV-Axis I diagnoses as a gold standard. The data show that the performance of the MHI-5 is rather unsatisfying in identifying the group having any common Axis I disorder. The MHI-5 had an AUC of 0.72 in this study, whereas the 12-item General Health Questionnaire (GHQ-12), for example, showed an average AUC of 0.88 in 15 centers of general health care (Goldberg et al., 1997). Comparing
Acknowledgements
This study was supported by German Ministry of Education and Research grant 01 EB 9406. Data are part of the German research network ‘Analytical Epidemiology of Substance Abuse (ANEPSA)’. Factors related to the use and abuse of psychoactive substances are analyzed by different research groups in the context of several longitudinal studies. For details, see ANEPSA Research Group (1998). Contact persons are: G. Bühringer/H. Küfner (IFT Institute for Therapy Research, Munich), H.U. Wittchen/R.
References (36)
- et al.
Primary health care providers’ recognition and diagnosis of mental disorders in their patients
General Hospital Psychiatry
(1988) German translation and psychometric testing of the SF-36 Health Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment
Social Science and Medicine
(1995)- et al.
The Diagnostic Interview Schedule
- et al.
Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project
Journal of Clinical Epidemiology
(1998) Reliability and validity studies of the WHO-Composite International Diagnostic Interview (CIDI): a critical review
Journal of Psychiatric Research
(1994)Ethical principles of psychologists and code of conduct
(1992)- et al.
The psychometric properties of the Composite International Diagnostic Interview
Social Psychiatry and Psychiatric Epidemiology
(1998) German research network ‘Analytical Epidemiology of Substance Abuse’ (ANEPSA)
European Addiction Research
(1998)