Soc Psychiatry Psychiatr Epidemiol (2000) 35: 248±254
ORIGINAL PAPER
K. Bhui á D. Bhugra á D. Goldberg
Cross-cultural validity of the Amritsar Depression Inventory
and the General Health Questionnaire amongst English
and Punjabi primary care attenders
Accepted: 21 January 2000
Abstract Background: In order to estimate the health
needs of cultural groups, the cross-cultural validity of
instruments requires investigation in distinct cultural
rather than ethnic or racial groups. Method: We
screened `Punjabi' and `English' primary care attenders
in South London (UK), using the General Health
Questionnaire (GHQ-12), an English origin instrument,
and the Amritsar Depression Inventory (ADI), which
was developed in the Punjab in India. The criterion
measure was the Clinical Interview Schedule (CIS-R).
We calculated the validity coecients, optimal thresh-
olds and the area under the `Receive Operating Char-
acteristic' curve to compare cross-cultural performance.
We identi®ed items on each questionnaire that contrib-
ute to performance of the instruments. Results: The
GHQ-12 has high validity coecients in both cultural
groups. The ADI performs as well amongst English
subjects, but among Punjabis it is poorer than the GHQ-
12. Among Punjabis who have been resident in the UK
for over 30 years, the ADI performs no better than
chance. Few items on the ADI or the GHQ are strongly
predictive of case status. Conclusions: The GHQ-12
shows good validity in both cultures. Expressions of
distress may change due to acculturation. `Culturally
sensitive' screening instruments need to re¯ect this.
Further work might attend to the changing expressions
of distress following migration.
Introduction
General practitioners (GPs) in the UK less often detect,
treat or o€er a specialist referral for common mental
disorder among `Asians' (Indian, Bangladeshi, and
K. Bhui (&) á D. Bhugra á D. Goldberg
Institute of Psychiatry, De Crespigny Park,
London SE5 8AF, UK
e-mail: K.S.Bhui@mds.qmw.ac.uk
Ó Steinkop€-Verlag 2000
Pakistani; Commander et al. 1997). `Asians' are re-
ported to repeatedly present to their GPs with physical
complaints (Gillam et al. 1980); even if psychological
complaints are presented, `Asians' more often receive a
physical diagnosis (Wilson and McCarthy 1994). The
routine use of cross-culturally validated screening in-
struments might signi®cantly improve GPs detection of
common mental disorders. Diculties in accurately de-
tecting disorders include the questionable sensitivity of
existing Euro-American instruments, cultural di€erences
in concepts of mental health that are at variance with
psychiatric nosology, and the aggregation of culturally
distinct social groups into `apparently' similar ethnic
and racial groups (Helman 1990; Nazroo 1997; Singh
1997). Although much work examines the use of British
and American screening instruments amongst samples
from the Indian subcontinent, it is unusual for epide-
miological instruments developed entirely in India to be
used in the UK and for comparisons to be made of their
validity amongst British samples of `British' and `Asian'
general practice attenders. We compare the performance
of two instruments where their cultural origins were
concordant and discordant to the culture of English and
Punjabi primary care attenders. We emphasise the use of
cultural groups rather than aggregated ethnic groups.
Subjects and methods
General practices and subjects
The subjects were attenders of ®ve general practices in a single
London electoral ward that includes signi®cant numbers of resident
Punjabi-Asian and White-English people. Consecutive subjects
were approached if, on arrival for their doctor's appointment, they
were of White-European or Asian-Indian sub-continent appear-
ance. The ®rst phase included a cultural screen. The Punjabis af-
®rmed themselves to be of Punjabi cultural origin and of a family
originally from the Indian subcontinent.
Punjabis form a well-circumscribed cultural group with com-
mon language, music, foods, dress and homeland. Punjabis can
however be Hindu, Muslim or Sikh, but all share Punjabi as a
language. The English group were those who were white, English

speaking and identi®ed themselves to be of English identity. Any-
one who was uncertain about their identity or who was from an-
other cultural group (for example, Scottish, Irish, Gujarati or
Bangladeshi origin) was excluded. Patients with learning dicul-
ties, severe hearing impairment, or a psychosis were also excluded.
Instruments
The General Health Questionnaire (GHQ-12) is a 12-item ques-
tionnaire that has been used extensively in the detection of non-
psychotic morbidity in many cultural contexts (Goldberg et al.
1997), but it has been criticised for under-detection of disorders in
some demographic groups (Lewis and Araya 1995; Williams and
Hunt 1997). The Amritsar Depression Inventory (ADI) is a 30-item
(yes/no) questionnaire, which was developed in the Punjab (Singh
et al. 1974) from 50 statements that are commonly used expressions
among Punjabi patients with depressive states. Patients were re-
cruited from outpatient clinics over a 5-year period. Commonly
described signs and symptoms of depression in the psychiatric lit-
erature and commonly used `illness statements' were also included.
The questions were suitable for uneducated rural workers as well as
literate groups. The developing questionnaire was administered to
75 patients, of whom 25 had severe depression, 25 had reactive
depression and 25 had an anxiety disorder; 25 normals were also
added. The 30 items of the ADI di€erentiated patients with `de-
pression and anxiety' from those with no disorder. The construct
validity using a psychiatrist's clinical diagnosis was 0.75, and the
reliability was 0.82.
The Clinical Interview Schedule (Revised; CIS-R) is a standard
semi-structured interview to assess non-psychotic disorders. It is
suitable for use by lay interviewers, as it minimises observer bias
(Lewis and Pelosi 1990). The `category fallacy argument' criticises
the application of diagnostic nosological categorisation developed
in one cultural group to members of another culture (Kleinman
1980; Littlewood 1990). We used the CIS-R total symptom score,
and individual symptom scores, to measure morbidity. This as-
sumes that symptoms rather than diagnostic groups are universally
associated with common non-psychotic mental disorders (Jacob
et al. 1998a; Nazroo 1997).
Questionnaire design and preparation
All the questionnaires were translated and back translated by two
bilingual psychiatrists and a social services worker in order to
achieve direct and conceptual equivalence with minimum alteration
to the structure of the sentence. The questionnaires were piloted in
two practices and discussed with a local Asian voluntary organi-
sation worker/user, a Punjabi bilingual local social services worker,
and a few members of the public. This ensured the translations
were understandable and sought only necessary information. Psy-
chologically `threatening' questions were asked after giving assur-
ance of con®dentiality, asking about demographics and asking
about physical ill-health; one ADI question about sexual function
was omitted after objections to this question in pilot studies. The
order of the two screens was reversed half way through the survey.
Interview procedure and sampling strategy
All questionnaires related to the preceding 7 days; they were read
out to subjects but completed by the research interviewer. Inter-
views were conducted in English, Punjabi or a mixture of the two
depending on the subject's preference. A two-phase sampling
procedure was used to maximise eciency of data collection
(Newman et al. 1990; Pickles et al. 1995). The ®rst phase included
®xed choice questions about cultural identity, demographics and
the two screening instruments: the General Health Questionnaire
(12 items) and the Amritsar Depression Inventory (29 items;
Goldberg 1972; Singh et al. 1974). Those scoring 2 or more on the
GHQ or 5 or more on the ADI proceeded to the second phase
249
interviews. These were `probable cases'. One-third of those who
scored less than 2 on the GHQ and less than 5 on the ADI
(`probable non-cases') also proceeded to the second phase. Two
research assistants helped with the ®rst stage. One of them was
Punjabi, and spoke Punjabi and English, and completed interviews
in Punjabi. The other was Asian, but not Punjabi, and so com-
pleted only English interviews. The two assistants helped for up to
one-®fth of the weekly surgery time. The majority of the ®rst stage
and all the second stage interviews were conducted by a single
bilingual psychiatrist (K.B.). Smoking habits, alcohol use, medi-
cation and physical illnesses were identi®ed in the second phase; the
CIS-R was completed in the second phase.
Statistical analysis
Data analysis was conducted using SPSS 6.0 and STATA 5.0. The
expansion weights used were the reciprocals of the sampling frac-
tions. The conventional threshold value to de®ne cases on the CIS-
R is 11/12, and unless speci®ed otherwise, `case' and `caseness' refer
to this threshold de®nition. The performance of the ADI may vary
with the severity of the disorder as de®ned along a continuum of
the CIS-R score. Consequently, we also examined the CIS-R
thresholds that de®ne the 25th, 50th, and 75th percentile cut-points
for the distribution of CIS-R scores. Stratum-speci®c estimates of
performance overcome the shortfalls of applying a ®xed threshold.
These strata were de®ned by thresholds of 4/5, 11/12 and 21/22,
which are the quartile thresholds. The 50th centile threshold was
the same as the conventional CIS-R threshold. The centile points
did not di€er by more than one CIS-R point for each cultural
group, hence the overall centile points were adopted.
Data on both GHQ-12 and ADI for all screened subjects was
available to investigate the split-half reliability of the GHQ-12 and
the ADI, correlation between the forms (split-half) and Cronbach's
a (standardised). The validity coecients and the `Area Under the
Receiver Operating Characteristic Curve' (AUC) were calculated
using STATA 5.0. The AUC is a measure of the performance of a
screening test (see Mari and Williams 1985; Swets and Pickett
1982). An AUC of 0.5 indicates that the screen performs no better
than chance, and the better the performance the nearer the AUC is
to 1.0. The AUC is calculated for all possible threshold values of
the GHQ-12 and ADI for any one case de®ning threshold value on
the CIS-R. Optimal threshold values are then identi®ed, and
comparisons made of the validity coecients for the GHQ and the
ADI when concordant and discordant with the cultural origins of
the sample. The di€erence between the areas under the ROC curves
were calculated using the ROC Curve Analyser programme. We
also examined the strength of the association of each of the GHQ
and ADI items with caseness on the CIS-R (11/12) using weighted
multiple logistic regression. Data for items that were associated
with case status at a P-value of less than 0.1 are presented.
Results
Sample characteristics
Of 561 individuals eligible for inclusion, 58 (10.4%) re-
fused to participate either at the ®rst or second stage.
Hence a total of 209 Punjabis and 185 English attenders
completed the second stage, of which 36 and 27 re-
spectively were `probable non-cases'. There were no
di€erences in age distribution, marital status, gender,
religion, accommodation, occupation, social class or
source general practice between refusers and non-refus-
ers. Completers had a signi®cantly lower GHQ score
(mean: refusers 4.28 vs completers 3.00, F = 5.05
df = 1, 539, P = 0.03), but similar ADI scores as
250
refusers (refusers 9.12 vs completers 8.76, df 1, 538
F = 0.05, P = 0.83). There were no age di€erences
between the two cultural groups (English mean age:
46.0 years vs Punjabi mean age: 45.5 years; t = 0.26,
df = 392, P = 0.79). Punjabis born outside the UK
(n = 174) had lived in the UK for an average of 24.3
years (range 1±43 years). Age at migration was not as-
sociated with a caseness rating on the CIS-R [mean age
at migration (SE) for non cases: 23.3 (1.05) years vs
cases: 25.5 (0.84) years; t = )1.60, P = 0.11]. Of
Punjabi subjects, 90 chose to complete interviews in
English, 108 preferred Punjabi and 11 used a mixture of
English and Punjabi.
Ethnic and cultural characteristics
Ninety-seven percent (181/185) of English and 15.8%
(33/209) of Punjabi subjects were born in the UK, while
7.7% of Punjabis were born in Pakistan, 62.4% in India,
12.9% in Africa and 1.4% in other countries. In terms of
ethnic origin, 60.8% of Punjabis classi®ed themselves as
Asian Indian, 7.7% as Asian Pakistani, 23.4% as Asian
British, 1.9% as Asian African and 6.2% as `other'.
Among English subjects, 99% were of White UK ethnic
origin. Among Punjabis, 85% were Sikh, 8.1% were
Muslim, 6.2% were Hindu, and 0.5% were Christian.
Sixty-®ve percent of English subjects were Christian and
29% had no religious aliation, with the remainder
having `other' religious beliefs.
Punjabis were less often in the ®fth age pentile (61.3-
to 85.9-year-old group; OR = 0.31, 95% CI = 0.15±
0.66, P = 0.002). There were no gender ratio di€erences
across cultural groups (OR = 0.91, 95% CI = 0.58±
1.42, P = 0.68). Punjabis were more often married
(OR = 3.4, 95% CI = 1.83±1.42, P < 0.001). Punjabis
were less often in rented accommodation (local author-
ity: OR = 0.2, 95% CI = 0.11±0.35, P < 0.001;
private rented: OR = 0.1, 95% CI = 0.04±0.26,
P < 0.001), less likely to be unemployed (OR = 0.25,
95% CI = 0.1±0.26, P = 0.002) and less likely to be
retired (OR = 0.17, 95% CI = 0.08±0.35, P < 0.001).
There were no cultural di€erences in social class distri-
butions or in the number of body systems a€ected by a
physical illness.
Reliability
The Guttman split-half reliability was the same for both
cultural groups. It was 0.92 for ADI scores, and for GHQ
scores it was 0.87. The correlation between forms (split-
half ADI) was 0.85 and 0.86 among Punjabi and English
subjects respectively. The same statistic using GHQ
scores was 0.77 for both Punjabi and English subjects.
Finally Cronbach's a (standardised) using ADI scores
was 0.92 (0.93) and 0.91 (0.92) among Punjabi and En-
glish subjects respectively. The same statistic for GHQ
scores was 0.87 (0.88) for Punjabi and English subjects.
Face, content and conceptual validity of the ADI
These observations were made during piloting of the
questionnaires and during the study. The content of the
questionnaires was meaningful, and there were few items
that created diculties of understanding; the items
seemed appropriate to tap experiences of common
mental disorders (content validity). Subjects in both
cultural groups readily identi®ed that the questions re-
lated to distress, depression, illness, and disabilities.
Subjects often advanced that the questions were `de-
pressing', whilst also expressing concern that some in-
dividuals su€ered with such feelings. The underlying
constructs appeared to be the same, but one can not
assume this, as illustrated by the following observations.
The absence of interpersonal a€ection (an ADI item)
might be part of a depressive picture in Punjabis but not
among all English subjects. Or at least, if present, this is
not a common expression of depressive feelings in the
English language. Feelings of inferiority (a GHQ item)
seems depressive in English subjects, but among some
Punjabis these were regarded as expressions of humility
and to be a desirable way of relating. Most items on the
instruments such as sleep loss, worry, panic, hopeless-
ness, depressive feelings, suicidal ideas all made sense in
both cultures and were identi®ed as part of the response
to distress and speci®cally depression. Nonetheless, even
where items were not readily identi®ed as being linked to
a common mental disorder, the disability that the item
tapped was recognised by subjects as a possible con-
comitant of mental distress.
Validity coecients and Area under ROC Curve
The sensitivity and speci®city data are presented in
Table 1. Firstly, using the conventional CIS-R threshold
of 11/12 to de®ne caseness, the optimal threshold value
for the GHQ is the same amongst Punjabis and English
subjects, namely 2/3. However, the optimal threshold for
the ADI di€ers across cultures: 6/7 for English subjects
and 11/12 for Punjabis. Signi®cant ®ndings are that on
using the ADI, the AUC amongst Punjabis (0.78) is
signi®cantly less than that for English subjects (0.87;
P = 0.01). Unexpectedly, this indicates the ADI to be a
poorer case detector amongst Punjabis. Amongst Pun-
jabis the GHQ is a better case detector (AUC = 0.88)
than the ADI (AUC = 0.78; P < 0.01).
In order to explore how exposure to English culture
might in¯uence the validity of the ADI amongst Pun-
jabis, we examined validity coecients for subgroups of
Punjabi patients. Those who were interviewed in English
(AUC = 0.79; Sens = 67.84%; Spec = 78.79%), those
who preferred an interview in Punjabi (AUC = 0.73;
Sens = 65.83%; Spec = 71.45%), those born in the
UK (AUC = 0.75; Sens = 37.18%; Spec = 88.16%),
those born outside the UK (AUC = 0.74;
Sens = 42.58%; Spec = 89.37%), those who had ar-
rived in the UK less than 19 years ago (AUC = 0.71;
 251

Table 1 Validity coecients for the 12-item General Health Questionnaire (GHQ-12) and Amritsar Depression Inventory (ADI) at
di€erent thresholds of the Clinical Interview Schedule (CIS) (PPV Positive predictive validity, NPV Negative predictive validity,
AUC Area Under Receiver Operating Characteristic Curve)

CIS Instrument Culture Best Sensitivity Speci®city PPV NPV % correct AUC
threshold threshold

4/5 GHQ-12 English 1/2 66.54 80.92 85.83 58.2 71.79 0.74
Punjabi 1/2 74.06 75.9 86.5 58.38 74.65 0.75
ADI English 4/5 69.13 88.78 91.45 62.34 76.3 0.79
Punjabi 6/7 79.03 64.0 81.5 56.14 72.13 0.70
11/12 GHQ-12 English 2/3 74.19 80.00 69.00 83.78 77.82 0.84
Punjabi 2/3 78.10 77.55 71.30 83.21 81.75 0.88
ADI English 6/7 72.04 87.18 74.68 83.95 81.53 0.87
Punjabi 11/12 70.19 72.79 62.93 77.54 71.71 0.78
21/22 GHQ-12 English 4/5 68.89 86.93 54.39 92.51 83.60 0.78
Punjabi 6/7 67.34 86.63 54.03 91.93 82.99 0.77
ADI English 9/10 75.56 85.42 53.97 93.92 83.6 0.81
Punjabi 18/19 60.87 89.36 58.33 90.78 84.33 0.75

Sens = 20%; Spec = 94.3%) and those who had lived about the validity of the ADI among this Punjabi
in the UK for over 30 years (AUC = 0.57; Sens: sample.
38.54%; Spec: 72.18%). None of these coecients in-
dicate better validity of the ADI. However, the ADI was
no better than chance among Punjabis who had been Discussion
resident in the country for over 30 years.
Methodological limitations

Validity of the instruments for di€ering severity
of disorder
The prevalence of common mental disorders, using the
conventional threshold of 11/12 for the CIS-R, is the
same in each cultural group (Bhui et al. 1999). There-
fore, the variable thresholds are not accounted for by
prevalence variations. We wished to investigate whether
the performance of an instrument was di€erent across
cultures at di€erent severities of disorder. For more
severe disorders (higher CIS-R threshold), the optimal
threshold on the GHQ is higher among Punjabi than
English subjects. For less severe disorders (CIS-R
threshold of 4/5) the optimal GHQ threshold is the
same in both cultural groups. However, the ADI
threshold consistently di€ers between the two cultures
at all levels of severity. Punjabis consistently require a
higher threshold, and the more severe the morbidity
(higher CIS-R threshold), the greater is the di€erence
between the optimal threshold for Punjabis and English
subjects.
The survey was conducted on consecutive attenders in
primary care, and hence the ®ndings are not necessarily
generalisable to population samples of Punjabis and
English subjects. A common complication in research
exploring the cultural expression of distress is the ag-
gregation of distinct cultural groups into ethnic or even
racial groups (Singh 1997). Black/white di€erences are
still reported in psychiatric literature, giving rise to ra-
cially based interpretation of research ®ndings rather
than cultural interpretations. We addressed this by
studying discrete cultural groups. Those with more ill-
ness (on the GHQ) were less likely to participate, per-
haps leading to a sampling bias towards lower GHQ
scores. The Clinical Interview Schedule (CIS-R; Lewis
and Pelosi 1990) has stable psychometric properties and
its semi-structured nature eliminates observer bias.
However, well-known instruments (in this instance the
GHQ and the CIS-R) may consistently be at variance
with `culturally sensitive' instruments (ADI).
Explaining the ®ndings

ADI and GHQ items and their association
with CIS-R case status (11/12)
The items that independently predict caseness on the
CIS-R (threshold of 11/12) are distinct for each cultural
group (see Table 2). Only three items are important case
predictors in both cultural groups: Feel unhappy most of
the time, Lost much sleep over worry, and Felt con-
stantly under strain. Only three items of the ADI were
predictive of case status among Punjabis, raising doubts
There are four possible explanations for our ®ndings.
Firstly, one might consider that the development of the
ADI was not as rigorous as that of the GHQ. However,
both screening instruments perform well amongst En-
glish subjects, suggesting that the ADI is not simply a
poor instrument but, unlike the GHQ-12, its perfor-
mance is not culturally invariant. A second possibility is
that the ADI may be a good instrument amongst Pun-
jabis in the Punjab, but not Punjabis living in the UK.
This might arise because of acculturation and altering
252

Table 2 ADI Items and their association with caseness (CIS rative acquisition of the host population's popular
threshold 11/12; weighted multiple logistic regression; P < 0.1) expressions.
Instrument Culture Items OR 95% CI P value A third possibility is that common mental disorders
are fundamentally di€erent in the two cultural groups. It
ADI Punjabi 1 1.91 0.93±3.91 0.08 is possible that the ADI and GHQ tap di€erent experi-
13a 2.42 0.97±6.11 0.06 ential constructions and symptom pro®les of `a common
16 0.35 0.13±0.89 0.03
English 4 2.68 0.96±7.48 0.06 mental disorder' in the two cultural groups. The ADI,
5 2.75 0.85±8.93 0.09 for example, has items about interpersonal a€ection,
6 2.81 0.98±8.08 0.06 hope, physical symptoms, community burden and mo-
13a 3.15 1.07±9.28 0.04 tivation as well as depressive items. The GHQ tends to
17 5.93 1.08±32.67 0.04
20 2.57 0.83±7.94 0.1
tap thinking capacity, depressive cognition, ability to
21 3.72 1.34±10.31 0.01 tolerate and overcome problems and sleep. Hence, if one
22 26.15 0.89±767.7 0.06 posits that the GHQ acts as a detector of psychological
27 0.02 0.0007±0.53 0.02 manifestations of distress (Patel et al. 1998), and the
GHQ Punjabi 1 1.65 0.95±2.86 0.07 ADI is better at tapping interpersonal, social and so-
2a 1.60 1.01±2.52 0.05 matic items, it is possible that the two instruments detect
5a 2.61 1.52±4.49 0.001 di€erent experiential dimensions of the same disorder.
9 1.74 1.06±2.86 0.03
12 2.37 1.09±5.15 0.03 The ADI and GHQ perform equally well among English
English 2a 1.75 1.12±2.72 0.01 subjects. One explanation is that these dimensions
5a 1.67 0.93±2.98 0.08 (psychological and social) are better correlated in En-
6 2.1 1.09±4.05 0.03 glish subjects' expressions of distress. The implication is
8 2.13 0.94±4.87 0.07
10 2.41 1.17±4.96 0.02
that these dimensions are di€erently correlated among
Punjabi subjects, perhaps accounting for the diculties
ADI item
1 I am unable to fully commit myself to anything
in the detection of disorder among Punjabi-Asians.
4 I am unable to carry on and complete new tasks A ®nal possible explanation for these ®ndings is that,
5 I do not have enough energy to carry on and while the ADI was developed in the Punjab, it used
complete new tasks psychiatric epidemiological concepts rather than local
6 When anything goes wrong, I am unable to put it ethnographies. One can still argue that the ADI is a
right
13a I feel unhappy most of the time psychiatric instrument, and therefore is ethnocentric,
16 I feel that I am inferior to others omitting important aspects of distress associated with
17 I feel that I am unable to do things as quickly mental illness among Punjabis. This might explain its
and eciently as other people value amongst English subjects. Comparison across
20 I feel sad because of aches and pains
21 I am a burden on society cultures using bi-culturally validated instruments, per-
22 I feel unhappy about the mistakes I made in the past haps by developing a hybrid between the GHQ-12 and
27 Deep down I regard myself a worthless person ADI, will selectively include symptoms that are common
GHQ item to the cultures under investigation. Such bi-culturally (or
1 Able to concentrate on what you're doing multi-culturally) valid instruments risk omission of items
2a Lost much sleep over worry that may not have epidemiological validity in accord
5a Felt constantly under strain with a criterion measure. These `omitted items' may
6 Felt you couldn't overcome things
8 Been able to face up to problems constitute an essential part of the illness experience of
9 Been feeling unhappy or depressed individuals. `Omitted items' might help de®ne mental
10 Been losing con®dence in yourself disorders in accord with lay and local ethnographic
12 Feeling reasonably happy approaches. If these are not meaningfully related to
a
Items common to both cultural groups `distress experiences' de®ned by psychiatric criteria, then
a revision of commonly used psychiatric criteria is un-
likely to be helpful.
health beliefs and lifestyle following exposure to the
dominant culture. One explanation is that the London-
resident Punjabi subjects' expressions of distress have Previous work on the GHQ-12
been shaped by exposure to English culture, and that
these expressions are di€erent from those of Punjabis The GHQ-12 yields high validity coecients when ad-
living in the Punjab. However, the validity coecients ministered in several languages and countries including
were no better for those Punjabis born outside the Bangalore in India (Goldberg et al. 1997). The GHQ-12
UK, for those arriving in this country more recently or has high validity coecients among Hindi speaking
for those clearly preferring to speak in Punjabi. How- women in West London, Bengali speakers in Calcutta,
ever, the ADI was no better than chance in the detection and Karnataka speakers in South India (Bandyo-
of a common mental disorder among Punjabis resident padhyay et al. 1988; Jacob et al. 1998a; Sriram et al.
in the UK for over 30 years. Hence, culturally engrained 1989). The GHQ-12 also had stable stratum-speci®c
expressions of distress may attenuate with accultu- likelihood ratios across 15 centres in a World Health

Organisation study (Furukawa and Goldberg 1999).
However, Williams and Hunt (1997) conclude that the
GHQ-12 underestimates distress amongst South Asians,
and especially amongst women. There are cultural dif-
ferences in the optimal threshold values, and these re-
¯ect variability in the severity and the prevalence of
disorders (Goldberg et al. 1997). There are also some
additional cultural and linguistic di€erences. Hysterical
conversion symptoms and somatic symptoms, which are
common in India, are not picked up by the Indian
translations of the GHQ (Sriram et al. 1989). The ADI
has somatic items, interpersonal a€ection items and
items that address the burden that the individual places
on the community. Thus, the ADI addresses social and
interpersonal dysfunction due to mood disturbance
rather than cognitive manifestations of depression as
assessed by the GHQ.
Universalism and relativism
This study provides further data to inform the debate
between the universalist premise that `etic' instruments
(ones developed in one culture and applied to another)
are e€ective for screening for common mental disor-
ders. The rival premise that `emic' instruments, ones
developed and applied to the same cultural group, are
better is at variance with our ®nding that the ADI is
not better amongst Punjabis. Any explanation depends
on `assumptions' about what constitutes a criterion
measure. A methodology that uses the same instru-
ments and validates them against others that originate
from within the same conceptual framework of mental
illness, a Western one, is liable to erroneous interpre-
tations as validation is conducted in a closed system
which invariably generates data to support its basic
assumptions. Yet, the evidence for the cultural invari-
ance of the GHQ-12, accepting such methodological
limitations, is substantial (Furukawa and Goldberg
1999).
One might expect the application of the ADI to En-
glish subjects to yield data that re¯ect similar biases as
the application of the GHQ-12 to Punjabis, unless the
degree of measurement bias in cross-cultural compari-
sons is not independent of the speci®c cultural groups
under study. The ADI and the GHQ-12 perform well
amongst English subjects. The performance character-
istics of instruments are not determined only by the
culture of origin of the instrument. `Psychiatric culture'
itself, being more closely allied with Western conceptu-
alisations of mental disorder, may pervade the devel-
opment of any instrument that is developed for
comparative work. Thus, the sort of information in an
`emic' evaluation of distress is di€erent from that of an
`etic' one, re¯ecting the di€erent emphases given by
psychiatrists (more comparative and essentially etic) and
anthropologists (more context-speci®c and emic) to the
description of a psychiatric disorder.
253
Acknowledgements The authors wish to thank Dr. Gurjinder
Malhi, Puspha Patel and Surinder Sandhu for assistance with
translations and screening procedures; all patients who gave will-
ingly of their time and their general practitioners. Dr. Bhui is
supported by the Wellcome Trust grant no: 043815/Z/95.
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