Thorsen et al.

BMC Medical Research Methodology 2013, 13:115

http://www.biomedcentral.com/1471-2288/13/115

RESEARCH ARTICLE Open Access

The predictive value of mental health for

long-term sickness absence: the Major Depression
Inventory (MDI) and the Mental Health Inventory
(MHI-5) compared
Sannie Vester Thorsen1*, Reiner Rugulies1, Pernille U Hjarsbech1 and Jakob Bue Bjorner1,2

Abstract
Background: Questionnaires are valuable for population surveys of mental health. Different survey instruments may
however give different results. The present study compares two mental health instruments, the Major Depression
Inventory (MDI) and the Mental Health Inventory (MHI-5), in regard to their prediction of long-term sickness
absence.
Method: Questionnaire data was collected from N = 4153 Danish employees. The questionnaire included the MDI
and the MHI-5. The information of long-term sickness absence was obtained from a register. We used Cox
regression to calculate covariance adjusted hazard ratios for long-term sickness absence for both measures.
Results: Both the MDI and the MHI-5 had a highly significant prediction of long-term sickness absence. A one
standard deviation change in score was associated with an increased risk of long-term sickness absence of 27% for
the MDI and 37% for the MHI-5. When both measures were included in the same analysis, the MHI-5 performed
best.
Conclusion: In general population surveys, the MHI-5 is a better predictor of long-term sickness absence than
the MDI.
Keywords: Head-to-head comparison, Survey instrument, Questionnaire

Background [4-7]. Questionnaires can, however, not find true preva-

Mental disorder is a main cause of the disease burden in lence but only estimate risk proportions [8].
developed countries [1]. Thus, policy makers have an Several mental health instruments exist and depending
interest in the level of mental health and prevalence of on the chosen questionnaire the estimate of the risk pro-
mental health problems in the population. Clinical inter- portion of the population may be very different: For ex-
views are the gold standard for measuring psychiatric ample, in Croatia, Rukavinia et al. used the Mental Health
morbidity, however such interviews are costly. An alter- Inventory (MHI-5) and estimated that the proportion with
native is self-report questionnaires of mental health. ‘psychological distress’ (scored from 0 to 100, cut-off at 52
These questionnaires are cheaper and practical for popu- point) was 34% in the adult population [9]. In Canada
lation surveys and they can provide an assessment of all the proportion with ‘high psychological distress’ was 38%
respondents. Questionnaire data on mental health has using the K-10 scale (scored from 0 to 40, cut-off at 9
been shown to be associated with reduced workability point) [10]. In Denmark, the risk proportion of ‘all kinds
[2,3], lower work performance, and sickness absence of depression’ was 7.1% using the Major Depression
Inventory (MDI) (scored from 0 to 50, cut-off at 20
* Correspondence: [email protected]
points) [11].
1
The Danish National Research Centre for the Working Environment, Lersø In the present study, we evaluate the two mental health
Parkallé 105, DK-2100, Copenhagen, Denmark instruments the Major Depression Inventory (MDI) and
Full list of author information is available at the end of the article

© 2013 Thorsen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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the Mental Health Inventory (MHI-5) in regard to the Methods

prediction of long-term sickness absence. If the mental Study sample and design
health of a person causes him or her to have a long-term Data was collected as part of the DAnish National work-
sickness absence period from work, it is a severe health ing Environment Survey (DANES) from late 2008 until
problem. Furthermore, the cumulative cost of sickness ab- early 2009. The DANES was approved by the Danish
sence due to mental health problems is an economic bur- Data Protection Agency, journal number: 2008-54-0553.
den for society. We therefore consider long-term sickness According to Danish law, questionnaire and register
absence to be a relevant outcome for evaluating the per- based studies do not need approval by ethical and scien-
formance of a mental health instrument used in popula- tific committees.
tion surveys. Questionnaire data was collected from a random sam-
The two questionnaires, the MDI and the MHI-5, have ple of the Danish employed population, age 18–59 years.
different designs (see Table 1): the MDI questions are a Participants could answer the questionnaire either by
list of specific symptoms of depression; the MHI-5 ques- internet or by post. Non-responders received two re-
tions are more generally formulated. Despite the differ- minders and were finally contacted and invited to par-
ences, both instruments have been validated as measures ticipate in a telephone interview. The study contacted
of depression [12,13] and both have been shown to pre- 9913 persons, 6531 responded (66%), of which 4919
dict sickness absence [4,5]. In the present study we com- were employees. We excluded participants with missing
pare the instruments in the same study in a so-called values on MHI-5 and MDI (n = 439), with missing re-
head-to-head comparison, and we are therefore able to sponse date (n = 150), with a sickness absence spell last-
identify the best performing instrument in regard to the ing 4 or more weeks in the preceding 3 months before
prediction of long-term sickness absence. We also divide or overlapping baseline (n = 177), yielding a study sample
the population into high risk and low risk groups by sev- of 4153 participants. In the multivariable adjusted analyses
eral methods for each instrument, and calculate the pre- the sample was, because of missing values to covariates,
diction of long-term sickness absence using different further reduced to 3713 participants. The 3713 participants
categorisations of the scales. are 75% of the employees that returned the questionnaire.

Table 1 The Mental Health Inventory (MHI-5) and the Major Depression Inventory (MDI)
MHI-5 Response categories
How much of the time during the last 4 weeks, have you….
(1) Been a very nervous person? (a) All of the time
(2) Felt so down in the dumps that nothing could cheer you up? (b) Most of the time
(3) Felt calm and peaceful? (c) A good bit of the time
(4) Felt downhearted and blue? (d) Some of the time
(5) Been a happy person? (e) A little of the time
( f) At no time
MDI Response categories
How much of the time in the last 2 weeks…
(1) Have you felt low in spirit or sad?
(2) Have you lost interest in your daily activities?
(3) Have you felt lacking in energy and strength?
(4) Have you felt less self-confident? (a) All of the time
(5) Have you had a bad conscience or feelings of guilt? (b) Most of the time
(6) Have you felt that life wasn’t worth living? (c) Slightly more than half of the time
(7) Have you had difficulty in concentrating, e.g., when reading the newspaper or watching television? (d) Slightly less than half of the time
(8a)* Have you felt very restless? (e) A little of the time
(8b)* Have you felt subdued? ( f) At no time
(9) have you had trouble sleeping at night?
(10a)* Have you suffered from reduced appetite?
(10b)* Have you suffered from increased appetite?
‘*’In the MDI is only the question with the highest response value of the questions 8a/8b and of the questions 10a/10b used in the total score.
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If we assume the return rate of the employees is equal to the responders into high risk and low risk group have
the return rate of the full sample, i.e., 66%, the sample for been suggested for the MHI-5. The cut-off points are de-
the final analysis is 50% of the employed people the ques- rived from ROC-curves or through another minimum
tionnaire originally was mailed to. misclassification criterion. The most used cut-off point is
Our long-term sickness absence data came from a na- probably 52 [4,22], other cut-off points include 54 and 74
tional register, the DREAM register [14]. The DREAM [18] and the cut-offs 60, 68 and 76 [23]. We calculated the
register has information on all Danish social transfer predictive value for long-term sickness absence using the
payments on a weekly basis. Employers are entitled to MHI-5 as: (1) a standardized scale score; (2) categorized
compensation from the municipalities if an employee into 5 ordinal levels; and (3) dichotomized by four differ-
has an absence spell of 22 days or longer. ent cut-offs, i.e. the cut-offs 52, 60, 68 and 76.

The major depression inventory Long-term sickness absence

The Major Depression Inventory (MDI) was developed Our outcome was time until onset of first episode of
in the late 1990s [12]. It was designed to measure de- long-term sickness absence. In our analysis, long-term
pression symptoms in accordance with the symptom sickness absence was defined as minimum 4 weeks of
guidelines defined by the WHO classification for uni- consecutive sickness absence, because 4 weeks are the
polar depression (ICD-10) and the American Psychiatric minimum period that is registered within the weekly
Association classification for major depression (DSM-IV) based DREAM register. We followed responders in the
[12,15]. The instrument consists of 12 questions and it in- register from 12 weeks before response date and until
cludes 2 algorithms that classify participants with risk of 60 weeks after response date. Participants, with long-
unipolar depression (mild, moderate or severe) according term sickness absence in the 12 weeks before or overlap-
to the ICD-10 definition or with risk of major depression ping the particular participant’s response date, were ex-
according to the DSM-IV definition. The instruments can cluded from the study. Only sickness absence that
also be used to measure depressive symptoms scored on a comes after the response of the questionnaire is included
scale ranging from 0 to 50, a higher score indicates a in our analyses.
higher level of depressive symptoms. Both Bech et al. [12]
and Forsell [16] have validated the MDI as a measure of Covariates
depression using SCAN clinical interviews. The following covariates were included in the analyses:
The questions of the MDI are shown in Table 1. Age, gender, family status, smoking, alcohol, body mass
We calculated the MDI’s predictive value for long- index, leisure time physical activity, social class, somatic
term sickness absence when we used the MDI as: (1) a chronic illness, self-rated health and method of data col-
standardized scale score, (2) the scale categorized into lection. With the exception of age and gender, which
five ordinal levels [5], (3) dichotomized into likely de- were retrieved from registers, the information on the co-
pression or not by the cut-off ≥20 in accordance with variates came from the questionnaire.
previous studies [5,16], likely depression or not based on We divided family status into four categories: (1)
the DSM-IV algorithm, and likely depression or not cohabitating, with children living at home, (2) cohabiting,
based on the ICD-10 algorithm (we pooled the ICD-10 without children living at home, (3) not cohabitating, with
categories mild, moderate and severe) [12]. children living at home, (4) not cohabiting, without chil-
dren living at home. Smoking was categorized into four
The mental health inventory levels; (1) never smoked, (2) ex-smoker, (3) light smoker,
The mental health inventory (MHI-5) is a five-question i.e., from occasional smoker to 14 cigarettes a day, and
subscale of the general health measure SF-36 [17]. The (4) heavy smoker ≥15 cigarettes a day. Alcohol intake was
MHI-5 includes questions referring to both positive and categorized into four levels following the guidelines of
negative aspects of mental health, and questions refer- the Danish National Board of Health: (1) ≤ 7 units weekly,
ring to both depression and anxiety [18,19]. Berwick (2) 8–14 units, (3) 15–21 units, (4) > 21 units weekly. Body
et al. [13], Cuijpers et al. [18] and Rumph et al. [20] have mass index was categorized into 4 levels according to the
validated the MHI-5 as a measure for depression using WHO categorization: (1) < 18.5 (underweight), (2) 18.5–25
clinical interviews as the gold standard. The MHI-5 has (normal weight), (3) 25–30 (overweight), (4) > 30 (obese).
also been tested as a measure of anxiety, somatoform Leisure time physical activity was scored on a scale from 0
disorders, and substance use disorders, but has failed to to 24 points. Social class was categorized in accordance
perform equally well in these tests [18,20]. The questions with the European Socio-economic Classification (ESeC).
of the MHI-5 are shown in Table 1. Somatic chronic illness was constructed as a binary vari-
We scored the MHI-5 from 0 (poor mental health) to able (somatic chronic illness or not). Self-rated health was
100 (good mental health) [21]. Several cut-offs for dividing scored on a scale from 1–5 points. The self-rated health
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question primarily measures physical health [24,25] and is The MHI-5

therefore used together with somatic chronic illness to The MHI-5 standardized score, the five-level categorized
control for the responders physical health. Method of data score, and the four dichotomized scores all predicted
collection was included, since responses are influenced by long-term sickness absence (see Table 2). The standard-
the data collection method [26]. Family status and social ized score had the highest significance level. The 5-level
status were used as categorical variables in the analyses. All categorization of MHI-5 showed an increase in HR for
other covariates were assumed to be ordinal or linear. each level. The increase between the next highest and
the highest level of the categorization was particular
Statistical analyses steep. This suggests that the best cut-off point for a di-
We compared the MDI and MHI-5 in a head-to-head chotomization is near 60 points (risk group = 14%). The
design [27]. We calculated the Pearson correlation be- risk group included from 304 to 1560 persons depending
tween the MDI and the MHI-5 and we compared the on which dichotomization we used, i.e., from 7 to 38%
distribution of MDI and the MHI-5 in two plots. We of the employed adult population.
calculated the predictive value for long-term sickness ab-
sence by Cox’s proportional hazard in both a univariate MDI and MHI-5 compared
regression analysis and a multivariate regression analysis. The HRs of the standardized scores estimate the in-
Participants were censored at the date of emigration, creased risk for one standard deviation increase of the
death, retirement, maternity leave or end of follow-up standardized score, i.e., the increased risk of sickness ab-
(60 weeks after baseline), whichever came first. We ex- sence for a one standard deviation of worse mental
amined the proportional hazard assumption by visual in- health. In the adjusted analyses, the HR of MDI was 1.27
spection of log-log-survival plots. The predictive value of and the HR of MHI-5 was 1.37, both were highly sig-
MDI and MHI-5 for long-term sickness absence was cal- nificant (see Table 2). With both instruments included
culated with (1) measures dichotomized by different cut- in the same regression analysis, the MHI-5 remained
offs, (2) 5-level categorical indexes, and (3) standardized significant and the MDI became non-significant (see
scores. We standardized the two scores of the MDI Table 2), i.e., the MHI-5 explained a significant part
and MHI-5 using mean = 0 and standard deviation = 1. of the variation in long-term sickness absence even
The standardized MHI-5 score was reversed so high when we controlled for the MDI. To confirm the sta-
score equalled poor mental health for both scores. In bility of this result, we cross-validated the result by
order to evaluate which mental health instrument that randomly splitting our sample in two independent
had the best prediction of long-term sickness absence, samples and then carry out the analysis in each sam-
we included both standardized scores in the same re- ple. Both results supported our initial finding (results
gression analysis. If one measure in such an analysis not shown). Thus, the MHI-5 explained the variation
have a substantial better significance level than the in long-term sickness absence better than the MDI.
other measure, it can be concluded that this measure Figure 1 shows the distribution of MDI and MHI-5
better capture the variation in the data. To further scores within the study population. Both distributions
confirm the result from this analysis, we performed a are positively skewed, indicating that they distinguish
cross-validation by randomly splitting our sample into better between degrees of reduced mental health than
two independent samples and then carry out the ana- degrees of good mental health. The MDI score corre-
lysis in each sample. lated with the MHI-5 score with a Pearson correlation
coefficient = −0.69 and p < 0.0001. The correlation is il-
Results lustrated in Figure 2. The Figure also illustrates that not
The MDI all participants classified as high risk by the MDI were
The MDI standardized score, the five-level categorized classified as high risk by the MHI-5 or vice versa. The
score, and the three dichotomized scores all predicted MDI ‘cut-off 20’ and the MHI-5 ‘cut-off 52’ each classi-
long-term sickness absence (see Table 2). The standard- fied 7.3% as high risk. However, only 3.8% of the ‘cases’
ized score had the highest significance level. The 5-level overlapped.
categorization of MDI showed a steep increase in HR
from the next highest to the highest level. This suggests Discussion
that the best cut-off point for a dichotomization into a Both the standardized MDI score and the standardized
risk group and non-risk group is near this score, i.e., MHI-5 score strongly predicted long-term sickness ab-
near 20 points (risk group = 7%). The risk group in- sence. However, the MHI-5 captured more of the vari-
cluded 90 to 301 persons depending on which dichoto- ability than the MDI when both instruments were
mization we used, i.e., the risk group was from 2 to 7% included in the same analysis. The MHI-5 therefore per-
of the employed adult population (see Table 2). forms better than the MDI as a predictor of long-term
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Table 2 The MDI’s and the MHI-5’s predictive value for long-term sickness absence
Univariate Adjusted ‘*’
N HR [CI 95] p-value HR [CI 95] p-value
MDI 4153 1.44 [1.31; 1.59] 3.31E-14 1.27 [1.12; 1.43] 0.0001
MHI-5 4153 1.50 [1.35; 1.66] 9E-15 1.37 [1.21; 1.55] 5.57E-07
MDI (with MHI-5 as covariate) 1.07 [0.92; 1.26] 0.37
MHI-5 (with MDI as covariate) 1.31 [1.11; 1.54] 0.001
MDI dichotomized
MDI cutpoint 20 depression (yes/no) 301 2.79 [2.00; 3.88] 1.5E-09 1.98 [1.36; 2.89] 0.0004
MDI ICD-10 depression (yes/no) 113 3.58 [2.29; 5.60] 2.28E-08 2.08 [1.26; 3.43] 0.004
MDI DSM-IV depression (yes/no) 90 3.40 [2.05; 5.64] 2.23E-06 1.92 [1.08; 3.41] 0.03
MDI categorical
MDI = 0–4 (reference level) 1591 1 1
MDI = 5-9 1456 1.55 [1.11; 2.17] 1.42 [0.99; 2.03]
MDI = 10-14 515 2.33 [1.57; 3.45] 1.60 [1.03; 2.50]
MDI = 15-19 290 2.05 [1.25; 3.38] 1.38 [0.80; 2.38]
MDI > =20 301 4.08 [2.74; 6.07] 2.68 [1.68; 4.27]
(p-value for all 5 levels) 8.52E-11 0.001
MHI-5 dichotomized
MHI cutpoint 52 mental ill (yes/no) 304 2.58 [1.84; 3.62] 4.32E-08 1.92 [1.32; 2.81] 0.0007
MHI cutpoint 60 mental ill (yes/no) 595 2.85 [2.17; 3.73] 2.82E-14 2.20 [1.62; 2.99] 4.83E-07
MHI cutpoint 68 mental ill (yes/no) 978 2.44 [1.90; 3.14] 4.82E-12 1.99 [1.49; 2.66] 2.83E-06
MHI cutpoint 76 mental ill (yes/no) 1560 2.05 [1.59; 2.64] 2.14E-08 1.57 [1.18; 2.09] 0.002
MHI-5 categorical
MHI = 91–100 (reference level) 1104 1 1
MHI = 81-90 1093 1.02 [0.67; 1.54] 1.01 [0.65; 1.57]
MHI = 71-80 978 1.39 [0.94; 2.07] 1.21 [0.78; 1.86]
MHI =61-70 383 1.77 [1.10; 2.87] 1.57 [0.94; 2.61]
MHI < 60 595 3.41 [2.35; 4.94] 2.56 [1.67; 3.92]
(p-value for all 5 levels) 5.75E-13 9.09E-06
‘*’The adjusted analyses include the covariates: sex, age, family status, smoking, alcohol, body mass index, leisure time physical activity, social class, somatic
chronic illness, self-rated health and data collection method.

Figure 1 The distribution of MDI and MHI-5 in a random sample of Danish employees.
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Figure 2 The association between MDI and MHI-5. Bubble size indicates no. of persons with the particular response pattern. The MDI cut-off
at 20 and the MHI-5 cut-off at 52 are marked with a line, the resulting cross-hair illustrates that ‘cases’ identified by MDI and MHI-5 is only
partly overlapping.

sickness absence. Furthermore, the MHI-5 consists of selection bias. Furthermore, long-term sickness absence
fewer questions than the MDI and is therefore more can be caused by other reasons than reduced mental
‘economic’. Our study can, however, not conclude that health. It could, as an example, be due to a somatic illness.
MHI-5 is a better measure of depression than the MDI; We have tried to control for physical health in the analyses,
it can only conclude that the predictive value for long- but it may not be sufficient.
term sickness absence is higher for the MHI-5 than for
the MDI. Conclusion
The size estimations of the high risk group from the The MHI-5 had a higher predictive value for long-term
different dichotomizations of the MDI (2 to 7%) were sickness absence than the MDI. In a study where the
more restrictive than the size estimations of the high risk predictive value for long-term sickness absence is of im-
group from the different dichotomizations of the MHI-5 portance the MHI-5 must be recommended as the best
(7 to 38%). If the MDI only identified people with risk of measure of mental health. The size of the high risk
depression and the MHI-5 identified people with re- group can for the same instrument be very different de-
duced mental health in general, the MDI should indeed pending on the choice of cut-off for case-ness, however,
identify less people than the MHI-5. This could also the MDI categorized in general fewer persons as ‘cases’
explain why the MHI-5 is a better predictor of sick- than the MHI-5.
ness absence than the MDI. However, studies show
that the MHI-5 performs better as a measure of de- Abbreviations
pression than as a measure of anxiety or substance MDI: Major depression inventory; MHI-5: Mental health inventory;
disorder [13,18,20,28]. It is possible that the MHI-5 is DANES: DAnish National working Environment Survey; HR: Hazard ratio.

more general than the MDI but the MHI-5 is not

general enough to show strong validity as a measure Competing interest
We would like to declare the following conflict of interest: The author Jakob
of other disorders than mood disorder. Bue Bjorner is currently employed by QualityMetric that owns the rights to
We chose to compare the predictive validity (i.e., the SF-36, of which the MHI-5 is a subscale. The remaining authors declare that
ability to predict a relevant outcome) of the two instru- they have no conflicts of interests.
ments. A limitation of our study is that only one out-
come was tested, time until long-term sickness absence. Authors’ contributions
Other outcomes, such as number of sick days or prod- SVT and JBJ were involved in the data collection. SVT, RER came up with the
original idea to the manuscript. SVT, RER, JBJ and PUH all contributed to the
uctivity at the workplace, may have given a different result. design/focus and the discussion of results. SVT carried out the statistical
The population, in which we test the instruments, may also analysis and prepared the manuscript. All authors read and approved the
be of importance for the result. The MDI might perform final manuscript.
better than the MHI-5 in a high risk population. The
population in our study is a general working population, Acknowledgement
and only approximately 50% of those the questionnaire We would like to thank Birthe Lykke Thomsen for inspiring discussions about
possible statistical approaches. The research was financed by the Danish
was aimed at ended up in the final regression analyses. National Research Centre for the Working Environment and partially the
The final sample may have been particular healthy due to Danish Working Environment Research Fund, project number 03-2008-09.
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1
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