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Psychological Reports
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Mental Health ! The Author(s) 2019
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Portuguese Version
of the MHI-38
and MHI-5

Ana M. S. Santos
Faculdade de Psicologia, Universidade de Lisboa, Portugal

Rosa F. Novo
CICPSI, Faculdade de Psicologia, Universidade
de Lisboa, Portugal

Abstract
Detection of mental distress cases is essential in clinical practice, especially in pri-
mary care. Screening instruments could be useful and effective tools to help identify
them. This study sought to evaluate the utility and capability of the Mental Health
Inventory (MHI)-38 and MHI-5 in identifying cases suffering from mental distress
from those who do not. The validity and accuracy of these MHI versions were tested
using as gold standards: two samples of adults, one with clinical complaints (n ¼ 33)
and another without clinical complaints (n ¼ 31); and the scores in Scales of
Psychological Well-Being and in a psychopathology inventory (Minnesota
Multiphasic Personality Inventory 2). Receiver operating characteristic curves were
used to define cutpoints, which is the Youden’s index for the optimization criteria.
The data analysis indicated an optimal cutpoint of 7.19 for MHI-38TOTAL and of 53
(recoded to a 0–100 scale) for MHI-5TOTAL to differentiate clinical cases from those
who are not. These results indicate cutpoint values similar to those of previous
studies in the case of MHI-5 and provide useful reference values for MHI-38. The

Corresponding Author:
Ana M. S. Santos, Faculdade de Psicologia, Universidade de Lisboa, Alameda da Universidade, 1649-013
Lisboa, Portugal.
Email: amss1991@gmail.com
2 Psychological Reports 0(0)

need to replicate this study with larger samples and with controlled clinical con-
ditions and type of pathology is also discussed.

Keywords
Mental health, screening, well-being, distress, validity

Introduction
The prevalence of mental disorders has been increasing over the years, reaching
high levels in many developed countries (World Health Organization [WHO],
2001). Although mental disorder is not usually fatal by itself, it is a major cause
of disability worldwide (Brundtland, 2000). It is troubling to consider that there
are data that indicate that mental health problems symptomatology is associated
with impairments in functioning and therefore in the quality of life of those
suffering from it, comparable to or greater than those demonstrated by people
with chronic medical conditions (Means-Christensen, Arnau, Tonidandel,
Bramson, & Meagher, 2005).
However, the stigma associated with the term “mental illness” alienates many
people from specialized mental health services, which are oriented for serious
conditions (e.g., schizophrenia, paranoia, major depression, or organic brain
syndromes). Thence, numerous clinical cases are not specifically targeted.
There are many people who suffer from emotional distress—associated to or
resultant of chronic diseases, unemployment, poverty, violations of human
rights, or natural disasters—that are not identified or treated. When these
cases are left untreated, there are not only an increase of the individual mor-
bidity but also an overuse of the general medical services (Von Korff, Ormel,
Katon, & Lin, 1992) that causes great overload for these settings and conse-
quently for physicians in primary care (Means-Christensen et al., 2005; Thorsen,
Rugulies, Hjarsbech, & Bjorner, 2013).
Consequently, there is a need to have a better scrutiny of the mental problems
and disorders and to improve the recognition and detection by primary care
providers of cases of debilitating distress that truly must benefit of treatment to
orient and treat them at the best of times and in an accurate and cost-effective
way. Nonetheless, due to time constraints and policies, mental evaluation is
occasionally overlooked (Borus, Howes, Devins, Rosenberg, & Livingston,
1988). Although a clinical interview with a mental status examination is a
good technique to identify psychiatric morbidity or stress-related disorders
and psychosocial problems (Rosenthal & Akiskal, 1985), it is also too expensive
and time consuming for professionals.
Screening instruments are a way of improving the early detection of a diver-
sified kind of problems related with mental health in primary care, contributing
Santos and Novo 3

to more immediate and effective interventions. They are like diagnostic tests in
the way that are used to determine if a person has the attribute in reference, but
they are instead given to a large group of asymptomatic people.
Screening tests should be ideally brief, easy to complete, and easily scored to
facilitate epidemiological studies and the identification of cases at risk that
deserve specific clinical attention. They should also have good indicators of
reliability and validity and specific norms of reference for different population
groups of age, sex, socioeconomic status, language, and cultural background
(Means-Christensen et al., 2005).
The Mental Health Inventory (MHI) is a screening tool that reflects a broad
concept of mental health, that is, not only the absence of psychopathology but
also the presence of a “state of well-being in which every individual realizes his
or her own potential, can cope with the normal stresses of life, can work pro-
ductively and fruitfully, and is able to make a contribution to her or his
community” (WHO, 2005). It is a widely used and recognized instrument devel-
oped by Veit and Ware (1983), under the Rand Corporation’s Health Insurance
Study. The factorial analysis of the original version, with 38 items (MHI-38),
confirmed a general factor of mental health, two related but distinct higher order
factors, Psychological Well-Being and Psychological Distress, and five correlated
factors of lower order, which correspond to the subscales of the instrument:
Positive Affect and Emotional Ties; and Anxiety, Depression, and Loss of
Emotional or Behavioral Control, respectively (Ware & Gandek, 1994). This
factorial structure was replicated with samples of diverse regions of the
United States (e.g., Veit & Ware, 1983). In different countries, where the
MHI has been subjected to translations and validity studies, the data have
revealed high levels of internal consistency and the same structure (e.g.,
Florian & Drory, 1990; Heubeck & Neill, 2000; Ostroff, Woolverton, Berry,
& Lesko, 1996).
Over the years, other MHI’s shorter versions were constructed. One has five
items (MHI-5) and has revealed a correlation between .95 and .93 with the
original MHI-38 (Ware & Gandek, 1994). This brief version has been extensive-
ly used in research in the last decades, or per se or included in some large
instruments, namely, the Medical Outcome Study (MOS) Short Form 20 and
36 (SF-20; Stewart, Hays, & Ware, 1988; SF-36; Ware & Sherbourne, 1992).
For various reasons, mental health indicators can be unique or have different
relevancy to specific cultures (Vaingankar et al., 2014). So, translation, valida-
tion, and setup standards for these instruments in other countries will allow to
increase the attainment of multidimensional value in an international level, and
of clinical trials and research in general, since it will use methods to make health
comparisons between countries and between groups within countries (Ware &
Gandek, 1994).
In our research in the literature, we did not find either national or interna-
tional studies that indicate cutpoint values for the MHI-38 version. There are
4 Psychological Reports 0(0)

international studies which indicate several specific cutpoints for research or for
screening mental health for the MHI-5 version (see “Discussion” section); how-
ever, there are no studies with Portuguese samples indicating and studying
specific cutpoints for it.
Thus, the main goal of this research was to find evidence of criterion validity
and propose cutpoints for the different measures of the MHI-38 and MHI-5 for
the Portuguese population. With that in mind, accuracy measures were calcu-
lated to determine the effectiveness and accuracy of the MHI as a screen-
ing measure.

Method
Participants and procedures
Two groups were studied: a clinical group (CG; participants with clinical psy-
chiatric history) and a nonclinical group (NCG; participants without any psy-
chopathology diagnose or relevant clinical history).
After a rigorous scrutiny of the pre-established conditions and after an exclu-
sion of six subjects who showed critical results on Minnesota Multiphasic
Personality Inventory’s (MMPI) validity scales (high levels of inconsistency,
bizarre, or insincerity according to the test standards, that is, T scores greater
or smaller by the threshold indicated by the test standards for each validity
scale) or physical diseases that induce a high level of psychological distress
(e.g., cancer), 64 individuals participated (CG: 31 and NCG: 33). They were
all Portuguese and had no suspected mental disability, cognitive impairment, or
critical clinical situation with implications of cognitive functions (see Table 1 for
a more detailed sample’s characterization).
The two groups had a similar distribution for age and employment status
(v2(2, N ¼ 64) ¼ 45.32, p ¼ .09 and v2(3, N ¼ 64) ¼ 7.56, p ¼ .06, respectively).
However, there were significant differences regarding sex (v2(5, N ¼ 64) ¼ 8.45,
p ¼ .004) and education (v2(5, N ¼ 64) ¼ 16.34, p ¼ .006), which are taken into con-
sideration in the analysis of the results.
CG was recruited from a public hospital in Azores (Hospital da Horta) and
from a private clinic in Lisbon (Cl
ınica Psiquiátrica de S~ao José). All partici-
pants were considered by their psychologist and/or psychiatrist able to partic-
ipate in the study and were inpatient in short-term hospitalization (17) or
outpatients (14), with different kinds of mental pathologies; mostly were
under some psychopharmacological treatment. NCG recruitment was con-
ducted through the diffusion of the study in the social network of students
and professors of the university.
In both groups, informed consent was obtained, and a brief individual inter-
view was conducted with the purpose of collecting demographic data and other
information about clinical history. The order of application of the instruments
Santos and Novo 5

Table 1. Sample’s demographic characteristics.

CG (n ¼ 31) NCG (n ¼ 33)

Age (years) n M (SD) n M (SD)

18–74 45.00 (16.5) 33.79 (14.9)

18–23 5 13
24–36 4 10
37–55 14 6
56–74 8 4
Sex
Male 6 18
Female 25 15
Educational level
Basic 8 1
High school 12 5
Higher education 11 27
Professional status
Employed 15 13
Retired 8 2
Student 6 14
Unemployed 2 4
CG: clinical group; NCG: nonclinical group.

was it follows: (1) MHI, (2) Scales of Psychological Well-Being (SPWB), and
(3) Minnesota Multiphasic Personality Inventory-2. In CG, the application of
the instruments was conducted in one to two individual sessions, in the institu-
tions involved in the study in accordance with their ethics committees. For the
NCG, individual or small group sessions (5 to 6 participants) were scheduled
and the applications were performed in just one session that lasted 2 hours.
Faculdade de Psicologia da Universidade de Lisboa Ethics Committee approved
this procedure.

Instruments
Mental Health Inventory. MHI (Veit & Ware, 1983) is a psychological well-being
and distress self-report measure. We consider two versions: the original MHI-38
and the short MHI-5.
MHI-38 provides eight measures: a global scale—Total Mental Health (MHI-
38TOTAL); two partial scales—Psychological Well-Being (MHI-38PWB) and
Psychological Distress (MHI-38PD). These encompass two and three subscales,
respectively: Positive Affect and Emotional Ties and Anxiety, Depression, and
Loss of Behavioral/Emotional Control. Each item requires a response on a six-
point scale, excluding two items that have a five-point scale; each point is
6 Psychological Reports 0(0)

associated with the frequency or the intensity level of the behaviors, feelings, or
thoughts the person experiences. Higher scores indicate a higher level of a global
mental health and on the specific dimensions of it.
The scoring was conducted in accordance with the original version.
Moreover, all measures were calculated and recoded so that we could have
comparability between the final measures of all scales. We used the following
procedure: first, the missing data (protocols with more than one unanswered
item per subscale or more than three on MHITOTAL were not accepted) were
replaced by the theoretical average of the respective item (i.e., “3” for items with
a response scale with six points or “2.5” for items with a response scale with five
points). Second, all the items with a five-point scale (item 9 and item 28) were
recoded to a six-point scale (the values obtained in these items were divided by
6). Third, after obtaining the sums of the scores for the eight measures, to allow
the comparison of the scores of scales with different number of items, all were
divided by the number of their constituent items (e.g., the total score of the
Depression scale was divided by five and, in turn, the sum of Positive Affect
scale was divided by 11). This procedure was done for all subscales. Fourth, the
values in the subscales that form the Psychological Well-Being scale
(MHI-38PWB) and the Psychological Distress scale (MHI-38PD), respectively,
were summed. Since each scale has a different number of associated subscales,
the values of MHI-38PWB scale were divided by two and the MHI-38PD scale by
three. Finally, the values obtained from these two scales were added and the
values of the total scale (MHI-38TOTAL) were attained. This means that the
values of the MHI-38TOTAL range between 2 and 12.
The MHI-5 comprises five items, each one coming from one of the subscales
of the original version and having only one global measure (MHI-5TOTAL), with
higher scores indicating a better mental health. The response is given in a six-
point scale; thus, the total score ranges between 5 and 30. Usually, the scores
obtained in this version are transformed into a 0 to 100 scale and we followed
the same procedure.
Veit and Ware (1983) reported internal consistency coefficients from .81 to
.96 for the MHI-38 subscales. The Portuguese version (Silva & Novo, 2002)
provides Cronbach’s alpha between .73 and .95 for the MHI-38 subscales and
.96, and .88 for MHI-5TOTAL (Novo, 2004). In this study, the Cronbach’s alpha
for the total sample was between .74 and .98 (see Table 2) and for the two
groups separately was between .57 and .95 (for CG) and .66 and .95 (for NCG).

Scales of Psychological Well-Being. The SPWB scale (Ryff, 1989) is an 84-item self-
report scale. Each item is a sentence that requires a response on a six-point scale;
each point is associated with the agreement/disagreement level of the behaviors,
feelings, or thoughts referred on the sentence in question. The instrument pro-
vides the following six psychological well-being dimensions that are theoretically
based: Autonomy, Environmental Mastery, Personal Growth, Positive Relations
Santos and Novo 7

Table 2. Descriptive statistic, Cronbach’s alphas, and MANCOVA for MHI-38 and ANCOVA
for MHI-5 for CG and NCG.

Total sample CG NCG

N ¼ 64 n ¼ 31 n ¼ 33

MHI M (SD) a M (SD) M (SD) F(1, 60) g2

MHI-38
Psychological distress 3.93 (1.06) .92 3.14 (0.84) 4.68 (0.62) 36.324* .377
Anxiety 3.69 (1.05) .92 2.94 (0.81) 4.38 (0.72) 30.687* .338
Depression 3.98 (1.13) .85 3.17 (0.91) 4.73 (0.71) 31.262* .343
Loss of control 4.14 (1.14) .94 3.31 (1.00) 4.92 (0.56) 30.900* .340
Psychological Well-Being 3.45 (0.96) .94 2.96 (0.97) 4.07 (0.75) 26.458* .306
Positive affect 3.25 (0.97) .94 2.60 (0.70) 3.86 (0.79) 24.019* .286
Emotional ties 3.65 (1.18) .74 2.96 (0.90) 4.29 (0.99) 14.234* .192
MHI-38 total 7.38 (1.91) .98 5.92 (1.35) 8.75 (1.21) 40.349* .402
MHI-5a
MHI-5 total 59.74 (19.94) .97 44.62 (14.52) 73.94 (12.49) 36.653* .379
CG: clinical group; NCG: nonclinical group; ANCOVA: analysis of covariance; MANCOVA: multivariate
analysis of covariance; MHI: Mental Health Inventory; a: Cronbach’s alpha.
a
Recoded values in a scale of 0 to 100.
*p < .001.

with Others, Purpose in Life, and Self-Acceptance. The Portuguese version also
provides a global measure (Novo, 2003). Higher scores mean a higher level of
well-being in general and in each measure indicate a higher level in the specific
dimension. The internal consistency coefficients of the original version range
from .81 to .88 (Ryff, 1989). The Portuguese version (Novo, 2003) showed .75 to
.86 Cronbach’s alpha values for the partial measures and .93 for the
global measure.

Minnesota Multiphasic Personality Inventory 2. The MMPI-2 (Butcher, Dahlstrom,

Graham, Tellegen, & Kaemmer, 1989) is a 567-item self-report inventory that
aims for the evaluation and characterization of personality and psychopathol-
ogy. We used the experimental Portuguese version (Silva, Novo, Prazeres, &
Pires, 2006). The test provides several final measures. We considered the five
validity scales that are used to determine the subject’s test-taking attitude and to
identify an invalid profile (VRIN: Variable Response Inconsistency; TRIN: True
Response Inconsistency; L: Lie; F: Infrequency; and K: Correction), and eight
clinical scales which reflect different psychological characteristics (Hs:
Hypochondriasis; D: Depression; Hy: Hysteria; Pd: Psychopathic deviate; Pa:
Paranoia; Pt: Psychasthenia; Sc: Schizophrenia; and Ma: Hypomania)
(Graham, 2012).
8 Psychological Reports 0(0)

Statistical analysis
MHI-38 and MHI-5’s validity was examined through two criteria: an external
clinic criterion—provided by a previous identification of persons with and with-
out mental disorder—and an empirical criterion—provided by the scores of the
instruments used as reference standard, namely, the MMPI-2 for assessment of
pathological distress and the SPWB for psychological well-being. These meth-
ods allowed to identify accuracy measures of the MHI-38 and MHI-5:
(a) Sensibility (Se)—identify the probability of people who have the attribute
who are detected by the index test, that is, a true positive; (b) Specificity (Sp)—
identify the probability of people without the attribute who are correctly labeled
by the test, that is, a true negative; (c) AUC—the area under the receiver oper-
ating characteristic (ROC) curve (i.e., index of the amount of diagnostic infor-
mation supplied by the screening measure); and (d) the Youden’s Index (i.e., a
single statistic that can capture the performance of a dichotomous diagnostic
test, not affected by the attribute prevalence, providing their maximum potential
effectiveness and summarizing sensitivity and specificity).
These methods also permitted to find optimal cutpoints because since the
MMPI and the SPWB are robust instruments, as well as the clinical cases iden-
tified previously by mental health professionals, and they constitute “gold stand-
ards” (i.e., a benchmark or a scale which can classify accurately people as a case
or a non-case, making, ideally, no misclassifications). This is essential because
the indexes mentioned beforehand are linked to the cutpoint chosen, that is, for
each one of the possible cutpoints elected for the measure under investigation,
there is an associated pair of diagnostic sensitivity and specificity, meaning that
as the cutpoint decreases, the sensitivity decreases, inasmuch the specificity
increases (Kelly, Dunstan, Lloyd, & Fone, 2008) and a gold standard will
allow to find the most suitable cutpoint.
In the case of the MMPI-2, the elevation of the profile was used as criterion.
Elevations (T  65) on three or more scales were considered profiles of clinical
relevance, that is, indicative of a pathological condition (Graham, 2012), while
all other profiles were considered as indicators of a nonpathological condition.
In the case of SPWB, the value considered as indicative of well-being was a
SPWBTOTAL’s raw score 359, mean reported in a study with a Portuguese
adult large sample (Novo, 2003); lower scores were considered as not indicative
of well-being.
These reference standards—(a) CG and NCG and (b) MMPI-2 profiles
(pathological/non-pathological) and the SPWBTOTAL (high/low levels of well-
being)—made possible the identification of the cutpoints for MHI-38TOTAL,
MHI-38PD, and MHI-38PWB and for MHI-5 TOTAL. Different ROC curves
were constructed for them and accuracy indexes were calculated (Se and Sp)
using the cutpoints found previously. For the MHI-38TOTAL, using two refer-
ence standards, we considered: (a) all participants in the CG and with
Santos and Novo 9

pathological MMPI-2 profiles scoring below the MHI-38TOTAL’s optimal cut-

point (i.e., with low levels of mental health) are considered True Negatives and
(b) all participants from the NCG or with normal MMPI-2 profiles scoring
higher than the MHI-38TOTAL’s optimal cutpoint (i.e., high levels of mental
health) are considered True Positives. In the case of the MHI-38PWB: (a) all
cases which are below the cutpoint in SPWBTOTAL and below the MHI-38PWB’s
optimal cutpoint are considered True Negatives (i.e., low levels of well-being in
the reference standard and low levels in the index test) and (b) all cases that are
above the SPWBTOTAL cutpoint and above MHI-38PWB’s optimal cutpoint are
considered True Positives (i.e., high levels of well-being in the reference standard
and high levels in the index test). For the MHI-38PD, the MMPI-2 profiles were
used as the reference standard: the same rational was used as it was explained
for the MHI-38TOTAL, but the optimal cutpoint in this case was of the
MHI-38PD. Finally, for the MHI-5TOTAL, the Clinical Condition was used as
the reference standard and the rational was the same as for the MHI-38TOTAL,
but the optimal cutpoint was of the MHI-5TOTAL.

Results
Multivariate analysis of covariance (MANCOVA) (MHI-38) and analysis of
covariance (ANCOVA) (MHI-5) analysis showed, after controlling for sex
and education variables, that there were significant effects between the CG
and NCG in the different MHI-38 and MHI-5 measures (MHI-38: F(5, 56) ¼
8.110, p < .000, Wilks’ K ¼ .580, partial g2 ¼ .420; MHI-5: F(1, 60) ¼ 36.653,
p < .000, partial g2 ¼ .379). When compared to NCG, the CG obtained signifi-
cantly lower scores on the different MHI’s subscales, which constitute evidence
of empirical or criterion validity (see Table 2). Given the high range of ages, the
MANCOVA and ANCOVA were conducted again, with the difference that this
variable (age) was also controlled: the effects between the CG and NCG in the
different MHI-38 and MHI-5 measures were likewise significant (MHI-38: F(5,
55) ¼ 7.002, p < .000, Wilks’ K ¼ .611, partial g2 ¼ .389; MHI-5: F(1, 59) ¼
31.821, p < .000, partial g2 ¼ .350).
With the aforementioned reference standards, for the three measures, we
found areas under the ROC curve (AUC’s) higher than .86, which means the
test, in both versions (MHI-38 and MHI-5), has an excellent ability to accurate-
ly distinguish persons with clinical complaints and/or MMPI-2’s pathological
profiles from those who do not have clinical complaints and/or have MMPI-2
“normal” profiles, because an AUC  0.80 is indicative of a useful screening
instrument (Holmes, 1998). Moreover, all the cutpoints pointed out by the
Youden’s Index showed high values (higher than 73%) of sensitivity and spe-
cificity (see Table 3 and Appendix 1).
10 Psychological Reports 0(0)

Table 3. Summary of AUC, sensitivity and specificity given by the ROC Curves analysis.
Clinical condition MMPI-2 profiles SPWBTotal

MHI Cutpointa AUC Se Sp Cutpointa AUC Se Sp Cutpointa AUC Se Sp

38TOTAL 7.19 .945 93.9 83.9 7.19 .904 96.7 79.4 6.40 .946 81.6 100
38PWB 3.64 .900 72.7 96.8 3.64 .856 73.3 91.2 3.08 .926 81.6 100
38PD 3.89 .930 93.9 77.4 3.89 .900 96.7 73.5 3.57 .903 79.6 100
5TOTALb 53 .931 90.9 80.7 53 .891 93.3 76.5 53 .904 73.5 100

MHI: Mental Health Inventory; MMPI: Minnesota Multiphasic Personality Inventory; ROC: receiver oper-
ating characteristic; AUC: Area under the curve; SPWB: Scales of Psychological Well-Being; Se: Sensibility;
Sp: Specificity.
a
Optimal threshold given by the Youden’s Index.
b
Recoded values in a scale of 0 to 100.

With all the criteria used for the different scales and subscales, MHI-
38TOTAL, the MHI-38PWB, MHI-38PD, and MHI-5TOTAL all showed values of
Sensibility and Specificity higher than 70% (see Table 4).

Discussion
This study suggests that the MHI’s Portuguese version, in MHI-38 and MHI-5’s
formats, constitutes a valid tool in mental health screening, demonstrating good
psychometric properties in the sample studied. Its use appears to be especially
useful to differentiate people with low levels of mental health (i.e., with probable
psychopathology) from those with high levels of mental health (i.e., with no
probable psychopathology): with all the criteria used (external clinical criterion
as a reference standard, i.e., people previously evaluated by a psychiatry and/or
psychologist as having a mental condition or not; and empirical reference stan-
dard, i.e., MMPI-2 and SPWB scores), we found high values in the different
measures of accuracy of the MHI’s global measures.
From the ROC curve analysis, a 7.19 cutpoint is suggested for the
MHI38TOTAL. For the MHI-38PWB, a cutpoint of 3.64 is proposed; in turn,
for the MHI-38PD, a cutpoint of 3.89 is recommended. These cutpoints are the
ones that best combine values of sensitivity and specificity. However, since a
perfect test, with no misclassifications, that can completely discriminate subjects
with and without the attribute that is evaluating, does not exist, depending on
the situation, sometimes it is better to increase or decrease the cutpoint chosen.
If higher levels of sensitivity are desired (i.e., if you want to identify all subjects
with mental health), the cutpoint should be smaller. But, if higher levels of
specificity are desired, to more effectively reduce the false-negative cases, that
is, pathological or clinical cases, a higher cutpoint is recommended. Considering
that in primary care, where it is essential to detect most people who are suffering
Santos and Novo 11

Table 4. MHI-38 and MHI-5’s accuracy indexes using clinical condition, MMPI-2’s clinical
profiles and SPWBTotal mean criteria.

Accuracy measuresa

Criteria Values Se Sp
i
MHI-38TOTAL
Clinical condition 7.19 <7.19
NCG (n ¼ 33) 31b 2c .94 .80
CG (n ¼ 31) 5 d
26e
MMPI-2—clinical profiles
Normal (n ¼ 30) 29b 1c .97 .80
Pathological (n ¼ 34) 7 d
27e
ii
MHI-38PWB
SPWBTotalf 3.64 <3.64
High (n ¼ 34) 30b 4c .88 .70
Low (n ¼ 30) 9 d
21e
iii
MHI-38PD
MMPI-2—clinical profiles 3.89 <3.89
Normal (n ¼ 30) 29b 1c .97 .70
Pathological (n ¼ 34) 9 d
25e
iv
MHI-5TOTAL
Clinical condition 53 <53
NCG (n ¼ 33) 32b 1c .97 .70
CG (n ¼ 31) 10 d
21e
MHI: Mental Health Inventory; MMPI: Minnesota Multiphasic Personality Inventory; SPWB: Scales of
Psychological Well-Being; Se: Sensibility; Sp: Specificity; CG: clinical group; NCG: nonclinical group.
a
Se (Sensibility) ¼ a/(a þ c); Sp (Specificity) ¼ d/(b þ d).
b
True Positives.
c
False Negatives.
d
False Positives.
e
True Negatives.
f
Scales of Psychological Well-Being (PWBTOTAL); i – Mental Health Inventory-38: Total; ii – Mental Health
Inventory-38: Psychological Well-Being Scale; iii - Mental Health Inventory-38: Psychological Distress Scale;
iv – Mental Health Inventory-5: Total.
The values that are in bold are the optimal cutpoints indicated in table 3.

from psychological distress and mental disturbance and not to miss a possible
clinical case, it will be more useful to use a higher cutpoint. In this way, we can
identify more cases that must benefit of posterior evaluation with diagnos-
tic purpose.
With respect to the MHI-5, it is proposed as indicator of general mental
health a cutpoint of >53 (in a scale 0 to 100). Nevertheless, for clinical purposes,
it might be better to use a higher cutpoint, since most of the participants from
the clinical sample were inpatients, which possible led to worst results. In fact,
12 Psychological Reports 0(0)

comparing with other studies that proposed cutpoints for specific clinical con-
ditions with other populations, the optimal cutpoint found in this study is lower.
In the study of Means-Christensen et al. (2005), they demonstrated that a cut-
point of 23 or less (corresponding to 72 or less on 0–100 scale) can identify
patients that may benefit from a more thorough evaluation for panic disorder or
major depression specifically. Rumpf, Meyer, Hapke, and John (2001) suggested
similar cutpoints, depending on the diagnostic groups: 60 for mood disorders, 70
for anxiety disorders, and 65 as the most appropriate as a single cutpoint for all
groups. Beukel et al. (2012) suggested an optimal cutpoint of 70 for the purposes
of screening applications.
As said earlier, since the participants were psychiatric patients, some in an
acute state and taking medication can cause the cutpoint to be lower. This can
affect the optimal cutpoint chosen because we used the Youden Index, which
summarizes the sensitivity and specificity of the test, this meaning that it con-
siders the proportion of true positives in relation to the proportion of true
negatives or vice versa. Since the participants in our CG scored quite low
values in the MHI, this also means that our true negatives have lower levels
than perhaps the samples gathered in the studies mentioned beforehand that did
not recruited them in places specialized in the treatment of psychological dis-
eases. This means that, in our case, a person to be considered a true positive
simply needs to score values higher than those shown by our clinical sample.
Since these values were quite low, because of the reasons mentioned, means that
a low cutpoint will certainly identify true negatives and a higher one may no
longer. On the other hand, in the other studies, the participants who were con-
sidered true negatives did not show such low values in MHI, meaning that their
cutpoints will be higher (because the bigger score in MHI, the better mental
health the person have), which will allow them to consider a true positive only if
a person scores high. It should be noted that this difference in values scored in
the MHI could also be due to the living and health conditions. On the countries
where those samples were gathered, namely Germany and Holland, that are
better quality of life and support to the health than in Portugal. The general
health investment in Portugal is about 30% lower than the European Union
average and the prevalence of psychiatric disorders is 43%, the second highest
in European Union (Xavier, M., et al., 2013).
To our knowledge, this is the first study to indicate cutpoints for the MHI-38,
which is important in clinical contexts, since a questionnaire with more items
allows a bigger qualitative information about the person who takes it, which in
turn will allow for more appropriate options at the referral level as it provides
more specific indicators of depression, anxiety, and emotional/behavioral con-
trol, or of the reduction of positive affect and of emotional ties. Besides that, it
gives more access points to explore problematics in the beginning of treatment if
necessary. MHI-5, in turn, provides a useful tool for research. This short version
Santos and Novo 13

could be valuable for very specific cases of primary health care, so physicians
can refer patients for further evaluation.
Therefore, the use of MHI can have an impact both in the early detection of
psychopathology and in the monitoring of the course of treatment. This is
particularly relevant as mental problems or disorders have become the central
cause of disability and one of the major causes of morbidity and premature
death in the world. In addition, most people with mental health problems first
seek help in primary care; however, due to time constraints, 50% of cases of
mental disorder are not identified by general practitioners (Xavier, Baptista,
Mendes, Magalh~ aes, & Caldas-de-Almeida, 2013).
There are some limitations inherent to this study, so it is advisable to con-
tinue the research in this area. Since measures of diagnostic accuracy are very
sensitive to the characteristic of the population in which the test is evaluated

(Simundi
c, 2009), we need more studies with larger samples and with different
levels and types of psychological distress.
The small sample size is a limitation, although it should be noted that our
sample has both sexes represented, is diversified in terms of geography, age,
schooling, and employment status. Also, because we used the Youden J statistic
it may eventually outweigh the limitation of the reduced sample size, since this
index is not affected by the attribute prevalence of the condition in the popula-
tion studied.
Nevertheless, the sample size might not be representative of the different
levels and types of psychological distress and well-being in the general popula-
tion. This limitation leads to a more specific one: the clinical sample is mainly
composed of people with high levels of pathology with a disparity of diagnosis.
To better clarify the role of each type of pathology, future investigations with
populations with evenly distributed severity levels and pathology types should
clarify the suitability of the MHI to different contexts and increase confidence in
the generalization of these results. Would also be interesting to evaluate the
prevalence of mental health levels in different populations, to intervene in a
more specific way in a clinical context. It would also be important to conduct
predictive validity studies of the measures examined here.
Replication of this study with people who show moderate levels of psycho-
logical distress and are not undergoing treatment, to perceive the sensitivity of
the instrument to people not yet identified as possessing a clinical chart, as well
as to investigate different cutpoints for different psychopathologies would also
be interesting. Although it is arguable that mental health should only have one
cutpoint to address a general psychopathology factor, since it is a dimensional
concept, evidence suggests that many disorders are comorbid, recurrent/chronic,
and exist on a continuum with normal-range functioning. Also, not a single
mental disorder has ever been established as a distinct, episodic, discrete cate-
gorical condition and that most common mental disorders are unified by a single
psychopathology dimension represents lesser-to-greater severity of
14 Psychological Reports 0(0)

psychopathology (Caspi et al., 2014; Kotov et al., 2017). Imposing a categorical

terminology on naturally dimensional phenomena leads to a considerable loss of
information. So, replicating this study with a larger sample, with different types
of psychopathology, comorbidities, and severity levels could be more advisable
and useful.
The imbalance between female and male frequency is another limitation.
Evidence show that the prevalence of disturbances and levels of well-being is
differentiated for each of the sexes. Therefore, the greater number of women
observed in this study may bias the results of it. Thus, future studies may
increase validity evidence by using more gender-balanced samples. Likewise,
future research may represent the diversity of socioeconomic status, education,
among other demographic variables and consider their influence on the results.

Appendix 1
Optimal cut-off points for the MHI-38 and MHI-5.

MHI-38TOTAL MHI-38PD MHI-38PWB MHI-5TOTAL

Se (%) Sp (%) Se (%) Sp (%) Se (%) Sp (%) Se (%) Sp (%)

Clinical condition
2.74 100 0 1.2 100 0 1.21 100 0 17 100 0
>4.31 100 12.9 >2.1 100 12.9 >1.55 100 9.68 >23 100 10
>5.67 100 38.71 >2.93 100 38.71 >2.56 96.97 25.81 >33 100 29
>5.96 96.97 48.39 >3.08 100 51.61 >2.86 93.94 54.84 >40 100 48
>6.4 96.97 74.19 >3.48 93.94 70.97 >3.15 90.91 70.97 >47 97 58
>7.19 93.94 83.87 >3.89 93.94 77.42 >3.35 84.85 77.42 >53 91 81
>7.52 84.85 87.1 >4.05 84.85 83.87 >3.42 78.79 80.65 >60 79 87
>8.04 69.7 96.77 >4.2 78.79 90.32 >3.64 72.73 96.77 >67 67 94
>8.61 60.61 100 >4.51 60.61 96.77 >3.88 51.52 100 >73 58 100
>9.29 36.36 100 >4.73 51.52 100 >4.59 27.27 100 >80 30 100
>10.01 12.12 100 >5.41 12.12 100 >5.09 6.06 100 >87 9 100
>10.94 0 100 >5.69 0 100 >5.45 0 100 >90 0 100
MMPI-2 Profiles
2.74 100 0 1.2 100 0 1.21 100 0 17 100 0
>4.31 96.67 8.82 >2.1 96.67 8.82 >1.55 96.67 5.88 >23 96.67 5.88
>5.67 96.67 32.35 >2.93 96.67 32.35 >2.56 96.67 23.53 >33 96.67 23.53
>5.96 96.67 44.12 >3.08 96.67 44.12 >2.86 93.33 50 >40 96.67 41.18
>6.4 96.67 67.65 >3.48 96.67 67.65 >3.15 90 64.71 >47 96.67 52.94
>7.19 96.67 79.41 >3.89 96.67 73.53 >3.35 83.33 70.59 >53 93.33 76.47
>7.52 86.67 82.35 >4.05 86.67 79.41 >3.42 80 76.47 >57 83.33 76.47
>8.04 70 91.18 >4.2 80 85.29 >3.64 73.33 91.18 >63 76.67 82.35
>8.61 63.33 97.06 >4.51 63.33 94.12 >3.88 53.33 97.06 >70 63.33 91.18

(continued)
Santos and Novo 15

Continued.
MHI-38TOTAL MHI-38PD MHI-38PWB MHI-5TOTAL

Se (%) Sp (%) Se (%) Sp (%) Se (%) Sp (%) Se (%) Sp (%)

>9.29 36.67 97.06 >4.73 53.33 97.06 >4.59 26.67 97.06 >77 50 97.06
>10.01 10 97.06 >5.41 13.33 100 >5.09 3.33 97.06 >83 23.33 97.06
>10.94 0 100 >5.69 0 100 >5.45 0 100 >90 0 100
SPWBTOTAL
2.74 100 0 1.2 100 0 1.21 100 0 17 100 0
>4.31 97.96 20 >2.1 95.92 13.33 >1.55 97.96 13.33 >23 95.92 6.67
>5.67 93.88 60 >2.93 91.84 53.33 >2.56 97.96 53.33 >33 93.88 40
>5.96 91.84 80 >3.08 89.8 73.33 >2.86 85.71 80 >40 89.8 66.67
>6.4 81.63 100 >3.57 79.59 100 >3.08 81.63 100 >47 85.71 80
>7.19 73.47 100 >3.89 77.55 100 >3.35 71.43 100 >53 73.47 100
>7.52 65.31 100 >4.05 67.35 100 >3.42 65.31 100 >57 67.35 100
>8.04 48.98 100 >4.2 59.18 100 >3.64 51.02 100 >63 59.18 100
>8.61 40.82 100 >4.51 42.86 100 >3.88 34.69 100 >70 44.9 100
>9.29 24.49 100 >4.73 34.69 100 >4.59 18.37 100 >77 32.65 100
>10.01 8.16 100 >5.41 8.16 100 >5.09 4.08 100 >83 16.33 100
>10.94 0 100 >5.69 0 100 >5.45 0 100 >90 0 100

Se: Sensitivity; Sp: Specificity; MMPI-2: Minnesota Multiphasic Personality Inventory 2; SPWBTOTAL: Scales
of Psychological Well-Being; MHI-38TOTAL: Mental Health Inventory-38: Total; MHI-38PWB: Mental Health
Inventory-38: Psychological Well-Being Scale; MHI-38PD: Mental Health Inventory-38: Psychological
Distress Scale; MHI-5TOTAL: Mental Health Inventory-5: Total.

Authors’ Note
This paper was not published elsewhere and was not submitted simultaneously for pub-
lication elsewhere. Data, analytic methods, and study materials are available
upon request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This research is supported by the CICPSI
(Research Center of Psychological Science).

ORCID iD
Ana M. S. Santos https://orcid.org/0000-0002-4700-6157
16 Psychological Reports 0(0)

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Author Biographies
Ana M. S. Santos, Master in Clinical Psychology – Integrated Cognitive
Behavioral Psychotherapy since 2015 at Faculdade de Psicologia –
Universidade de Lisboa Currently undertaking another master in Applied
Social Cognition at Faculdade de Psicologia – Universidade de Lisboa.

Rosa F. Novo, PhD in Clinical Psychology on 2001, at the University of Lisbon.

Associate Professor since 2007 at the Faculty of Psychology. Responsible for
teaching of the courses related with Psychological Assessment of Chilren,
Adolesnts and Adults. Clinical Psychologist with regular practice on the
Psychological Assessment and Diagnosis requested by courts, schools and
diverse oficials institutions. Responsible for the Psychological Assessment
Unit at the Public Services of the Faculty of Psychology. Member of the
Research Center of the CICPSI.