Measuring Risk
Interpreting scores on the Kessler
Psychological Distress Scale (K10)
Abstract
Objective: To provide normative data on
the Kessler Psychological Distress Scale
(K10), a scale that is being increasingly
used for clinical and epidemiological
purposes.
Method: The National Survey of Mental
Health And Well-Being was used to provide
normative comparative data on symptoms,
disability, service utilisation and diagnosis
for the range of possible K10 scores.
Results: The K10 is related in predictable
ways to these other measures.
Implications: The K10 is suitable to assess
morbidity in the population, and may be
appropriate for use in clinical practice.
(Aust N Z J Public Health 2001; 25: 494-7)
Submitted: April 2001
Revision requested: September 2001
Accepted: October 2001
494 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH
Gavin Andrews and Tim Slade
World Health Organization Collaborating Centre in Evidence for Mental
Health Policy and School of Psychiatry, University of New South Wales
at St Vincent’s Hospital
I
n 1997, the Australian Bureau of Statis-
tics conducted a household survey on
mental disorders and Mathers et al.
found that mental disorders accounted for
13.5% of the burden of disease, ranking third
behind heart disease and cancers.1,2 A brief
screening scale was needed to identify vari-
ations in the population. When developing
the national survey the authors sought for a
brief symptom scale that might be suitable
for use in other health surveys and might
inform clinicians about the level of morbid-
ity in individual patients. They chose the
scale of psychological distress (K10) devel-
oped by Kessler et al.3-5 In this paper we
present comparative normative data on that
scale from the Australian national survey.
Method
Development of the K10: Kessler and
Mroczek repor ted the development of a
screening battery for non-specific psycho-
logical distress for use in the annual US Na-
tional Health Interview Survey.3,4 They
acknowledged that a number of excellent
scales were in existence but argued that de-
velopments in item response theory would
permit a shorter scale with more informa-
tion than has previously been achieved. They
assembled a large item pool from 22 sources
(list available from GA). The 500 or so items
in those sources were then reviewed and re-
duced to 45 non-redundant items. They en-
sured that the items were relevant to special
populations (adolescents, US racial and eth-
nic groups, rural populations) and covered
Correspondence to:
Professor Gavin Andrews, UNSW at St Vincent’s Hospital, 299 Forbes Street, Darlinghurst,
NSW 2010. Fax: (02) 9332 4316; e-mail: gavina@crufad.unsw.edu.au
Article
16 domains from depression, anxiety and
worry to the physical symptoms of arousal,
fatigue and thoughts of death. These 45 items
were administered by mail to a national sam-
ple of 1,401 respondents, further ref ined and
32 items were administered to another na-
tional sample. They used psychometric mod-
els based on item response theory to analyse
the results of both surveys. On the basis of
each item’s difficulty and discrimination they
selected a 6- and 10-item set that represented
the entire range of distress and was discrimi-
nating along that continuum.5
The 10-item (or K10) scale is:
In the past 30 days how often ...
1. Did you feel tired out for no good rea-
son.
2. Did you feel nervous.
3. Did you feel so nervous that nothing
could calm you down.
4. Did you feel hopeless.
5. Did you feel restless or fidgety.
6. Did you feel so restless that you could
not sit still.
7. Did you feel depressed.
8. Did you feel that everything was an
effort.
9. Did you feel so sad that nothing could
cheer you up.
10.Did you feel worthless.
The scale used a f ive-value response
option for each question – all of the time,
most of the time, some of the time, a little of
the time, and none of the time – that were
scored from f ive through to one. The
maximum score is therefore 50, indicating
severe distress, and the minimum score is
2001 VOL. 25 NO. 6
Measuring Risk The Kessler Psychological Distress Scale (K10)

10, indicating no distress. Items 3 and 6 are not asked if the re- Table 1: Correspondence between psychological
sponse to the preceding question was ‘none of the time’. distress as measured by the K10, and scores for
The K10 scale was a part of the National Survey of Mental Health respondents in that category on the GHQ, the SF-12 (all
measured with respect to the last 30 days), and the
and Well Being conducted in Australia in 1997.1 This was a strati-
frequency of consultations for a mental health problem
fied household survey of a population sample of persons 18 years
over the past year.
and older. The response rate was 78% and 10,641 people were in-
terviewed, all of whom completed the K10. The Composite Inter- K10 % in GHQ SF-12 n of
national Diagnostic Interview v2.06 was used to provide DSM-IV score category score score consultations
(weighted)
diagnoses of the common anxiety, affective and substance use dis-
10-14 67.5 0.3 (0.0) 55.6 (0.1) 0.2 (0.0)
orders. In addition, screening instruments were used for personal-
ity disorders, psychosis and neurasthenia. Disability was measured 15-19 20.4 1.4 (0.1) 48.3 (0.0) 0.9 (0.1)

by the SF-127 and psychological distress by the 12-item GHQ8 and 20-24 7.2 2.4 (0.1) 41.5 (0.4) 1.9 (0.2)

by the K10. Service utilisation was also measured. 25-29 2.7 4.0 (0.2) 34.3 (0.6) 3.4 (0.3)

All scores on all variables were weighted to reflect the compo- 30-34 1.3 5.4 (0.4) 31.2 (1.1) 5.8 (0.9)

sition of the whole population. Routine data analytic procedures 35-39 0.5 5.4 (0.4) 29.2 (1.4) 8.0 (1.3)
were used, but as a result of the complex sample design and weight- 40-50 0.4a 7.6 (0.9) 26.2 (1.5) 10.2 (1.7)
ing the SUDAAN package was used to estimate standard errors Overall mean NA 0.9 (0.0) 52.0 (0.1) 0.7 (0.0)
around prevalence estimates.9 Overall skew NA 3.0 -1.4 6.7
Correlation
with K10 (rho) NA 0.5 -0.6 0.3

Results
The K10 had a mean of 14.2, a median of 12, range 10-50, with
68% of respondents scoring under 15 and 3% scoring 30 and
above (skewness = 2.2). The distribution, like all measures of
psychological distress is heavily skewed (skew 2.2) and the
majority of people report little or no distress. The mean for fe-
males was higher than that for males; 14.5 vs. 13.9 (p<0.001).
The K10 scores were banded into seven categories to facilitate
comparison with the GHQ (a symptom measure that can predict
casedness), the mental health component score of the SF-12 (a
measure of disability), the number of consultations for a mental
health problem in the past year (a measure of met need), and the
probability of meeting criteria for a diagnosis either currently or
in the past 12 months. The results comparing the K10 Scores with
those of the GHQ, the SF-12 and the frequency of mental health
consultations are displayed in Table 1. The correspondence be-
tween K10 scores and the probability of being identified as a
Notes:
(a) 0.4% equals 45 respondents before weighting back to the population.
current DSM-IV or ICD-10 case by the CIDI is respectively dis-
played in Tables 2 and 3 in respect to any anxiety, affective, sub-
stance use or personality disorder and for any disorder identif ied
in the survey. Similar data in respect to cases that met criteria for
one of these diagnoses at some point in the previous 12 months
are displayed in Tables 4 and 5. The sensitivity and specif icity of
the K10 as a marker for diagnosis of any current DSM-IV or ICD-
10 anxiety or affective disorders is displayed in Table 6.
Discussion
There is a significant association between scores on the K10
and scores on the GHQ and SF-12, measures of symptoms and
disability respectively, and between the K10 and the number of

Table 2: Correspondence between psychological distress as measured by the K10 and the probability of meeting
criteria for a current DSM-IV mental disorder (exclusion criteria operationalised) for respondents scoring in each K10
category.

K10 score Anxiety disorder Affective disorder Substance use Any study disorder
(weighted) prevalence % (SE) prevalence % (SE) disorder prevalence prevalence
% (SE) % (SE)
10-14 0.5 (0.1) 0.2 (0.1) 1.8 (0.2) 5.4 (0.3)
15-19 3.8 (0.4) 3.0 (0.4) 4.8 (0.5) 17.8 (0.9)
20-24 12.6 (1.3) 10.4 (1.2) 8.4 (1.1) 35.7 (2.0)
25-29 27.3 (2.4) 27.5 (3.0) 10.6 (1.8) 58.9 (3.5)
30-34 39.9 (3.1) 54.2 (5.6) 10.0 (2.7) 76.3 (5.1)
35-39 55.5 (8.1) 62.5 (7.2) 16.8 (5.4) 84.0 (5.9)
40-50 59.1 (8.9) 73.2 (8.8) 16.3 (4.8) 87.5 (7.3)
Overall prevalence 3.8 (0.2) 3.5 (0.2) 3.4 (0.2) 13.1 (0.4)
Chi square df=6 p<0.0001 441.02 381.11 166.40 848.57

2001 VOL. 25 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 495
Andrews and Slade Article

Table 3: Correspondence between psychological distress as measured by the K10 and the probability of meeting
criteria for a current ICD-10 mental disorder (exclusion criteria operationalised) for respondents scoring in each K10
category.

K10 score Anxiety disorder Affective disorder Substance use Personality Any study
(weighted) prevalence prevalence disorder disorder disorder
% (SE) % (SE) prevalence prevalence prevalence
% (SE) % (SE) % (SE)
10-14 1.1 (0.2) 0.2 (0.1) 1.4 (0.2) 1.7 (0.2) 5.4 (0.4)
15-19 6.8 (0.5) 3.5 (0.4) 3.8 (0.5) 7.1 (0.6) 19.0 (0.8)
20-24 18.7 (1.7) 11.8 (1.3) 8.2 (1.3) 16.4 (1.2) 41.2 (1.7)
25-29 31.8 (3.4) 30.3 (3.4) 9.4 (1.5) 26.5 (3.2) 61.4 (3.6)
30-34 42.1 (3.1) 54.9 (6.2) 10.5 (2.6) 30.2 (4.7) 77.1 (5.0)
35-39 65.1 (7.5) 62.9 (6.6) 17.6 (4.9) 42.2 (5.6) 86.1 (6.1)
40-50 75.0 (7.3) 74.5 (8.7) 15.1 (4.9) 43.6 (7.7) 89.1 (5.5)
Overall prevalence 5.5 (0.3) 3.8 (0.2) 2.8 (0.2) 5.2 (0.2) 13.9 (0.5)
Chi square df=6 p<0.0001 529.82 359.56 187.41 274.66 966.19

consultations for a mental problem in the previous 12 months.
These findings support the validity of the K10 as a measure of
psychological distress. The K10 is to be preferred over the GHQ
because of the larger range and because the K10 is in the public
domain and may be used without charge, whereas the GHQ is
proprietary and is paid for each time it is used. The K10 is to be
preferred over the SF-12 because it was designed as a measure of
distress not disability and because it is simpler to administer and
score. The K10 is to be preferred over the number of consulta-
tions because consulting is a measure of met need, not morbidity.
There is a strong association between a high score on the K10
and a current CIDI diagnosis of anxiety and affective disorders
and a lesser, but still significant association between the K10 and
other mental disorder categories, or the presence of any current
mental disorder. The associations between the K10 and mental
disorders identified in the previous 12 months are also signifi-
cant and similar to the corresponding category of current disor-
der. The sensitivity and specificity data make it clear that the K10
is appropriate as a screening instrument to identify likely cases in
the community but further work is need to determine whether the
cutoff points given in www.crufad.org for clinical decision mak-
ing are correct.
The questions in the K10 focus on anxiety and depression, the
usual focus of scales that measure psychological distress. There
are no questions directed at identifying people with psychosis
simply because identifying people with psychosis by brief ques-
tionnaire is difficult. This would be important if the K10 was
used as an outcome measure in people with psychosis, but when
used with people with the common mental disorders this is not a
problem. If used to estimate the needs of a population for com-
munity mental health services, the K10 may still be appropriate,
simply because people with psychosis do get distressed. The preva-
lence of psychosis (0.4%) is so low that estimates based on the
K10 would not seriously under-estimate population need. There
are no data in the present study to inform about the test retest
reliability of the K10. There are no data to show that the K10 is
sensitive to change, whether that is occurring naturally or due to
the effects of treatment. Both sets of work are required.
There have been a number of consequences of the inclusion of
the K10 in the national survey. The K10 is promoted on a website

Table 4: Correspondence between psychological distress as measured by the K10 from symptoms in the past 30 days
and the probability of meeting criteria for a DSM-IV mental disorder (exclusion criteria operationalised) sometime in the
previous 12 months. Includes current cases for respondents in each K10 category.

K10 score Anxiety disorder Affective disorder Substance use Any study disorder
(weighted) prevalence % (SE) prevalence % (SE) disorder prevalence prevalence
% (SE) % (SE)
10-14 1.4 (0.2) 1.8 (0.2) 4.7 (0.3) 10.4 (0.5)
15-19 6.6 (0.6) 7.8 (0.7) 11.6 (0.8) 29.2 (1.2)
20-24 17.4 (1.1) 19.2 (1.8) 18.2 (1.8) 48.5 (2.3)
25-29 32.1 (3.5) 37.9 (3.4) 17.8 (2.7) 69.4 (3.1)
30-34 47.7 (4.3) 56.8 (5.6) 19.3 (4.6) 82.4 (3.8)
35-39 61.8 (7.0) 68.5 (6.5) 23.3 (4.9) 88.9 (4.6)
40-50 68.1 (8.7) 77.8 (8.2) 34.9 (7.0) 94.0 (4.2)
Overall prevalence 5.6 (0.2) 6.6 (0.3) 7.9 (0.2) 20.2 (0.5)
Chi square df=6, p<0.0001 664.00 446.16 299.86 1298.48

496 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2001 VOL. 25 NO. 6
Measuring Risk The Kessler Psychological Distress Scale (K10)

Table 5: Correspondence between psychological distress as measured by the K10 from symptoms in the past 30 days
and the probability of meeting criteria for a ICD-10 mental disorder (exclusion criteria operationalised) sometime in the
previous 12 months. Includes current cases for respondents in each K10 category.

K10 score Anxiety disorder Affective disorder Substance use Personality Any study
(weighted) prevalence prevalence disorder disorder disorder
% (SE) % (SE) prevalence prevalence prevalence
% (SE) % (SE) % (SE)
10-14 3.7 (0.3) 2.0 (0.2) 4.3 (0.3) 2.2 (0.2) 12.0 (0.6)
15-19 12.6 (0.7) 9.0 (0.8) 11.6 (0.9) 9.1 (0.7) 33.0 (1.1)
20-24 27.8 (2.0) 21.2 (2.0) 18.3 (1.7) 20.0 (1.7) 55.2 (2.3)
25-29 43.6 (3.8) 41.3 (3.8) 18.6 (2.6) 30.3 (3.5) 74.8 (3.3)
30-34 51.1 (4.6) 57.9 (6.2) 19.3 (4.4) 37.3 (6.0) 84.7 (3.6)
35-39 78.3 (5.0) 69.9 (5.8) 25.4 (5.4) 42.9 (5.8) 91.1 (4.6)
40-50 86.2 (5.8) 79.1 (8.3) 33.3 (7.2) 51.6 (7.2) 99.0 (1.0)
Overall prevalence 9.6 (0.3) 7.2 (0.3) 7.6 (0.3) 6.5 (0.3) 22.7 (0.6)
Chi square df =6, p<0.0001 501.63 351.23 286.96 278.75 1029.88

(www.crufad.org) as a self-report measure to identify need for Table 6: Sensitivity and specificity of the K10 in
treatment. The K10 scale has been chosen for routine public health identifying people who met CIDI criteria for any current
telephone surveys in a number of Australian States, for the ABS anxiety or affective disorder (prevalence 7.1%).
regular survey of Australian health and for routine use in all
K10 score Sensitivity Specificity
patients in contact with the mental health services in NSW. It is greater than (hit rate) correct (rejection
being considered as a routine outcome measure in other States. It or equal to rate)
is widely recommended as a simple measure of outcome follow- 14 0.94 0.63
ing treatment for the common mental disorders. To illuminate these 15 0.90 0.72
uses this paper has presented normative data on the K10 but ad- 16 0.86 0.78
ditional data are required from sources other than the National 17 0.81 0.83
Survey to support the present wide use of the K10. 18 0.77 0.87
19 0.71 0.90
20 0.66 0.92
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2001 VOL. 25 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 497