measures of self-perceived well-being

Journal of Psychosomatic Research 69 (2010) 69–79

Review articles

Measures of self-perceived well-being

Ian McDowell⁎

Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada

Received 31 January 2009; received in revised form 15 June 2009; accepted 7 July 2009

Abstract

As people lead longer and generally healthier lives, aspirationsand expectations of health care extend to include well-being andenhanced quality of life. Several measurement scales exist toevaluate how well health care reaches these goals. However, thedefinitions of well-being or quality of life remain open toconsiderable debate, which complicates the design, validation,and subsequent choice of an appropriate measurement. Objective:This article reviews nine measures of psychological well-being,tracing their origins in alternative conceptual approaches todefining well-being. It compares their psychometric propertiesand suggests how they may be used. Methods: The review coversthe Life Satisfaction Index, the Bradburn Affect Balance Scale,single-item measures, the Philadelphia Morale scale, the General

⁎ Department of Epidemiology and Community Medicine, Faculty ofMedicine, University of Ottawa, 451 Smyth Rd, Ottawa, Ontario, CanadaK1H 8M5. Tel.: +1 613 562 5800x8284; fax: +1 613 562 5465.

E-mail address: [email protected].

0022-3999/09/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.jpsychores.2009.07.002

Well-Being Schedule, the Satisfaction With Life scale, the Positiveand Negative Affect Scale, the World Health Organization 5-itemwell-being index, and the Ryff's scales of psychological well-being. Results: Scales range in size from a single item to 22; levelsof reliability and validity range from good to excellent, althoughfor some of the newer scales we lack information on some forms ofvalidity. Conclusion: Measures exist to assess several conceptionsof psychological well-being. Most instruments perform adequatelyfor survey research, but we know less about their adequacy for usein evaluating health care interventions. There remains active debateover how adequately the questions included portray the theoreticaldefinition of well-being on which they are based.© 2010 Elsevier Inc. All rights reserved.

Keywords: Psychological well-being; Happiness; Life satisfaction; Health measurement; Evaluation

Introduction

As therapeutic advances raised expectations for health,the focus of health measurements broadened, from recordingdeath, disease, and disability toward function, thence to well-being and, most recently, to health-related quality of life.This was foreshadowed by the World Health Organization's(WHO) 1948 definition of health in terms of “physical,mental, and social well-being, and not merely the absence ofdisease and infirmity” [1] (p. 459). “Well-being” is nowcommonly proposed as a theme for outcome measures as itreflects the expanded goals of treatment, from medicaltreatment toward broader health care.

Early measures of well-being recorded it in terms of theabsence of distress, so scales from the 1930s and 1940scontained checklists of behavioral and somatic symptoms ofdistress. Distress is relevant as it forms a common stimulusfor seeking care. Furthermore, observable symptoms wereconsidered appropriate for a generation of people who couldbe reticent in responding to questions about their feelings. Forexample, Macmillan felt it necessary to conceal the intent ofhis 1951 psychological screening scale, naming it the “HealthOpinion Survey” to conceal its true intent [2]. Unfortunately,symptom checklists almost certainly misclassified somephysical disorders as psychological; they can also only detectrelatively severe forms of disorder and only emotionaldistress that is manifested somatically or behaviorally.

Over time, the argument that people will not respondhonestly to direct questions about their emotional well-beingpassed from favor. Gurin, and later Bradburn, led amovement toward asking directly about feelings of happi-ness and emotional well-being. This reflected growing

http://dx.doi.org/10.1016/j.jpsychores.2009.07.002

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70 I. McDowell / Journal of Psychosomatic Research 69 (2010) 69–79

interest in positive mental health, which may be traced back,through Jahoda's work [3], to the WHO conception ofhealth. The new measures recorded affective responses—thefeeling states inspired by daily experience. They approachedsubjective well-being as a cognitive process in which peoplecompare their perceptions of their current situation with theiraspirations. This led logically to defining well-being in termsof morale and life satisfaction, as with the 1961 LifeSatisfaction Index (LSI) and the 1972 Philadelphia GeriatricCenter Morale Scale. While patient autonomy was becominga central theme in medical ethics, subjective patientassessments came to play a prominent role in measuringthe outcomes of care.

However, symptom checklists were not completelyabandoned. Despite their limitations, numerous studiesshowed close agreement between checklists and psychiatricratings, so scales such as Goldberg's 1972 General HealthQuestionnaire [4], and Dupuy's [5] 1977 General Well-BeingSchedule (GWB) combined symptom checklists with ques-tions on feelings to form a hybrid. Scales that are more recenthave distinguished separate facets of well-being; Ryff'sscales of psychological well-being are a leading example.

Conceptions of well-being

At its core, well-being refers to contentment, satisfaction,or happiness derived from optimal functioning. This neednot imply perfect function; it is subjective and is a relative,rather than an absolute, concept. The reference point forjudging well-being is person's own aspirations, based on ablend of objective reality and their subjective reactions to it[6]. However, this brings measurement challenges. Just as aperson's objective health status can change over time, so cantheir aspirations. For example, there is the “hedonic tread-mill,” in which gaining success or possessions further raisesexpectations and aspirations [7]. On the other hand, it canchange in the other direction, as when a person adapts todeclining health with lowered expectations and thereby feelscontent [8]. Overall, interpreting subjective judgments ofwell-being is complex. Indeed, it challenges the wholenotion of validity: either we can consider subjectivejudgments, such as expressions of feelings, as inherentlyvalid or we continue to try and test their validity bycomparing them with objective reality despite acknowl-edging that the latter is not an ideal criterion.

Well-being can be assessed in each domain of health:physical, emotional, social, and spiritual; these sum toproduce judgments of health-related quality of life. Sub-jective well-being is perceived through filters of personalityand of cognitive and emotional judgment; it implies apositive self-appraisal. Therefore, a woman with a disabilitycan report feelings of emotional well-being; within theconstraints of her incapacity, she may feel perfectly well.Likewise, social well-being is judged not merely in factualterms of how many friends she has but of how satisfactory

she judges her social network to be. This article focuses onmeasures of psychological well-being. The relevance ofpsychological well-being was underscored by a review of 35prospective studies by Chida and Steptoe [9], showing that ininitially healthy samples, positive well-being significantlypredicted lower subsequent mortality, with a hazard ratio of0.82. Positive well-being was even slightly associated withlowered mortality in patient samples. Ryff and Singer [10]have made an extensive review of the health benefits ofpositive psychological experiences.

Despite general agreement that well-being is a subjectivefeeling state in which positive feelings predominate, there isdisagreement over more detailed ingredients of its definition.In the light of the long debate over how to define health,perhaps this should not surprise us, and Ryff [11] traced thedebate back to Greek and Roman times, also linking it toEastern philosophies. The diverging views are often groupedunder two broad perspectives [12,13]. The first hedonistictradition is built on the notion that the goal of living is tomaximize happiness and reduce pain; the focus is onsubjective well-being—the pleasure and satisfaction ofachieving one's goals, whatever these may be. In theformulation of Diener et al. [14], this involves two emotionalcomponents: positive affect combined with the absence ofnegative affect, and one cognitive element: life satisfaction,which refers to the person's internal subjective assessment oftheir overall quality of life. Measurements based on thehedonic perspective commonly take an overall summaryapproach rather than separating different subcomponents ofwell-being. In Diener's words, “although health, energy, andso forth, may be desirable, particular individuals may placedifferent values on them,” so forming an overall ratingshould be left to the individual's subjective valuation.Measures of this type include the LSI, Diener's ownSatisfaction With Life scale (SWLS), or the items fromBradburn's Affect Balance Scale (ABS): “During the pastfew weeks, did you ever feel … proud because someonecomplimented you on something you had done?” or “… thatthings were going your way?” It is also implied in the overallquestion “Taking everything into consideration, how wouldyou describe your health today? Excellent, very good, good,fair, or poor?”

The rival eudaimonistic perspective criticizes the exclu-sive focus on pleasure as being too narrowly self-indulgent;man should aspire higher than a life of mere pleasure.Instead, true psychological well-being derives from personalgrowth and from actively contributing: giving rather thanmerely receiving, enjoyment rather than merely pleasure[15]. Eudaimonism is an ethical theory that calls people tolive in accord with their true self, their daimon [13]. This isan ideal “of excellence towards which one strives, and itgives meaning and direction to one's life.” [16] (p. 1070).This perspective is portrayed by many theorists of well-being: Maslow's theme of self-actualization; Rogers's fullyfunctioning person; Heath's maturing person, Seeman'stheory of personality integration, or the University of

71I. McDowell / Journal of Psychosomatic Research 69 (2010) 69–79

Chicago school, among others [11,17]. The hedonist focuson individualism also rings false in more collectivist cultures[18]. The eudaimonic perspective shifts focus subtly fromsubjective to psychological well-being, emphasizing con-tinued personal growth and adaptation, and holding virtueand doing what is right as values. Happiness becomes apleasant result but is no longer the core. In place ofenjoyment, this perspective implies vitality, activation, andself-actualization [12]. Measurement methods include Ryff'smultidimensional scale that covers six aspects of well-beingwith items such as “For me, life has been a continuousprocess of learning, changing, and growth.”

Despite their contrasts, the hedonic and eudaimonic viewsare not independent, and this has been shown empirically.Waterman [13] has shown an asymmetrical relationship inwhich eudaimonic personal fulfillment will lead to pleasure,but that pleasure has many other sources so does not implyeudaimonic well-being. An analysis of a variety of well-being measures suggested a correlation of 0.36 between thetwo main components, labeled subjective well-being andpersonal growth (Table 2 in reference [17]). The topic ofcontrasting, yet overlapping, theoretical perspectives recallsthe long discussions of positive and negative affect. This wasderived from Bradburn's somewhat surprising finding in the1960s that positive and negative affects formed distinctdimensions, rather than simply being opposite ends of asingle continuum of well-being. This finding furtherstimulated investigation of positive well-being, rather thanmerely inferring it from the absence of negative feelings [7].The debate over the independence of positive and negative

Fig. 1. Example of a circumpl

feelings has endured [19]; some still view them as polaropposites [20], others as distinct but correlated aspects ofemotion [21], or else as deriving from other major axes:Pleasure–Displeasure, Arousal–Nonarousal, and Domi-nance–Submissiveness [22]. Different cultural perspectiveshave also been heard: a Buddhist perspective, for example,portrayed well-being as a balance between opposites on fourseparate dimensions [23].

For those who think visually, a conceptual map of moodstates may help to make sense of these debates, as shown inFig. 1. This is a general representation of a variety of suchdiagrams, proposed since the 1970s and called circumplexmodels of affect; several are reviewed by Russell and Carroll[20] and by Watson et al. [24]. This schematic portrays amoderate inverse correlation between positive (on the N-Saxis) and negative affect (NW-SE axis). Clearly, the anglesbetween these axes can be debated and will reflect details oftheir precise definition; the intention here is to illustrate thegeneral idea. The diagram also allows us to map theeudaimonic themes of activation and engagement, shown onthe NE-SW axis, while a theme close to the hedonic viewruns along a NNW-SSE axis. The diagram could also be usedto illustrate the conceptual coverage of measurement scales.For example, many distress scales cover the SE corner of thediagram, while depression scales would be in the SSEquadrant and anxiety scales may lie roughly in the E and ESEquadrants; morale scales cover the NNW quadrant. The SWsector might be covered by measures of social withdrawal.The scales of psychological and subjective well-beingreviewed here mainly fall in the WNW to the ENE sector.

ex model of well-being.


Review of measurement scales

Nine scales are chosen for review; they represent differentconceptualizations of well-being. Any selection of methodsfor review is subjective, and space constraints forced theomission of several worthy scales. I have included someolder scales to give a historical perspective, as manysubsequent scales were developed out of criticisms of theearlier instruments. For simplicity, scales are presented inchronological order of their creation.

The LSI (B.L. Neugarten and R.J. Havighurst, 1961)

The LSI records general feelings of well-being amongolder people in the general population to identify successfulaging [25]. The authors viewed life satisfaction as closelyrelated to morale, adjustment, and psychological well-being.They identified five components: zest (as opposed toapathy), resolution and fortitude, congruence among desiredand achieved goals, a positive self-concept, and mood tone[25]. Positive well-being is indicated by the individualderiving pleasure from his daily activities, finding lifemeaningful, reporting a feeling of success in achieving majorgoals, having a positive self-image, and maintainingoptimism [25].

The original, version A (LSIA), has 12 positive and 8negative items with 3-point agree/disagree/uncertainresponse scales. A subsequent version, the LSIZ, wasproposed as a refinement of the LSIA and retains 13 of the20 items [26]. The items take the form of agree/disagreestatements, such as “As I grow older, things seem better thanI thought they would be”; “These are the best years of mylife,” or “When I think back over my life, I didn't get most ofthe important things I wanted.”

Estimates of internal consistency range from 0.7 to 0.9[27]; retest reliability estimates fall in the range 0.8 to 0.9[28]. Many factor analyses have tested the correspondence ofthe LSIA to the intended five-component structure. Theresults are mixed, but very few analyses identified all fivecomponents [29–31].

Convergent validity has been studied extensively, but theresults do not show high correlations. For example,Neugarten et al. reported a correlation of 0.55 between theLSIA and the longer Life Satisfaction Rating Scale; a secondstudy reported a correlation of 0.56 between the same scales[32]. Correlations with the Bradburn positive and negativeaffect scores have often been reported, generally rangingfrom 0.30 to 0.45 [33,34].

The LSIAwas one of the earliest scales to cover the themeof satisfaction, morale, or well-being; its coverage of topicssuch as self-concept and zest recalls the eudaimonisticperspective, but in practice, most of the items are phrasednegatively, and it is not clear that the scale really does matchthe scope of Neugarten's conceptual framework. The LSIAhas seen reasonably wide psychometric testing; the results

are comparable with those for other equivalent scales. It stillsees some use. The chief debate has surrounded quite whatthe LSIA does measure. For example, whereas a single scoreis often used, the scale covers more than one dimension,although apparently not the five originally postulated [35].The history of the LSIA illustrates how difficult it is to findempirical measures that distinguish between related conceptssuch as pleasure, meaningfulness, satisfaction, etc. Therecurring debate over how many dimensions of well-beingcan be contained in a single measure is picked up by analysesof subsequent scales.

The ABS (Norman M. Bradburn, 1965)

Bradburn's 10 questions were designed to indicate thepositive and negative psychological reactions of people inthe general population to events in their daily lives.Bradburn described his scale as an indicator of happinessor of general psychological well-being; these reflect anindividual's ability to cope with the stresses of everydayliving. The scale was not intended to detect psychologicalor psychiatric disorders [36].

Originally, Bradburn and Caplovitz [37] proposed thatsubjective well-being could be indicated by a person'sposition on two dimensions, termed positive and negativeaffect. Overall well-being is expressed as the balancebetween these two compensatory forces: positive experi-ences such as being complimented on something couldcompensate for negative feelings. The “affect balance score”represents this theme. Subsequent testing indicated thatpositive and negative feelings varied independently of oneanother and should not be seem as opposite ends of a singlecontinuum of well-being. A man could have an argumentwith his wife; this may increase their negative feelingswithout changing their underlying positive affect [37].

The wording of the 10 questions has remained constant inmost studies, and a three-point frequency response scale(“often,” “sometimes,” “never”) is most commonly used.Positive and negative scores are generally calculated, and theaffect balance score is the positive score minus the negative(zero represents balance). The questions and a detailedreview of validity and reliability are shown in reference [27](pp. 221–225).

Internal consistency of the scales generally lies between0.6 and 0.75. Watson et al. [38] cited these relatively lowvalues in justifying their development of the Positive andNegative Affect Scales (PANAS). The independence ofpositive and negative affect scores and their lack ofassociation with age have been widely replicated and haveoccasioned extended debate over possible methodologicalreasons for this [39–42]. The ABS has been extensivelyvalidated in social surveys and discriminates betweenemployed and unemployed [40,43], between rich and poor,and among occupational grades [36]. Positive affect scoresrelate to social participation, satisfaction with social life, and


engaging in novel activities [39,41,43,44]. There is moderateevidence for convergent validity in patient samples.Correlations with neurosis and anxiety scales tend to belower than those obtained using purpose-built scales.

The Bradburn scale was innovative in including bothpositive and negative questions; it has been widely used andhas exerted a major influence over the subsequent develop-ment of the field. At the same time, both conceptual andmethodological criticisms have been made [39,41,42,44].The somewhat surprising finding of statistical independencebetween positive and negative affect may merely be anartifact of the question phrasing, a possibility that Bradburnhad recognized [36]. It proves very hard to write good itemsto represent subtle contrasts, such as that between satisfac-tion and morale. While Bradburn's questions focus on affect,they also cover activation or participation, somethingbroader than a hedonic model [39]. Reflecting this, Beiseret al. [41,44] altered the term positive affect to pleasurableinvolvement.

While Bradburn's two-dimensional model may be anoversimplification [39], other researchers took a yet simplerapproach, proposing that respondents could summarize theirwell-being by answering a single question.

Single-item health indicators (Various authors, circa1965 onward)

A single question on well-being, along the lines of“Taking everything into consideration, how would you sayyou are today—excellent, very good, good, fair or poor?”offers a summary indicator of subjective well-being. Thisformat could be applied to several aspects of health: health orquality of life in general, life satisfaction, or specific feelings[45]. Questions of this type are frequently used in surveysand are on the US Institute of Medicine's list of eightnational health outcome indicators. This is because empiricalstudies have shown that such questions are capable ofexplaining variance in mortality, even after adjustment forconventional risk factors and other clinical information [46].

There are several formats for such questions, asreviewed in several sources [47–50]. Five variants areworthy of mention.

1. In the Delighted–Terrible scale, respondents are told“We want to find out how you feel about various partsof your life. Please indicate the feelings you have now—taking into account what has happened in the lastyear and what you expect in the near future…. How doyou feel about __________? (your health, quality oflife, etc.).” The seven-point response scale ranges from“delighted” to “terrible” [48].

2. The Faces Scale includes seven stylized drawings, eachcomprising a circle with eyes and a mouth that varies inshape from a smile of almost a half-circle to an invertedhalf-circle, representing gloom [27] (p. 579). A typical

instruction reads “Here are some faces expressingvarious feelings …. Which face comes closest toexpressing how you feel?” [48] (p. 5). The scale hasalso been adapted to depict levels of pain [51].

3. The Ladder Scale was proposed byHadley Cantril [52].In a drawing of a ladder with nine rungs, the top islabeled “best I could expect to have” and the bottom“worst I could expect to have.” Respondents indicatewhere on the ladder they place their current well-being(or health, quality of life, etc.). They can then alsoindicate where they hope to be in a year and where theywere last year. The scale is often termed self-anchoringbecause ratings are made relative to the person's ownconception ofminimum andmaximum life satisfaction.

4. Visual Analogue Scale. A 10-cm line represents acontinuum from the worst possible to perfect well-being; the respondent marks the line to indicate his orher current status. The line may include labels at eachend indicating the range being considered, butnumbers or hatch marks are not placed along thescale to avoid clustering of responses [53]. Variantsinclude drawing the line vertically with intermediatemarkings [54], sometimes called a mood thermometer.

5. Summary Self-Rating Question. Wording varies, but atypical example would be “In general, would you sayyour health today is: excellent? very good? good? fair?poor?” [53]. Alternative phrasings were given by Idlerand Benyamini [46] and in reference [27] (p. 581).

Test stability for single items appears to range fromaround 0.7 to 0.8 for a brief time interval to around 0.4 for a2-year interval [27]. Validity results commonly showsurprisingly high correlations between single-item indicatorsand much longer scales. Convergent correlations have beenreported with life satisfaction scales, with anxiety anddepression measures, and with general health measures suchas the Health Utilities Index. Correlations range from 0.5 toaround 0.75, suggesting that a substantial amount of thevariance in much longer scales can be captured by a singlequestion (see reference [27], pp. 578–587 for a detailedreview). Perhaps the most striking finding, however, is thatnumerous longitudinal studies have confirmed predictivevalidity associations between self-rating scores and subse-quent mortality, even after controlling for other risk factors[9,46,55–57]. In Idler and Benyamini's summary [46], 23 of27 studies reported that a self-rating question explainedvariance in mortality after controlling for age, socioeco-nomic status, and, in several studies, chronic conditions andselected medical risk factors.

Single-item scales are attractive for surveys: they arecost-effective and simple to apply, and a nonverbal formatavoids translation issues in cross-cultural research. Apictorial format such as the faces scale may also directlytap into the feelings associated with well-being withoutlanguage filtering. There are also limitations to suchmeasures. Some respondents have difficulty in merging


multiple issues into a single average rating [58]. Care isrequired especially with elderly patients, among whom aresponse shift may occur due to their declining expecta-tions; this may especially occur when the question isphrased in terms of comparisons with other people their age[8]. Single-item scales may also be more sensitive thanmulti-item scales to contextual effects from the precedingquestions in a survey. For example, if the single item waspreceded by a section on depression, answers will tend tobe more negative than if the item was preceded by a sectionon well-being. Multi-item scales dilute this effect becausethe items in the scale form the cognitive reference for eachother and the score is based on the set of items.

The Philadelphia Geriatric Center Morale Scale(M. Powell Lawton, 1972)

This scale was designed to measure three dimensions ofemotional adjustment in persons aged 70 to 90, either incommunity or institutional settings. Lawton viewed moraleas “a generalized feeling of well-being with diverse specificindicators …. The person of high morale has a feeling ofhaving attained something in his life and of being useful nowand thinks of himself as an adequate person” [59].

The scale includes 17 dichotomously scored items, suchas “As you get older, you feel less useful”; “I am as happynow as I was when I was younger”; “I take things hard.”Compared with other scales, more of the items are wordednegatively. Liang and Bollen [60] suggested that scores becalculated to form three subscales (agitation, lonelydissatisfaction, and attitudes toward one's own aging), andthis has been widely followed; an overall score reflectingglobal life satisfaction can also be formed.

Evidence for reliability and validity are modest; internalconsistency of the subscales, for example, is typically around0.6 [27] (p. 236–240). Factor analyses generally produce thethree factors mentioned above [61–63]. A second-orderfactor representing general well-being has also been obtained[60]. Correlations with the LSIA range from 0.55 to 0.75[59,64] and 0.6 with the negative score on the Bradburn scale[33].

This scale, intended for elderly people, offers analternative to the LSIA. It has been quite widely used andcovers more than a single dimension of well-being. It lacksextensive information on agreement with other well-beingscales, however, and also focuses on the negative end of thewell-being spectrum, so it represents an approach to agingthat was later superseded by Ryff's emphasis on positiveaspects of successful aging.

The GWB (Harold J. Dupuy, 1977)

The GWB offers a brief but broad-ranging indicator ofsubjective feelings of psychological well-being and distressfor use in community surveys. Reflecting the theories of Kurt

Lewin, the scale is designed to assess how the individualfeels about his “inner personal state” rather than aboutexternal conditions such as income, work environment, orneighborhood [5]. The scale covers positive and negativefeelings; six dimensions assessed include positive well-being, self-control, vitality, anxiety, depression, and generalhealth—picking up themes of the eudaimonistic perspective.The 18 items take the form of questions with six-pointanswer scales (“How have you been feeling in general duringthe past month?”; “Have you been under or felt you wereunder any strain, stress, or pressure?”); they are shown inreference [27] (p. 241). A total score and six subscores maybe calculated.

Substantial evidence exists for the reliability and validityof the GWB. Retest reliability results fall between 0.68 and0.85 [27]; several studies have recorded internal consistencyvalues over 0.90 [5,65–67]. Factor analyses typicallyproduce three or four correlated factors, supporting the useof a single score. Most of the validity information comesfrom correlations with other self-report scales; convergentcorrelations typically fall in the range of 0.65 to 0.8 [27].

In addition to the 18-item version, Dupuy [68] proposed a22-item version named the Psychological General Well-Being index (PGWB). This appears to show a factorstructure more closely resembling the originally hypothe-sized six components [66,68]. Reliability and validity resultsare again very good, with correlations between the PGWBand leading depression scales in the range −0.68 to −0.77[68]. α reliability for the PGWB ranged from 0.90 to 0.94 inseven samples [68]. Fifteen of the GWB items were includedin the RAND Mental Health Inventory [66,69].

The GWB extends the theme of positive well-being intoseparate dimensions. Some debate has arisen over the mostuseful way to score the GWB: as the internal consistency isvery high, subscores may be redundant. However it isscored, the GWB and PGWB offer valuable populationindicators of subjective well-being. In this, they stand incontrast to the other leading scale, Goldberg's GeneralHealth Questionnaire, which is intended chiefly to detectdiagnosable psychiatric disorder and which is therefore notreviewed here.

The SWLS (E. Diener, 1985)

In Diener's formulation, subjective well-being includesthe emotional components of positive affect and theabsence of negative affect, plus one cognitive element:life satisfaction, which refers to the person's internal,subjective assessment of their overall quality of life. Heargued that most measures had neglected the theme of lifesatisfaction [70]. The SWLS offers a brief measure ofpeople's global satisfaction with their lives, originallydesigned for survey use. It provides an overall summaryapproach rather than indicating separate facets of satisfac-tion [14,70].


There are five items: “In most ways my life is close to myideal”; “The conditions of my life are excellent”; “I amsatisfied with my life”; “So far I have gotten the importantthings I want in life”; and “If I could live my life over, Iwould change almost nothing” [14]. Responses use a 1 to 7Likert scale; a score of 20 represents the neutral point.

Reliability and validity have been tested in numerousstudies in many countries [70,71]. Internal consistency of thescale is appropriate, with α coefficients in nine studiesranging from 0.79 to 0.89 [17,70,72] and item-totalcorrelations ranging from 0.51 to 0.80 [70]. Test–retestcoefficients range from 0.5 to 0.84 [71]. Principal compo-nents analyses typically identify a single factor.

Evidence for validity was based initially on correlationswith other scales. Pavot and Diener [70] summarized 15convergent validity coefficients from nine studies; they allfell within the range of 0.45 to 0.82. Other results includecorrelations of 0.46, 0.50, and 0.51 with the positive scoreon Bradburn scale [14,17] and −0.37 and −0.32 with thenegative score. Correlations with Cantril's ladder scalewere 0.62 and 0.66 [14]. Correlations included 0.46 withthe LSI and 0.58 with Ryff's Scales of Psychological Well-Being [17]. Correlations with the positive scale of thePANAS ranged from 0.3 to 0.52; correlations with thenegative scale ran from −0.26 to −0.48 [72]. More recently,studies have shown the SWLS to be sensitive to change[71], even though one might expect life satisfaction torepresent a relatively enduring judgment. Pavot and Dienerlist normative data from over 30 samples (Table 1 inreference [17]), and cite nine translations.

The SWLS is brief and practical to apply; it represents thehedonic approach to well-being, focusing solidly on thepleasure and satisfaction of achieving one's goals. In this, itappears complementary to another five-item scale, the WorldHealth Organization 5-item well-being index (WHO-5)

Table 1Summary comparison of the well-being scales

ScaleNo. ofitems Administration Time Reliability Validity

1. LSI 20 Self,interviewer

5 min *** ***

2. ABS 10 Self 4 min ** **3. Single items 1 Self,

interviewer30 s ** **

4. PhiladelphiaMorale

22 Self 5 min ** **

5. GWB 18 Self 4 min *** ***6. Satisfaction

With Life5 Self 1 – 2

min** **

7. Positive andNegative Affect

20 Self 4 min *** ***

8. WHO-5 5 Self 1 – 2min

** ***

9. Ryff 18 Self,interviewer

5 min ** **

** indicates good reliability or validity; *** indicates excellent reliabilityor validity.

described below, which takes a more eudaimonisticapproach. Validity analyses of the scale have also shed lighton conceptual debates over the nature of life satisfaction: towhat extent does it, for example, reflect “top-down”influences such as personality vs. a summation of “bottom-up” influences such as current life circumstances and mood?Empirical results suggest a mixture of both, so the SWLS candetect short-term mood fluctuations, as tempered by long-term personality characteristics [71,73]. Pavot and Diener[71] (p. 140) conclude that life satisfaction chiefly reflectspersonality characteristics and longer-term contextual lifeevents such as unemployment or widowhood; transient moodstates have an influence, “but these ‘noise’ variablesgenerally do not eliminate the ‘signal’ of life satisfaction.”

The PANAS (D. Watson, L.A. Clark and A. Tellegen,1988)

The PANAS provides a brief measure of positive andnegative affect, developed partly out of criticisms of theBradburn scale. It has been used mainly in studies of moodstates rather than in evaluative studies of health care [38].Mood may be measured in terms of specific types of affectsuch as depression or anxiety, or with nonspecific scales.Watson and Clark [19] argued that these represent differentlevels in a hierarchical structure in which generalizedpositive and negative affects underlie more specific repre-sentations, such as anxiety, depression, or fear. They furtherdistinguished between short-term emotional states (feelingthrilled, or joyful) and those related to mood traits that showa person's characteristic ways of reacting to situations, suchas extroversion vs. neuroticism [38] (p. 1063). Watson andTellegen [74] approached positive affect in terms ofenthusiasm, alertness, and positive engagement, bringingthe PANAS close to the eudaimonistic view.

The PANAS contains 10 positive and 10 negative wordssuch as “interested”, “excited”, and “alert” and “distressed”,“hostile”, or “scared”. The respondent indicates to whatextent they feel that way on a 5-point scale [38] (p. 1064).The questions are shown in reference [27] (pp. 225–231). A10-item abbreviation is available [75].

Internal consistency values are typically around 0.85,considerably higher than for the Bradburn scale [76–78].The correlations between positive and negative scores arelow and negative, ranging from −0.12 to −0.32 [38,74].Factor analyses generally identify two factors. Eight-weekstability scores range from about 0.4 to 0.7 [38,79].

Extensive evidence exists for concurrent validity of thePANAS. In brief, correlations between the negative affectscore and measures of depression and anxiety typically rangefrom0.55 to 0.75 [27] (pp. 227–228).Meanwhile, the positivescore shows somewhat lower but inverse correlations.

The PANAS has become widely used in psychologicalresearch and has largely replaced the Bradburn scale: Egloffet al. [80] mentioned 1600 citations as of 2003. Growing


psychometric evidence is accumulating, and convergentcorrelations with other more clinical scales are strong. As ameasurement of health, limitations include the lack ofinformation on criterion validity and on sensitivity to change.We do not yet know whether the PANAS will be useful as ascreening or as an evaluative instrument.

The internal structure of the PANAS has been extensivelyinvestigated, using factor analysis [38,78,81] and clusteranalysis [80]. As well as the positive–negative affectdimension, the PANAS offers some coverage of activation[80], although Mehrabian [82] was critical of its scope as ameasure of overall well-being. Furthermore, the adequacy ofits coverage of the negative end of each spectrum has beencriticized [77,82–84], and this might create a floor effect,preventing it from distinguishing among low levels of well-being. Nonetheless, the PANAS deserves serious considera-tion as a measure of general affect; as a rival to the PANAS,Derogatis and Palmer [85] also developed an ABS that wassimilarly based on Watson's conceptual model.

The WHO-5 Well-Being Index (P. Bech, 1998)

The WHO-5 gives a brief assessment of emotional well-being over a 14-day period. Reflecting the positive tone of theWHO definition of health, the five items record mental well-being as opposed to symptoms [86,87]. The items coverpositive mood (feeling in good spirits, feeling relaxed),vitality (being active and waking up fresh and rested), andbeing interested in things. TheWHO-5 can be used as a surveymeasure of subjective quality of life and, despite its positivewording, as a screen for depression [88,89]. The questionstake a minute or two to answer, and cutting points have beenproposed to indicate mental distress (see www.who-5.org).The scale is available in most European languages.

Several studies have reported internal consistency, with αcoefficients ranging from 0.82 to 0.95 [86–89]. Mokkenanalysis demonstrates unidimensionality [86,90]. Validitycoefficients include correlations with the Center forEpidemiologic Studies Depression scale, ranging from -0.4to -0.67 [87,88]. Higher correlations were obtained with theHospital Anxiety and Depression scale, at −0.76, and −0.73with the Patient Health Questionnaire [89]. Criterion validityhas been assessed against the DIA-X Structured ClinicalInterview (sensitivity, 82.5%, and specificity, 70.3%, fordetecting any affective disorders [91]) and against theComposite International Diagnostic Interview: sensitivity of93% for depression at a specificity of 64% [92]. Comparedagainst the Structured Clinical Interview for the DSM-IV, theWHO-5 showed sensitivity results for major depressivedisorder ranging from 86% to 95% and specificity of 73% to83% for varying cut points [89]. In a Danish national survey(n=9542), the WHO-5 showed a broader scale distribution,with less marked floor and ceiling effects, than the mentalhealth subscale of the SF-36 [86]. The WHO-5 provided abetter screening test for depression than the 12-item General

Health Questionnaire [93], better than the Hospital Anxietyand Depression Questionnaire [89], and it had lower ceilingeffects than the Short-Form-36 Mental Health scale [86].

Even though the WHO-5 measures only positive affect, itstill offers a good screen for depression by recording theabsence of positive feelings. Indeed, Henkel et al. [94]showed that selecting just two questions from the WHO-5proved only slightly less adequate than the whole scale inscreening for depression and dysthymia: echoes of thesingle-item measures described earlier. Because of its broadscope and general statements, the WHO-5 achieves sensi-tivity, but at the cost of lower specificity [95]. The WHO-5holds considerable promise, and evidence for its validity asan outcome measure is beginning to collect (see, forexample, reference [96]).

The Ryff's Scales of Psychological Well-Being (C.D.Ryff, 1989, revised 1995)

Ryff's scales were designed to test her six-componentmodel of personal growth and psychological well-being.Ryff's work focused initially on definitions of successfulaging; previous conceptions lacked clear theoretical founda-tion; they were negative, defining success in terms of theabsence of distress, and ignored the potential for growth inold age. Ryff proposed six defining criteria for an integratedmodel of personal development in aging: self-acceptance(SA), positive relations with others (PR), autonomy (AU),environmental mastery (EM), purpose in life (PL), andpersonal growth (PG) [11,16]. These “multiple convergingaspects of positive psychological functioning” extendbeyond the scope of previous measures, offering a fullermeasure of the eudaimonistic approach to well-being.

Items were written for the six scales; the 1989 versioncontained 20 items per scale (120 in total) [16]. In 1995, Ryffand Keyes [97] published an 18-item abbreviation with 3positively or negatively phrased items per scale. Items takethe form of statements (“I am not afraid to voice my opinionseven when they are in opposition to the opinions of mostpeople”—AU), and the responses are a 6-point scale “agreestrongly” to “disagree strongly.” The items are shown bySpringer et al. [98] and by Abbott et al. [99].

Reliability has been tested in roughly a dozen studies; αinternal consistency ranged from 0.86 (AU) to 0.93 (SA) forthe 120-item preliminary version [17]. The 18-item versionshows lower α's, ranging from 0.33 (PL) to 0.56 (PR) [97].Stability over time seems good (coefficients ranging from0.81 [PG and EM] to 0.88 [AU]) [16].

The internal structure of the measure has beenextensively studied using confirmatory factor analysis toassess fit with the hypothesized six dimensions. Ryff andSinger [100] reviewed six such studies and concluded thatthe scale does, indeed, reflect the intended six dimensions.Springer and Hauser [98], however, disagreed, arguing thatthe scales correlate too highly with each other to be

http://www.whoorg


considered distinct facets of well-being [101]. There havebeen other suggestions that some of the items may need tobe reworded [102]. There is reasonably extensive evidenceon concurrent validity, comparing the measure to scalessuch as the Bradburn or the LSIA. The SA, EM, and PLscales correlate well with existing scales, while scales ofPG, PR, and AU appear to measure new constructs [16].The scales have seen little testing on patient samples.

Ryff's scales of well-being represent the leading attemptto cover a broader definition of well-being than that impliedby positive affect or life satisfaction alone. Her scholarlyarticles offer a broad and cogently argued conceptual basisfor the content of the scale, much more so than for othermeasures in the field. The 18-item version has seen wideuse, including in several national surveys. The validationresults offer general support for the scales, although it maybe that further refinements to the instrument would improveits performance.

Conclusion

Academic interest in the nature of psychological well-being has grown over the past 15 years, and major advanceshave been made. First, the importance of the topic has beenemphasized by studies that link well-being to physiologicalchanges [10], to enhanced coping with stress [103], and evento reduced mortality [9]. Second, the earlier conception thatcontrasted multiple forms of negative well-being (anxiety,depression, etc.) with one general dimension of positivewell-being has been replaced by one that recognizes multiplepositive dimensions. Third, sophisticated forms of dataanalysis (item response theory [104,105], Latent State Traitanalysis [80], Mokken analysis [106]) have contributedempirical evidence to these conceptual debates overdimensionality. Fourth, several new measurement scaleshave been developed, some described here. To illustrate therange of potential measures for users to choose, this reviewcompared three general well-being scales, two morale, twolife satisfaction, and two happiness scales. Table 1summarizes their characteristics.

These advances have opened a sizable agenda for futureresearch. First, while theoretical distinctions may be drawnbetween fine-grained elements of well-being, the questionswe have to test these distinctions empirically are relativelyimprecise, and of course, there is great interindividualvariability in how a question is interpreted. Empirical testingof the theories, therefore, remains a major challenge. Second,many of the measures that we do have were designed forgeneral survey research (Diener, WHO-5, ABS) and may notprovide sufficiently precise estimates for use with individualpatients, which is the interest of many working in the healthfield. While some of the measures have been shown capableof demonstrating change in therapeutic trials, this aspect ofvalidity has not yet been systematically investigated. Third,to achieve this, it will be good to bridge the research

traditions of psychology, which focuses on understandingthe dimensional structure of well-being, and health servicesresearch, which focuses chiefly on practical application ofthese measures to evaluate the outcomes of care.

For those whose interest in measures of well-being lies inapplying them as outcome measures, some basic choicesmust be made. Should the outcome measure deductivelyrepresent a particular theoretical approach, as with Ryff'sscales, or should it reflect well-being inductively, inwhatever manner the respondent views it, as with Diener'sscale? This latter approach is represented in other healthmeasures, such as the Patient Generated Index [107] or theSchedule for the Evaluation of Individual Quality of Life[108] for which there was insufficient space to review here.The chronological perspective in this review suggests agradual broadening of approach over time from thehedonistic model toward a multidimensional, eudaimonisticapproach. Second, should the measure identify pathology, ora reduction in pathology, or should it distinguish degrees ofpositivity? The former implies a predominance of negativelyphrased items as in the LSIA, the Morale Scale or the GWB;the latter is the field of Diener's scale or the WHO-5.Whatever the preferred approach, we now have a number ofcredible measurement scales whose performance character-istics have been investigated quite thoroughly.

References

[1] World Health Organization. The first ten years of the World HealthOrganization. Geneva: World Health Organization, 1958.

[2] Macmillan. The Health Opinion Survey: technique for estimatingprevalence of psychoneurotic and related types of disorder incommunities. Psychol Rep 1957;3:325–39.

[3] Jahoda M. Current concepts of positive mental health. New York:Basic Books, 1958.

[4] Goldberg DP. The detection of psychiatric illness by questionnaire.London: Oxford University Press (Maudsley Monograph No. 21),1972.

[5] Dupuy HJ. Self-representations of general psychological well-beingof American adults. Los Angeles. California: Paper presented atAmerican Public Health Association Meeting, 1978.

[6] Diener E, Horwitz J, Emmons RA. Happiness of the very wealthy.Soc Indic Res 1985;16:263–74.

[7] Diener E. Subjective well-being: the science of happiness and aproposal for a national index. Am Psychol 2000;55:34–43.

[8] Schwartz CE, Bode R, Repucci N, Becker J, Sprangers MAG, FayersPM. The clinical significance of adaptation to changing health: ameta-analysis of response shift. Qual Life Res 2006;15:1533–50.

[9] Chida Y, Steptoe A. Positive psychological well-being and mortality:a quantitative review of prospective observational studies. Psycho-som Med 2008;70:741–56.

[10] Ryff CD, Singer B. The contours of positive human health. PsycholInq 1998;9:1–28.

[11] Ryff CD. Beyond Ponce de Leon and life satisfaction: new directionsin quest of successful aging. Int J Behav Dev 1989;12:35–55.

[12] Ryan RM, Deci EL. On happiness and human potentials: a review ofresearch on hedonic and eudaimonic well-being. Annu Rev Psychol2001;52:141–66.

[13] Watermans AS. Two conceptions of happiness: contrasts of personalexpressiveness (eudaimonia) and hedonic enjoyment. J Pers SocPsychol 1993;64:678–91.


[14] Diener E, Emmons R, Larsen RJ, Griffin S. The Satisfaction WithLife Scale. J Pers Assess 1985;49:71–5.

[15] Seligman MEP, Csikszentmihalyi M. Positive psychology: anintroduction. Am Psychol 2000;55:5–14.

[16] Ryff CD. Happiness is everything, or is it? Explorations on themeaning of psychological well-being. J Pers Soc Psychol 1989;57:1069–81.

[17] Compton WC, Smith MK, Cornish KA, Qualls DL. Factor structureof mental health measures. J Pers Soc Psychol 1996;71:406–13.

[18] Bond MH. Beyond the Chinese face: insights from psychology.Oxford: Oxford University Press, 1991.

[19] Watson D, Clark LA. Measurement and mismeasurement of mood:recurrent and emergent issues. J Pers Assess 1997;68:267–96.

[20] Russell JA, Carroll JM. On the bipolarity of positive and negativeaffect. Psychol Bull 1999;125:3–30.

[21] Zautra AJ, Guarnaccia CA, Reich JW. Factor structure of mentalhealth measures for older adults. J Consult Clin Psychol 1988;56:514–9.

[22] Mehrabian A. Framework for a comprehensive description andmeasurement of emotional states. Genet Soc Gen Psychol Monogr1995;121:339–61.

[23] Wallace BA, Shapiro SL. Mental balance and well-being: buildingbridges between Buddhism and western psychology. Am Psychol2006;61:690–701.

[24] Watson D, Wiese D, Vaidya J, Tellegen A. The two general activationsystems of affect: structural findings, evolutionary considerations,and psychobiological evidence. J Pers Soc Psychol 1999;76:820–38.

[25] Neugarten BL, Havighurst RJ, Tobin SS. The measurement of lifesatisfaction. J Gerontol 1961;16:134–43.

[26] Adams DL. Analysis of a Life Satisfaction Index. J Gerontol 1969;24:470–4.

[27] McDowell I. Measuring health: a guide to rating scales andquestionnaires. 3 ed. New York: Oxford University Press, 2006.

[28] Burckhardt CS, Woods SL, Schultz AA, Ziebarth DM. Quality of lifeof adults with chronic illness: a psychometric study. Res Nurs Health1989;12:347–54.

[29] Wilson GA, Elias JW, Brownlee LJ. Factor invariance and the LifeSatisfaction Index. J Gerontol 1985;40:344–6.

[30] Cutler NE. Age variations in the dimensionality of life satisfaction.J Gerontol 1979;34:573–8.

[31] Hoyt DR, Creech JC. The Life Satisfaction Index: a methodologicaland theoretical critique. J Gerontol 1983;38:111–6.

[32] Wood V, Wylie ML, Sheafor B. An analysis of a short self-reportmeasure of life satisfaction: correlation with rater judgments.J Gerontol 1969;24:465–9.

[33] Stock WA, Okun MA, Gómez Benito J. Subjective well-beingmeasures: reliability and validity among Spanish elders. Int J AgingHum Dev 1994;38:221–35.

[34] Stock WA, Okun MA. The construct validity of life satisfactionamong the elderly. J Gerontol 1982;37:625–7.

[35] Helmes E, Goffin RD, Chrisjohn RD. Confirmatory factor analysis ofthe Life Satisfaction Index. Soc Indic Res 1998;45:371–90.

[36] Bradburn NM. The structure of psychological well-being. Chicago:Aldine, 1969.

[37] Bradburn NM, Caplovitz D. Reports on happiness: a pilot study ofbehavior related to mental health. Chicago: Aldine, 1965.

[38] Watson D, Clark LA, Tellegen A. Development and validation ofbrief measures of positive and negative affect: the PANAS scales.J Pers Soc Psychol 1988;54:1063–70.

[39] Cherlin A, Reeder LG. The dimensions of psychological well-being:a critical review. Soc Methods Res 1975;4:189–214.

[40] Warr P. A study of psychological well-being. Br J Psychol 1978;69:111–21.

[41] Beiser M. Components and correlates of mental well-being. J HealthSoc Behav 1974;15:320–7.

[42] Brenner B. Quality of affect and self-evaluated happiness. Soc IndicRes 1975;2:315–31.

[43] Kushman J, Lane S. A multivariate analysis of factors affectingperceived life satisfaction and psychological well-being among theelderly. Soc Sci Q 1980;61:264–77.

[44] Beiser M, Feldman JJ, Egelhoff CJ. Assets and affects: a study ofpositive mental health. Arch Gen Psychiatry 1972;27:545–9.

[45] Headey B, Kelley J, Wearing A. Dimensions of mental health: lifesatisfaction, positive affect, anxiety and depression. Soc Indic Res1993;29:63–82.

[46] Idler EL, Benyamini Y. Self-rated health and mortality: a review oftwenty-seven community studies. J Health Soc Behav 1997;38:21–37.

[47] Andrews FM. Social indicators of perceived life quality. Soc IndicRes 1974;1:279–99.

[48] Andrews FM, Crandall R. The validity of measures of self-reportedwell-being. Soc Indic Res 1976;3:1–19.

[49] Knäuper B, Turner PA. Measuring health: improving the validity ofhealth assessments. Qual Life Res 2003;12(Suppl 1):81–9.

[50] Verbrugge LM. A global disability indicator. J Aging Stud 1997;11:337–62.

[51] Herr KA, Mobily PR, Kohout FJ, Wagenaar D. Evaluation of thefaces pain scale for use with the elderly. Clin J Pain 1998;14:29–38.

[52] Cantril H. The pattern of human concerns. New Brunswick. NewJersey: Rutgers University Press, 1965.

[53] Bélanger A, Berthelot J-M, Guimond E, Houle CA. Head-to-headcomparison of two generic health status measures in the householdpopulation: McMaster Health Utilities Index (Mark3) and the EQ-5D.Statistics Canada Report, 1–62. Ottawa, Canada, 2002.

[54] EuroQol Group. EuroQol: a new facility for the measurement ofhealth-related quality of life. Health Policy 1990;16:199–208.

[55] Ho SC. Health and social predictors of mortality in an elderly Chinesecohort. Am J Epidemiol 1991;133:907–21.

[56] Idler EL, Angel RJ. Self-rated health and mortality in the NHANES-IEpidemiologic Follow-up Study. Am J Public Health 1990;80:446–52.

[57] Idler EL, Kasl S. Health perceptions and survival: do globalevaluations of health status really predict mortality? J Gerontol1991;46:S55–65.

[58] Paterson C. Seeking the patient's perspective: a qualitative assess-ment of EuroQol, COOP-WONCA charts and MYMOP. Qual LifeRes 2004;13:871–81.

[59] Lawton MP. The dimensions of morale. In: Kent DP, Kastenbaum R,Sherwood S, editors. Research planning and action for the elderly: thepower and potential of social science. New York: BehavioralPublications, 1972. pp. 144–65.

[60] Liang J, Bollen KA. The structure of the Philadelphia Geriatric CenterMorale Scale: a reinterpretation. J Gerontol 1983;38:181–9.

[61] Morris JN, Sherwood S. A retesting and modification of thePhiladelphia Geriatric Center Morale Scale. J Gerontol 1975;30:77–84.

[62] Lawton MP. The Philadelphia Geriatric Center Morale Scale: arevision. J Gerontol 1975;30:85–9.

[63] McCulloch BJ. A longitudinal investigation of the factor structure ofsubjective well-being: the case of the Philadelphia Geriatric CenterMorale Scale. J Gerontol 1991;46:P251–8.

[64] Kozma A, Stones MJ. Social desirability in measures ofsubjective well-being: a systematic evaluation. J Gerontol 1987;42:56–9.

[65] Fazio AF. A concurrent validational study of the NCHSGeneral Well-Being Schedule. Hyattsville, Maryland: U.S. DHEW, National Centerfor Health Statistics, 1977.

[66] Ware JE, Johnston SA, Davies-Avery A, Brook RH. Conceptualiza-tion and measurement of health for adults in the Health InsuranceStudy. Vol. III, Mental health. Santa Monica, California: RANDCorporation (Publication No. R-1987/3-HEW), 1979.

[67] Edwards DW, Yarvis RM, Mueller DP, Zingale HC, Wagman WJ.Test-taking and the stability of adjustment scales: can we assesspatient deterioration? Eval Q 1978;2:275–91.


[68] Dupuy HJ. The Psychological General Well-Being (PGWB) index.In: Wenger NK, Mattson ME, Furberg CD, Elinson J, editors.Assessment of quality of life in clinical trial of cardiovasculartherapies. New York: Le Jacq, 1984. pp. 170–83.

[69] Veit CT, Ware JE. The structure of psychological distress and well-being in general populations. J Consult Clin Psychol 1983;51:730–42.

[70] Pavot W, Diener E. Review of the Satisfaction With Life Scale.Psychol Assess 1993;5:164–72.

[71] PavotW, Diener E. The SatisfactionWith Life Scale and the emergingconstruct of life satisfaction. J Posit Psychol 2008;3:137–52.

[72] Lucas RE, Diener E, Suh E. Discriminant validity of well-beingmeasures. J Pers Soc Psychol 1996;71:616–28.

[73] Oishi S, Schimmack U, Colcombe SJ. The contextual and systematicnature of life satisfaction judgments. J Exp Soc Psychol 2003;39:232–47.

[74] Watson D, Tellegen A. Issues in the dimensional structure of affect—effects of descriptors, measurement error, and response formats:comment on Russell and Carroll (1999). Psychol Bull 1999;125:601–10.

[75] Kercher K. Assessing subjective well-being in the old-old. Res Aging1992;14:131–68.

[76] Watson D, Clark LA. The PANAS-X: manual for the positive andnegative affect schedule - expanded form. 2 ed. Iowa: University ofIowa, 1999.

[77] Crocker PRE. A confirmatory factor analysis of the Positive AffectNegative Affect Schedule (PANAS) with a youth sport sample.J Sport Exerc Psychol 1997;19:331–57.

[78] Crawford JR, Henry JD. The Positive and Negative Affect Schedule(PANAS): construct validity, measurement properties and normativedata in a large non-clinical sample. Br J Clin Psychol 2004;43:245–65.

[79] Manne S, Schnoll R. Measuring cancer patients' psychologicaldistress and well-being: a factor analytic assessment of the MentalHealth Inventory. Psychol Assess 2001;13:99–109.

[80] Egloff B, Schmukle SC, Burns LR, Kohlmann C-W, Hock M. Facetsof dynamic positive affect: differentiating joy, interest, and activationin the Positive and Negative Affect Schedule (PANAS). J Pers SocPsychol 2003;85:528–40.

[81] Melvin GA, Molloy GN. Some psychometric properties of thePositive and Negative Affect Schedule among Australian youth.Psychol Rep 2000;86:1209–12.

[82] Mehrabian A. Comparison of PAD and PANAS as models fordescribing emotions and for differentiating anxiety from depression.J Psychopathol Behav Assess 1997;19:331–57.

[83] Killgore WDS. Evidence for a third factor on the Positive andNegative Affect Schedule in a college student sample. Percept MotSkills 2000;90:147–52.

[84] Nemanick RC, Munz DC. Measuring the poles of negative andpositive mood using the positive affect negative affect schedule andactivation deactivation adjective check list. Psychol Rep 1994;74:195–9.

[85] Derogatis LR, Palmer AB. The Derogatis Affects Balance Scale: ameasure of affective balance and disregulation. In: Zalaquett CP,Wood RJ, editors. Evaluating stress: a book of resources, Vol 2.Lanham, MD: Scarecrow Press, 1998. pp. 89–117.

[86] Bech P, Olsen LR, Kjoller M, Rasmussen NK. Measuring well-beingrather than the absence of distress symptoms: a comparison of the SF-36 mental health subscale and the WHO-Five well-being scale. Int JMethods Psychiat Res 2003;12:85–91.

[87] de Wit M, Pouwer F, Gemke RJBJ, Delemarre-van deWaal HA,Snoek FJ. Validation of the WHO-5 well-being index in adolescentswith type 1 diabetes. Diabetes Care 2007;30:2003–6.

[88] Heun R, Burkart M, Maier W, Bech P. Internal and external validity ofthe WHO Well-Being Scale in the elderly general population. ActaPsychiatr Scand 1999;99:171–8.

[89] Löwe B, Spitzer RL, Gräfe K, Kroneke K, Quenter A, Zipfel S, et al.Comparative validity of three screening questionnaires for DSM-IVdepressive disorder and physicians' diagnoses. J Affect Disord 2004;78:131–40.

[90] Awata S, Bech P, Koizumi Y, Seki T, Kuriyama S, Hozawa A, et al.Validity and utility of the Japanese version of the WHO-Five Well-Being Index in the context of detecting suicidal ideation in elderlycommunity residents. Int Psychogeriatr 2007;19:77–88.

[91] Liwowsky I, Kramer D, Mergl R, Bramesfeld A, Allgaier AK, PöppelE, et al. Screening for depression in the older long-term unemployed.Soc Psychiatry Psychiatr Epidemiol 2008.

[92] Henkel V, Mergl R, Kohnen R, Maier W, Möller HJ, Hegerl U.Identifying depression in primary care: a comparison of differentmethods in a prospective cohort study. Br Med J 2003;326:200–1.

[93] Henkel V, Mergl R, Kohnen R, Allgaier A-K, Möller H-J, Hegerl U.Use of brief depression screening tools in primary care: considerationof heterogeneity in performance in different patient groups. Gen HospPsychiatry 2004;26:190–8.

[94] Henkel V, Mergl R, Coyne JC, Kohnen R, Möller H-J, Hegerl U.Screening for depression in primary care: will one or two itemssuffice? Eur Arch Psychiatry Clin Neurosci 2004;254:215–23.

[95] Sisask M, Värnik A, Kõlves K, Konstabel K, Wasserman D.Subjective psychological well-being (WHO-5) in assessment of theseverity of suicide attempt. Nord J Psychiatry 2008;62:431–5.

[96] Boyer P, Montgomery S, Lepola U, Germain J-M, Brisard C, GangulyR, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine50 and 100 mg/day for major depressive disorder in a placebo-controlled trial. Int Clin Psychopharmacol 2008;23:243–53.

[97] Ryff CD, Keyes CL. The structure of psychological well-beingrevisited. J Pers Soc Psychol 1995;69:719–27.

[98] Springer KW, Hauser RM. An assessment of the construct validity ofRyff's Scales of Psychological Well-Being: method, mode, andmeasurement effects. Soc Sci Res 2006;35:1080–102.

[99] Abbott RA, Ploubidis GB, Huppert FA, Kuh D, Wadsworth ME,Croudace TJ. Psychometric evaluation and predictive validity ofRyff's psychological well-being items in a UK birth cohort sample ofwomen. Health Qual Life Outcomes 2006;4:76–92.

[100] Ryff CD, Singer BH. Best news yet on the six-factor model of well-being. Soc Sci Res 2006;35:1103–19.

[101] Springer KW, Hauser RM, Freese J. Bad news indeed for Ryff's six-factor model of well-being. Soc Sci Res 2006;35:1120–31.

[102] Clarke PJ, Marshall VW, Ryff CD, Rosenthal CJ. Well-being inCanadian seniors: findings from the Canadian Study of Health andAging. Can J Aging 2000;19:139–59.

[103] Salovey P, Rothman AJ, Detweiler JB, Steward WT. Emotional statesand physical health. Am Psychol 2000;55:110–21.

[104] Hays RD, Morales LS, Reise SP. Item response theory and healthoutcomes measurement in the 21st century. Med Care 2000;38(SupplII):II-28–42.

[105] McHorney CA, Cohen AS. Equating health status measures with itemresponse theory. Med Care 2000;38(9, Suppl II):II-43–59.

[106] van der Heijden PGM, van Buuren S, Fekkes M, Radder J, Verrips E.Unidimensionality and reliability under Mokken scaling of the Dutchlanguage version of the SF-36. Qual Life Res 2003;12:189–98.

[107] Ruta DA, Garratt AM, Leng M, Russell IT, MacDonald LM. A Newapproach to the measurement of quality of life: the patient-generatedindex. Med Care 1994;32:1109–26.

[108] Joyce CRB, Hickey A, McGee HM, O'Boyle CA. A theory-basedmethod for the evaluation of individual quality of life: the SEIQoL.Qual Life Res 2003;12:275–80.

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