Montgomery Asberg Depression Rating Scale (MADRS)

Purpose

The Montgomery Asberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Rating Scale (MADRS) is used by clinicians to assess the severity of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
among patients with a diagnosis of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
. It is designed to be sensitive to change resulting from antidepressant therapy.

In-Depth Review

Purpose of the measure

The Montgomery Asberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Rating Scale (MADRS) is used by clinicians to assess the severity of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
among patients with a diagnosis of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
. It is designed to be sensitive to change resulting from antidepressant therapy.

Available versions

The MADRS was developed by Stuart Montgomery and Marie Asberg in 1979. It was developed from Asberg’s Comprehensive Psychopathological Rating Scale, which was designed to evaluate psychiatric treatment.

Features of the measure

Items:
The MADRS has 10 items that are completed during a clinical interview. The following items are included in the MADRS:

1. Apparent sadness
2. Reported sadness
3. Inner tension
4. Reduced sleep
5. Reduced appetite
6. Concentration difficulties
7. Lassitude
8. Inability to feel
9. Pessimistic thoughts
10. Suicidal thoughts

Originally the MADRS was published without suggested questions for clinicians to use in eliciting the information they need to rate the items. In 2008, Williams and Kobak developed the Structured Interview Guide for the MADRS (SIGMA) to provide structured questions that should be asked exactly as written to ensure standardisation of administration. Follow-up questions are also provided to clarify symptoms if required. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
using Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient with the SIGMA was reported to be excellent (r = 0.93).

Scoring:
Each item has a severity scale from 0 to 6, with higher scores reflecting more severe symptoms. Ratings can be added to form an overall score (from 0 to 60). Snaith, Harrop, Newby, and Teale (1986) proposed the following cut-offs: scores of 0-6 indicate an absence of symptoms; 7-19 represent mild depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
; 20-34 moderate; 35-60 indicate severe depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
.

Time:
Interviews take 20 to 60 minutes to complete.

Subscales:
The MADRS has 10 subtests (each item is therefore considered a subtest): 1. Apparent sadness; 2. Reported sadness; 3. Inner tension; 4. Reduced sleep; 5. Reduced appetite; 6. Concentration difficulties; 7. Lassitude; 8. Inability to feel; 9. Pessimistic thoughts; 10. Suicidal thoughts

Equipment:
Only the questionnaire and a pencil are required to complete the MADRS.

Training:
No formal training is required to complete the MADRS.

Alternative form of the Montgomery Asberg Depression Rating Scale

A self-report version of the MADRS, the MADRS-S, was developed by Svanborg and Asberg in 1994. The MADRS-S has 9-items which are based on feelings over the past 3 days. The items of the MADRS-S are as follows: Mood; Feelings of unease; Sleep; Appetite; Ability to concentrate; Initiative; Emotional involvement; Pessimism; Zest for life.

Client suitability

Can be used with:

The MADRS can be administered to clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

• The MADRS can be used with clients with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada), however one study examining its use in patients with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) found that the MADRS was more difficult to complete than the DSM-IV, especially for patients with global, mixed non-fluent, and Wernicke types of aphasias. The MADRS also became less valid when a proxy was required (Laska, Martensson, Kahan, von Arbin, & Murray, 2007).

Should not be used with:

The MADRS is intended for use with patients with a diagnosis of a depressive illness only.

• Although the MADRS can be used with clients with cognitive impairments, certain features of the MADRS could bias the scores of these patients in the direction of higher depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
  scores and therefore should be used with caution in individuals with cognitive impairments. This is due to the complex wording of some of the subtests (especially the subtests of Concentration difficulty; Inability to feel; Lassitude; and Inner tension) (Sadavoy, Smith, Conn, & Richards, 2004).

In what languages is the measure available?

The MADRS has been translated into the following languages:

• Afrikaans
• Bulgarian
• Czech
• Danish
• Dutch
• English for Canada
• English for India
• English for South Africa
• Estonian
• Finnish
• French
• French for Canada
• German
• German for Austria
• Hebrew
• Hungarian
• Italian
• Japanese
• Korean
• Latvian
• Lithuanian
• Malay
• Mandarin for China
• Mandarin for Taiwan
• Norwegian
• Polish
• Portuguese for Brazil
• Romanian
• Russian
• Russian for Ukrain
• Spanish
• Spanish for Argentina
• Spanish for Chile
• Spanish for Colombia
• Spanish for Mexico
• Spanish for the USA
• Swedish
• Tagalog
• Thai
• Turkish
• Ukrainian

The following translations have been validated:

• French (Peyre, Martinez, Calache, Verdoux, Bourgeois et al., 1989)
• German (Schmidtke, Fleckenstein, Moises, & Beckmann,1988)
• Japanese (MADRSJ) (Kasa & Hitomi, 1987)
• Spanish (Lobo, Chamorro, Luque, Dal-Re, Badia, Baro et al., 2002)
• Thai (Satthapisit, Posayaanuwat, Sasaluksananont, Kaewpornsawan, & Singhakun, 2007)

Summary

What does the tool measure?	DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. severity.
What types of clients can the tool be used for?	Individuals with a diagnosis of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. . Can be used, but is not limited to, persons with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment.
Time to administer	The MADRS takes 20-60 minutes to be completed by interview.
Versions	The MADRS was developed by Stuart Montgomery and Marie Asberg in 1979. It was developed from Asberg’s Comprehensive Psychopathological Rating Scale. A self-report version of the MADRS, the MADRS-S, was developed by Svanborg and Asberg in 1994. The MADRS-S has 9-items which are based on feelings over the past 3 days.
Other Languages	Translated and validated in: French, German, Japanese, Thai, and Spanish The MADRS has been translated but not necessarily validated in 41 languages (see MADRS module for the full list of translations)
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the MADRS in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. clientele and reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.. Test-retest: No studies have examined the test-retest, intra-rater or inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the MADRS in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Two studies examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the MADRS and reported excellent correlations with the Geriatric DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Scale, the Zung Scale, the Center for Epidemiologic Studies DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Scale, the Hamilton Rating Scale, and the Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Inventory. The scale correlated adequately with the Cornell Scale. Construct: One study examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed. of the MADRS using factor analysis in 163 individuals StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. They identified three distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., and Agitation related to somatic factors not directly related to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Does the tool detect change in patients?	Not yet examined in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.
Acceptability	MADRS is typically interview-administered, however it can be self-administered. The MADRS should be used with caution in patients with cognitive impairment as results can be skewed towards higher depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. scores, however the MADRS can be used with individuals with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada).
Feasibility	The MADRS is easy to administer due to the Structured Interview Guide for the MADRS (SIGMA) that was developed in 2008 which provides structured questions that should be asked exactly as written to ensure standardization of administration. No special training or equipment is required to complete the measure.
How to obtain the tool?	The original MADRS is available by clicking here. The structured interview version of the MADRS (SIGMA) is also available as an appendix in the article by Williams and Kobak (2008).

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the MADRS in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. We identified 4 studies.

Floor/Ceiling Effects

No studies were identified that examined the floor/ceiling effects of the MADRS in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Fantino and Moore (2009) examined the floor and ceiling effects of the 9-item self-administered version of the MADRS-S in 278 outpatients diagnosed with Major Depressive Disorder. All items had adequate ceiling effects (total score: 0.4%). Floor effects ranged from poor (appetite item, 21.6) to excellent (total score: 0.0%).

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Agrell and Dehlin (1989) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of 6 depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
rating scales in 40 elderly individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., 17 of whom were depressed according to clinical examination.

According to the authors, in the MADRS, all items correlated significantly and 8/10 items were very highly correlated (coefficients not provided in article) and Cronbach’s alpha was excellent (alpha = 0.89).
Note: This publication refers to the MADRS as the Comprehensive Psychopathological Rating Scale-Depression (CPRS-D), which was the original name for the MADRS (Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978).

Test-retest:
No studies were identified that measured the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the MADRS in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

Fantino and Moore (2009) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the 9-item self-administered version of the MADRS in 278 outpatients diagnosed with Major Depressive Disorder. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
using intraclass correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient was excellent (r = 0.78).

Intra-rater:
No studies were identified that measured the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the MADRS in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

Inter-rater:
No studies were identified that measured the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MADRS in a stroke population.

Montgomery and Asberg (1979) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MADRS in 64 patients with a primary depressive illness. Comparisons were made between two English raters; two Swedish raters; one English and one Swedish rater; a trained psychiatrist and a general practitioner; and a trained psychiatrist and a psychiatric nurseIn charge of, but not limited to, the "assessment and provision of care needs; support and education for patients and families; discharge planning."(Suggested by Philips et al, 2002)
. The inter-rater correlations were excellent (ranging from r = 0.89 to r = 0.97).

Validity

Content:
The MADRS covers the core symptoms of depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
with the exception of motor retardation which was excluded from the primary selection, since it occurred in relatively few patients (Montgomery & Asberg, 1979).

Criterion:
Concurrent:
Agrell and Dehlin (1989) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the MADRS with 5 other depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
rating scales: Geriatric DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (GDS) (Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982); Zung Scale (Zung, 1965) Center for Epidemiologic Studies DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (CES-D) (Shinar, Gross, Price, Banko, Bolduc, & Robinson, 1986); Hamilton Rating Scale (HRS) (Hamilton, 1967); Cornell Scale (Alexopoulos, Abrams, Young, & Shamoian, 1988) in 40 elderly individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. using Pearson Product Moment Correlations. The MADRS had excellent correlations with the GDS (r = 0.86), the Zung Scale (r = 0.82), the CES-D (r = 0.83) and the HRS (r = 0.87). The MADRS had an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Cornell Scale, which did not correlate highly with any of the scales.
Note: This publication refers to the MADRS as the Comprehensive Psychopathological Rating Scale-Depression (CPRS-D), which was the original name for the MADRS (Asberg, Montgomery, Perris, Schalling, & Sedvall, 1978).

Tamaklo, Schubert, Mentari, and Lee (1992) compared the MADRS to the Beck DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Inventory (BDI – Beck, Ward, & Mendelson, 1961) in 22 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and found an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = 0.65).

Construct:
Farner, Wagle, Flekkoy, Wyller, Fure, Stensrod, et al. (2009) examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the MADRS using factor analysis in 163 individuals with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. They identified 3 distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., and Agitation related to somatic factors not directly related to the strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
/Specificity:
Sagen, Vik, Moum, Morland, Finset, and Dammen (2009) estimated the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the MADRS in 104 patients 4 months post-stroke by comparing it to the DSM-IV diagnosis of DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
as the gold standardA measurement that is widely accepted as being the best available to measure a construct.
. At a cut-off of >6, the MADRS had a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 0.90 and a specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 0.66. At a cut-off of >12, a sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 0.70 and a specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 0.86 was found. All cut-offs lower than 9 yielded sensitivities >0.80 and specificities >0.60. Of these, a cut-off of >8 had the highest overall agreement (0.74), kappa (0.40), and positive predictive value (0.41). The AUC for the MADRS was excellent (AUC = 0.91).

Responsiveness

Not yet examined in a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. population.

References

• Alexopoulos, G. S., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell Scale for depression in dementia. Biol Psychiatry, 23, 271-284.
• Asberg, M., Montgomery, S. A., Perris, C., Schalling, D., & Sedvall, G. (1978). A comprehensive psychopathological rating scale. Acta Psychiatr Scand [Suppl], 271, 5-27.
• Beck, A.T., Ward, C., Mendelson, M. (1961). Beck Depression Inventory (BDI). Arch Gen Psychiatry, 4, 561-571.
• Bondolfi, G., Jermann, F., Rouget, B. W., Gex-Fabry, M., McQuillan, A., Dupont-Willemin, D., et al. (2009). Self- and clinician-rated Montgomery-Ã…sberg Depression Rating Scale: Evaluation in clinical practice. Journal of Affective Disorders (in press).
• Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P. H., Adey, M., & Rose, T. L. (1982). Screening tests for geriatric depression. Clin Gerontol, l, 37-43.
• Davidson, J., Turnbull, C. D., Strickland, R., Miller, R., & Graves, K. (1986). The Montgomery-Asberg Depression Scale: reliability and validity. Acta Psychiatrica Scandinavica 73(5), 544-548.
• Fantino, B., Moore, N. (2009). The self-reported Montgomery-Ã…sberg depression rating scale is a useful evaluative tool in major depressive disorder. BMC Psychiatry, 9, 26.
• Farner, L., Wagle, J., Flekkoy, K., Wyller, T. B., Fure, B., Stensrod, B., & Engedal, K. (2009). Factor analysis of the Montgomery Asberg depression rating scale in an elderly stroke population. International Journal of Geriatric Psychiatry (in press).
• Hamilton, M. (1967). Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol, 6, 278-298.
• Kasa M, Hitomi K. 1987. The introduction of the Japanese version of comprehensive psychopathological rating scale. Rinsyo Seishin Igaku (Jpn J Clin Psychiatr), 16, 83-94.
• Kearns, N. P., Cruickshank, C. A. & McGuigan, K. J. (1982). A comparison of depression rating scales. British Journal of Psychiatry, 141, 45-49.
• Laska, A. C., Martensson, B., Kahan, T., von Arbin, M., Murray, V. (2007). Recognition of depression in aphasic stroke patients. Cerebrovasc Dis, 24, 74-79.
• Lobo, A., Chamorro, L., Luque, A., Dal-Re, R., Badia, X., & Baro, E. (2002). Grupo de Validacion en Espanol de Escalas Psicometricas (GVEEP): Validation of the Spanish versions of the Montgomery-Asberg depression and Hamilton anxiety rating scales. Med Clin (Barc), 118, 493-499.
• Montgomery, S. A., Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134(4), 382-389.
• Peyre, F., Martinez, R., Calache, M., Verdoux, H., & Bourgeois, M. (1989). New validation of the Montgomery and Asberg Depression Scale (MADRS) on a sample of 147 hospitalized depressed patients. Ann Med Psychol (Paris), 147, 762-767.
• Sadavoy, J., Smith, I., Conn, D. K., & Richards, B. (2004). Depression in geriatric patients with chronic medical illness, International Journal of Geriatric Psychiatry. 5(3), 187-192.
• Sagen, U., Vik, T. G., Moum, T., Morland, T., Finset, A., & Dammen, T. (2009). Screening for anxiety and depression after stroke: Comparison of the Hospital Anxiety and Depression Scale and the Montgomery and Ã…sberg Depression Rating Scale. Journal of Psychosomatic Research (in press).
• Satthapisit, S., Posayaanuwat, N., Sasaluksananont, C., Kaewpornsawan, T., Singhakun, S. (2007). The comparison of Montgomery and Asberg Depression Rating Scale (MADRS Thai) to Diagnostic and Statistical Manual of Mental Disorders (DSM) and to Hamilton Rating Scale for Depression (HRSD): Validity and reliability. J Med Assoc Thai, 90(3), 524-531.
• Schmidtke, A., Fleckenstein, P., Moises, W., & Beckmann, H. (1988). Studies of the reliability and validity of the German version of the Montgomery-Asberg Depression Rating Scale (MADRS). Schweiz Arch Neurol Psychiatry, 139, 51-65.
• Shinar, D., Gross, C. R., Price, T. R., Banko, M., Bolduc, P. L., & Robinson, R. G. (1986). Screening for depression in stroke patients: The reliability and validity of the Center for Epidemiologic Studies Depression Scale. Stroke, 17, 241-245.
• Snaith, R. P., Harrop, F. M., Newby, D. A., & Teale, C. (1986). Grade Scores of the Montgomery-Asberg Depression and the Clinical Anxiety Scales. British Journal of Psychiatry, 148, 599-601.
• Svanborg, P., Asberg, M. (1994). A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr. Scand, 89, 21-28.
• Tamaklo, W., Schubert, D. S., Mentari, A., Lee, S., Taylor, C. (1992). Assessing depression in the medical patient using the MADRS, a sensitive screening scale. Integrative Psychiatry, 8, 264-270.
• Williams, J. B. W., & Kobak, K. A. (2008). Development and reliability of a structured interview guide for the Montgomery-Ã…sberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52-58.
• Zigmond, A. S., & Snaith, R. P. (1983). Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.
• Zung, W. W. K. (1965). A self rating depression scale. Arch Gen Psychiatry, 12, 63-70.

See the measure

How to obtain the MADRS?

The structured interview version of the MADRS is available as an appendix in the following publication:

Williams, J. B. W., & Kobak, K. A. (2008). Development and reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of a structured interview guide for the Montgomery-Ãsberg DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52-58.

Click here to obtain the original, unstructured version of the MADRS.