Montgomery Asberg Depression Rating Scale (MADRS)

Evidence Reviewed as of before: 21-09-2009
Author(s): Lisa Blum, M.Sc. OT (Candidate)
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The Montgomery Asberg Depression Rating Scale (MADRS) is used by clinicians to assess the severity of depression among patients with a diagnosis of depression. It is designed to be sensitive to change resulting from antidepressant therapy.

In-Depth Review

Purpose of the measure

The Montgomery Asberg Depression Rating Scale (MADRS) is used by clinicians to assess the severity of depression among patients with a diagnosis of 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 reliability using Intraclass 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 depression; 20-34 moderate; 35-60 indicate severe 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 stroke.

  • The MADRS can be used with clients with aphasia, however one study examining its use in patients with aphasia 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 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? Depression severity.
What types of clients can the tool be used for? Individuals with a diagnosis of depression. Can be used, but is not limited to, persons with stroke.
Is this a screening 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
Reliability
  • One study examined the internal consistency of the MADRS in a stroke clientele and reported excellent internal consistency.
  • No studies have examined the test-retest, intra-rater or inter-rater reliability of the MADRS in clients with stroke.
Validity

Criterion:

Two studies examined the concurrent validity of the MADRS and reported excellent correlations with the Geriatric Depression Scale, the Zung Scale, the Center for Epidemiologic Studies Depression Scale, the Hamilton Rating Scale, and the Beck Depression Inventory. The scale correlated adequately with the Cornell Scale.

Construct:

One study examined the construct validity of the MADRS using factor analysis in 163 individuals with stroke. They identified 3 distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the stroke, and Agitation related to somatic factors not directly related to the stroke.

Does the tool detect change in patients? Not yet examined in a stroke 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 depression scores, however the MADRS can be used with individuals with aphasia.
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 stroke. We identified 4 studies.

Floor/Ceiling Effects

No studies were identified that examined the floor/ceiling effects of the MADRS in individuals with stroke.

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 consistency:

Agrell and Dehlin (1989) examined the internal consistency of 6 depression rating scales in 40 elderly individuals with stroke, 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 reliability of the MADRS in a stroke population.

Fantino and Moore (2009) examined the test-retest reliability of the 9-item self-administered version of the MADRS in 278 outpatients diagnosed with Major Depressive Disorder. The test-retest reliability using intraclass correlation coefficient was excellent (r = 0.78).

Intra-rater:

No studies were identified that measured the intra-rater reliability of the MADRS in a stroke population.

Inter-rater:

No studies were identified that measured the inter-rater reliability of the MADRS in a stroke population.

Montgomery and Asberg (1979) examined the inter-rater reliability 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 nurse. The inter-rater correlations were excellent (ranging from r = 0.89 to r = 0.97).

Validity

Content:

The MADRS covers the core symptoms of depression with the exception of motor retardation which was excluded from the primary selection, since it occurred in relatively few patients (Montgomery & Asberg, 1979).

Construct:

Farner, Wagle, Flekkoy, Wyller, Fure, Stensrod, et al. (2009) examined the construct validity of the MADRS using factor analysis in 163 individuals with stroke. They identified 3 distinct factors: Anhedonia; Sadness; and Agitation. The factor Anhedonia was related to cognitive impairment, Sadness to neurological impairment due to the stroke, and Agitation related to somatic factors not directly related to the stroke.

Criterion:

Concurrent:

Agrell and Dehlin (1989) examined the concurrent validity of the MADRS with 5 other depression rating scales: Geriatric Depression Scale (GDS) (Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982); Zung Scale (Zung, 1965) Center for Epidemiologic Studies 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 stroke 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 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 Depression Inventory (BDI – Beck, Ward, & Mendelson, 1961) in 22 patients with stroke and found an excellent correlation (r = 0.65).

Sensitivity/Specificity:

Sagen, Vik, Moum, Morland, Finset, and Dammen (2009) estimated the sensitivity and specificity of the MADRS in 104 patients 4 months post-stroke by comparing it to the DSM-IV diagnosis of Depression as the gold standard. At a cut-off of >6, the MADRS had a sensitivity of 0.90 and a specificity of 0.66. At a cut-off of >12, a sensitivity of 0.70 and a specificity 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 stroke 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 reliability of a structured interview guide for the Montgomery-Ãsberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52-58.

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

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