MADRS: Montgomery-Åsberg Depression Rating Scale

Reviewed by: Constantin Rezlescu | Associate Professor | UCL Psychology

Introduction

The Montgomery-Åsberg Depression Rating Scale (MADRS) is a ten-item clinician-administered questionnaire developed in 1979 by British psychiatrist Stuart Montgomery and Swedish psychiatrist Marie Åsberg. Designed specifically as an adjunct to the Hamilton Depression Rating Scale, the MADRS was created to provide superior sensitivity to treatment-induced changes in depression, particularly those brought on by antidepressants and other therapeutic interventions.

Revolutionary Treatment Sensitivity: The MADRS emerged from a critical need in depression research for an instrument that could more accurately detect the subtle but meaningful changes occurring during antidepressant treatment. While existing scales like the Hamilton Depression Rating Scale provided reliable severity measurement, they often failed to capture the nuanced improvements that patients and clinicians observed during successful therapy.

Strategic Development Approach

The MADRS was strategically developed by extracting ten specific items from the Comprehensive Psychopathological Rating Scale (CPRS) based explicitly on their demonstrated ability to detect depression change in response to treatment. This evidence-based item selection process distinguished the MADRS from other depression measures that were developed primarily for diagnostic or severity assessment purposes.

Core Assessment Philosophy

The MADRS embodies a unique assessment philosophy that prioritizes:

• Treatment responsiveness – Items selected specifically for change sensitivity
• Core mood symptoms – Focus on central depressive experiences rather than peripheral features
• Functional emphasis – Assessment of mood-related functional impairment and quality of life
• Clinical utility – Practical tool for monitoring therapeutic progress
• Research optimization – Enhanced statistical power for detecting treatment effects

🔬 Clinical Trials Standard: The MADRS has become the preferred depression outcome measure in European pharmaceutical research, valued for its superior sensitivity to antidepressant effects and ability to detect meaningful clinical change.

Key Features

Assessment Characteristics

• 10 items focused on treatment-sensitive symptoms
• 15-20 minutes administration by trained clinician
• Adult populations (18+ years with validated adolescent versions)
• 7-point scales (0-6) for each item providing detailed gradation
• Change-focused design optimized for detecting treatment response

Symptom Assessment Domains

• Apparent sadness – Observable signs of depression during interview
• Reported sadness – Subjective experience of depressed mood
• Inner tension – Anxiety and agitation components
• Sleep disturbances – Reduced sleep quality and duration
• Appetite changes – Decreased appetite and eating patterns
• Concentration difficulties – Cognitive impairment and focus problems
• Lassitude – Fatigue and energy depletion
• Inability to feel – Anhedonia and emotional numbing
• Pessimistic thoughts – Negative future expectations
• Suicidal thoughts – Risk assessment and safety monitoring

Research and Clinical Applications

• Antidepressant trials – Primary outcome measure in pharmaceutical research
• Treatment monitoring – Superior sensitivity to therapeutic changes over time
• European research – Preferred instrument in European clinical trials
• Comparative studies – Standard comparator against Hamilton Depression Rating Scale
• Patient-reported versions – MADRS-S self-assessment variant available

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Scoring and Interpretation

Response Format

Each item is scored by the clinician on a 7-point scale (0-6) based on information gathered during a structured clinical interview. Ratings reflect symptom severity over the previous week, with specific anchor points provided for each level to ensure consistent scoring across raters.

Sample MADRS Item Structure

Item 1: Apparent Sadness (0-6 scale)

• 0: No sadness
• 2: Looks dispirited but does brighten up without difficulty
• 4: Appears sad and unhappy most of the time
• 6: Looks miserable all the time, extremely despondent

Item 7: Lassitude (0-6 scale)

• 0: Hardly any difficulty in getting started, no sluggishness
• 2: Difficulties in starting activities
• 4: Difficulties in starting simple routine activities which are carried out with effort
• 6: Complete lassitude, unable to do anything without help

Item 10: Suicidal Thoughts (0-6 scale)

• 0: Enjoys life or takes it as it comes
• 2: Weary of life, only fleeting suicidal thoughts
• 4: Probably better off dead, suicidal thoughts are common, suicide considered as a possible solution but without specific plans or intention
• 6: Explicit plans for suicide when there is an opportunity, active preparations for suicide

MADRS Severity Interpretation

Total Score	Severity Level	Clinical Interpretation
0-6	Normal/Remission	No significant depression or successful treatment response
7-19	Mild depression	Mild symptoms with minimal functional impairment
20-34	Moderate depression	Clinically significant depression requiring treatment
35-60	Severe depression	Substantial depression requiring intensive intervention

Treatment Response Criteria

• Remission: MADRS total score ≤10 (some studies use ≤8)
• Response: ≥50% reduction from baseline score
• Clinically meaningful change: ≥6 point improvement (Turkoz et al., 2020)
• Clinically substantial change: ≥12 point improvement (Turkoz et al., 2020)
• Suicide risk: Any score >0 on Item 10 requires immediate clinical attention

Research Evidence and Psychometric Properties

Reliability Evidence

Internal consistency:

• Cronbach’s α: 0.84-0.87 across multiple validation studies in diverse clinical populations (Montgomery & Åsberg, 1979)
• Item-total correlations: High correlations indicating items measure a coherent construct (Montgomery & Åsberg, 1979)

Inter-rater reliability:

• Intraclass correlation: ICC = 0.89-0.97 for total scores across different rater pairs (Montgomery & Åsberg, 1979)
• Individual item agreement: Good to excellent inter-rater reliability for most items (Williams & Kobak, 2008)
• Structured interview improvement: SIGMA (Structured Interview Guide) further enhances inter-rater reliability (Williams & Kobak, 2008)

Test-retest reliability:

• Short-term stability: ICC = 0.78 over one-week intervals in stable patients (Svanborg & Åsberg, 2001)
• Appropriate sensitivity: Lower test-retest in actively improving patients, indicating sensitivity to change (Svanborg & Åsberg, 2001)

Validity Evidence

Convergent validity:

• Correlation with Hamilton: r = 0.87-0.92, indicating strong relationship while maintaining distinctiveness (Carmody et al., 2006)
• Correlation with Beck Depression Inventory: r = 0.73-0.81 with self-report measures (Svanborg & Åsberg, 2001)
• Clinical ratings: High correlation with global clinical assessments of depression severity (Montgomery & Åsberg, 1979)

Discriminant validity:

• Depression vs. anxiety: Moderate correlations with anxiety measures, showing some overlap but distinctiveness (Montgomery & Åsberg, 1979)
• Specificity: Better discrimination of pure depressive symptoms compared to scales with heavy somatic emphasis (Carmody et al., 2006)

Concurrent validity:

• Diagnostic agreement: High agreement with structured diagnostic interviews for major depression (Montgomery & Åsberg, 1979)
• Severity gradation: Accurately discriminates between different levels of depression severity (Montgomery & Åsberg, 1979)

Predictive validity:

• Treatment outcomes: MADRS scores predict treatment response and functional outcomes (Carmody et al., 2006)
• Remission prediction: Low endpoint scores predict sustained recovery and reduced relapse (Carmody et al., 2006)

Factor Structure

Dimensional structure:

• Predominantly unidimensional: Most studies support a single general depression factor (Hammond, 2013)
• Two-factor solutions: Some studies identify dysphoria and neurovegetative symptom factors (Hammond, 2013)
• Consistent core: Core mood items (sadness, inability to feel, pessimism) consistently load together (Hammond, 2013)
• Treatment sensitivity: Factor structure remains stable across treatment, supporting use as change measure (Hammond, 2013)

Treatment Sensitivity

Change detection:

• Superior sensitivity: More sensitive to treatment effects than Hamilton in head-to-head comparisons (Carmody et al., 2006)
• Effect size advantage: Demonstrates larger effect sizes in antidepressant trials (Carmody et al., 2006)
• Early change detection: Capable of detecting improvements within first 1-2 weeks of treatment (Turkoz et al., 2020)

Clinical meaningfulness:

• Minimal important difference: 6-point reduction represents meaningful clinical improvement (Turkoz et al., 2020)
• Substantial improvement: 12-point reduction indicates substantial clinical benefit (Turkoz et al., 2020)
• Remission threshold: Score ≤10 predicts functional recovery and quality of life improvements (Carmody et al., 2006)

Advantages Over Hamilton Depression Rating Scale

Psychometric superiority:

• Higher internal consistency: More coherent item set than Hamilton (Carmody et al., 2006)
• Uniform scaling: All items use same 7-point scale vs. Hamilton’s mixed 3- and 5-point scales (Carmody et al., 2006)
• Better change sensitivity: Superior at detecting treatment-induced changes (Carmody et al., 2006)

Content advantages:

• Reduced somatic emphasis: Less contamination from physical illness symptoms (Carmody et al., 2006)
• Core mood focus: Better captures psychological essence of depression (Carmody et al., 2006)
• Fewer items: More efficient administration (10 vs. 17-21 items) (Montgomery & Åsberg, 1979)

Cross-Cultural and International Validation

Global applications:

• Multiple translations: Validated in 30+ languages with consistent psychometric properties (multiple international studies)
• Cultural invariance: Demonstrates measurement equivalence across European, North American, and Asian populations (international validation studies)
• European standard: Particularly established as preferred measure in European psychiatric research (Carmody et al., 2006)

Self-Report Version (MADRS-S)

Patient-administered variant:

• Correlation with clinician MADRS: r = 0.80-0.89, indicating good agreement (Svanborg & Åsberg, 2001)
• Clinical utility: Enables efficient monitoring between clinician assessments (Svanborg & Åsberg, 2001)
• Treatment sensitivity: Retains sensitivity to change in self-report format (Svanborg & Åsberg, 2001)
• Screening application: Useful for large-scale screening and outcome monitoring (Svanborg & Åsberg, 2001)

Usage Guidelines and Applications

Primary Research Applications

• Pharmaceutical trials – Primary efficacy endpoint in antidepressant development studies
• Treatment comparisons – Superior sensitivity for comparing different therapeutic interventions
• Dose-finding studies – Detection of dose-response relationships in medication trials
• Biomarker research – Outcome measure in studies linking biological markers to treatment response
• Rapid-acting treatments – Specialized applications for novel treatments like ketamine and derivatives

Clinical Practice Applications

• Treatment monitoring – Regular assessment of therapeutic progress in clinical settings
• Outcome measurement – Objective documentation of treatment effectiveness
• Clinical decision support – Data-driven treatment adjustment and optimization
• Patient engagement – Collaborative monitoring using MADRS-S self-report version
• Quality improvement – Standardized outcome measurement in healthcare systems

Administration Requirements

Clinician Training

• Structured training: Comprehensive training in MADRS administration and scoring principles
• SIGMA protocol: Use of Structured Interview Guide for improved reliability and consistency
• Calibration exercises: Regular inter-rater reliability assessments and refresher training
• Clinical judgment: Balance between standardized questions and clinical interview skills

Assessment Protocol

• Time frame: Systematic review of symptoms over the previous week
• Interview structure: Semi-structured clinical interview lasting 15-20 minutes
• Documentation: Detailed rationale for each item score supporting clinical decisions
• Quality assurance: Regular reliability monitoring and score verification procedures

Research Design Considerations

• Sample planning: MADRS ≥20 typically required for clinical trial entry ensuring adequate severity
• Power calculations: Well-established effect sizes available for statistical planning
• Primary endpoints: Standard criteria for response (≥50% improvement) and remission (≤10)
• Secondary outcomes: MADRS-S for patient-reported perspectives and treatment satisfaction

Treatment Monitoring Applications

Clinical Decision Support

• Baseline assessment: Comprehensive symptom profiling before treatment initiation
• Progress tracking: Regular monitoring (weekly to monthly) during active treatment phases
• Dose optimization: Objective data supporting medication adjustments and titration decisions
• Treatment modification: Clear criteria for changing therapeutic approaches based on response patterns

Outcome Documentation

• Electronic records: Integration with clinical documentation systems for standardized reporting
• Progress visualization: Graphical tracking of symptom changes over treatment course
• Treatment history: Longitudinal documentation of response patterns across multiple episodes
• Quality metrics: Standardized outcome measurement for healthcare quality initiatives

Specialized Applications

Rapid-Acting Antidepressants

• Ketamine research: Adapted protocols for rapid onset treatments requiring frequent assessment
• Time-sensitive monitoring: Modified administration schedules for treatments with rapid effects
• Remote assessment: Validated protocols for telehealth administration maintaining reliability
• Safety monitoring: Enhanced attention to suicidal ideation in rapid-acting treatment contexts

Comparative Effectiveness Research

• Head-to-head trials: Direct comparison of different antidepressant classes and mechanisms
• Combination therapy: Assessment of additive effects in multi-modal treatment approaches
• Personalized medicine: Outcome measurement in studies developing individualized treatment selection
• Real-world evidence: Effectiveness studies in routine clinical practice settings

Training and Implementation

Certification Programs

• Initial training: Comprehensive didactic and practical training in MADRS administration
• Competency assessment: Standardized evaluation of rating accuracy and consistency
• Ongoing education: Regular updates on best practices and emerging applications
• Quality maintenance: Systematic programs for maintaining inter-rater reliability over time

Implementation Support

• Protocol development: Customized assessment protocols for specific research or clinical contexts
• Technology integration: Electronic data capture systems optimized for MADRS administration
• Staff training: Comprehensive training programs for clinical and research staff
• Quality assurance: Systematic monitoring and feedback systems for maintaining assessment quality

Limitations and Considerations

• Training requirements – Extensive clinician training needed for reliable and valid administration
• Time investment – 15-20 minute administration may limit use in high-volume clinical settings
• Narrow focus – Optimized for change detection rather than comprehensive symptom assessment
• Cultural considerations – Items may require cultural adaptation for optimal performance across diverse populations

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Legal and Copyright Information

Copyright and Usage Responsibility: Check that you have the proper rights and permissions to use this assessment tool in your research. This may include purchasing appropriate licenses, obtaining permissions from authors/copyright holders, or ensuring your usage falls within fair use guidelines.

The Montgomery-Åsberg Depression Rating Scale is copyrighted by the British Journal of Psychiatry, where it was originally published in 1979. The scale requires permission for commercial use and reproduction, though individual researchers and clinicians may use it for their own research and clinical practice.

Proper Attribution: When using or referencing this scale, cite the original development:

• Montgomery, S. A., and Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Structured Interview Guide: The SIGMA (Structured Interview Guide for the Montgomery-Åsberg Depression Rating Scale) may be copied by individual researchers or clinicians for their own use without seeking permission from the publishers, provided the scale is copied in full and proper attribution is maintained.

Usage Permissions: Written permission must be obtained from the Royal College of Psychiatrists for copying or distribution beyond individual research or clinical use. Commercial applications and large-scale implementations require formal licensing agreements.

External Links and Resources

• Montgomery-Åsberg Depression Rating Scale – Wikipedia
• MDCalc MADRS Calculator
• Psychology Tools MADRS
• NINDS Common Data Elements
• British Journal of Psychiatry

References

Original Development Citation:

• Montgomery, S. A., & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.

Structured Interview Guide (SIGMA):

• Williams, J. B. W., & Kobak, K. A. (2008). Development and reliability of a structured interview guide for the Montgomery-Åsberg Depression Rating Scale (SIGMA). British Journal of Psychiatry, 192, 52-58.

Psychometric Validation:

• Carmody, T. J., Rush, A. J., Bernstein, I., Warden, D., Brannan, S., Burnham, D., & Trivedi, M. H. (2006). The Montgomery-Åsberg and the Hamilton ratings of depression: A comparison of measures. European Neuropsychopharmacology, 16(8), 601-611.

Factor Structure Research:

• Hammond, M. F. (2013). The structure of the Montgomery-Åsberg depression rating scale over the course of treatment for depression. International Journal of Methods in Psychiatric Research, 22(3), 175-184.

Self-Report Version (MADRS-S):

• Svanborg, P., & Åsberg, M. (2001). A comparison between the Beck Depression Inventory (BDI) and the self-rated version of the Montgomery-Åsberg Depression Rating Scale (MADRS). Journal of Affective Disorders, 64(2-3), 203-216.

Treatment Sensitivity:

• Turkoz, I., Alphs, L., Singh, J., Jamieson, C., Daly, E., Shawi, M., … & Greenbaum, M. (2020). Clinically meaningful changes on depressive symptom measures and patient-reported outcomes in patients with treatment-resistant depression. Journal of Psychiatric Research, 124, 69-77.