DEPRESSION 4:31-33 (1996)

o
FACTOR ANALYSIS OF THE MONTGOMERY-ASBERG
DEPRESSION RATING SCALE
W. Edward Craighead, Ph.D., and Donald D. Evans, Ph.D.

A maximum likelihood factor analysis with Promax rotation was performed

on the Montgomery-Asberg Depression Rating Scale for 340 adult inpatients
in an Affective Disorders Program. Four factors were identified and labeled
cognitive-pessimism, affective, cognitive-anxiety, and vegetative. Recommen-
dations were offered for the research and clinical use of the factor scores.
Depression 4:31-33 (1996). © 1996 Wiley-Liss, Inc.

Key words: depression rating scale, assessment, factor analysis, nurse

ratings, depression symptoms

INTRODUCTION
The Montgomery-Asberg Depression Rating Scale
(MADRS; Montgomery and Asberg, 1979) is a 10-
item clinical rating scale that measures severity of sev-
eral symptoms of depressive disorders. Items were
originally chosen to be sensitive to pre-post change,
especially those resulting from antidepressant medica-
tion treatments.
Several studies have shown the scale to be reliable
and valid when based on a clinical interview (Mont-
gomery and Asberg, 1979; Kearns et al., 1982;
Davidson et al., 1986; Snaith et al., 1986; Korner et
al., 1990). The MADRS has been shown to be reli-
able and valid when ratings are completed by a
trained nursing staff and based on observations and
interactions with depressed inpatients in a psychi-
atric unit (Craighead et al., 1996).
Although less comprehensive than some other clini-
cal rating scales and most self-report measures of de-
pression, the MADRS does rate characteristics of
multiple components of depressive disorders. The
scale contains items reflecting biological, cognitive, af-
fective, and behavioral characteristics of depression. A
MADRS factor analysis that provided factor subscale
scores seemed warranted. Because the scale is de-
signed to measure treatment change and because both
the degree of change and speed of change may vary
across symptoms, having subscale scores from the
MADRS would be valuable.
Furthermore, some items (e.g., inner tension, pessi-
mistic thoughts, and suicidal thoughts) are not reliable
when considered individually (Craighead et aL, 1996).
In the comparison of treatment modalities, determining
whether there are treatment specific differences in the
rate and type of symptom change would be valuable.
The purpose of the current study, therefore, was to con-
duct a needed factor analysis of the MADRS.
METHOD
SUBJECTS
The MADRS was completed on 340 (227 women,
113 men) inpatients in the Duke University Medical
Center Affective Disorders Program. The patients' av-
erage age was 51.9 years, ranging from 18 to 92 years
(S.D. = 18.8), and the average length of hospitalization
was 25.8 d (S.D. = 16.4). The primary diagnoses were
major depression, bipolar disorder, schizoaffective dis-
order, panic disorder, and obsessive-compulsive disor-
der (225 unipolar depression, 12 adjustment disorder
with depressed mood, 47 bipolar depressed or mixed,
56 other).
RATERS
MADRS raters were 1 male and 12 female regis-
tered nurses. At the beginning of the study, 6 nurses
were introduced to the MADRS during a clinical con-
ference in which the scale was reviewed and sample
patients were rated by the nurses. The resulting scores
and any questions were discussed. Before the begin-
ning of this study, these nurses had had 3-8 months of
experience using the MADRS. Both before and during
the current study, nurses had the opportunity to dis-
cuss any problems with the instrument at weekly pri-
mary nurse meetings. One nurse (the primary nurse)
was assigned directly to the care of each individual
patient. These nurses rated 192 patients.
From the University of Colorado, Boulder (W.E.C.); Drake
University, Des Moines, IA (D.D.E.).
Received for publication January 19, 1994; revised June 24,
1996; accepted June 24, 1996.
Address reprint requests to W. Edward Craighead, Ph.D., De-
partment of Psychology, University of Colorado, Boulder, CO
80309-0345.

© 1996 WILEY-L1SS, INC.

32 Craighead and Evans
During the study period, seven additional primary
nurses joined the unit staff and were trained to rate
inpatients on the MADRS. These nurses completed
MADRS ratings for an additional 148 patients. Thus,
a total of 340 patients were rated.
INSTRUMENT
Patients were rated on the MADRS, a lO-item scale
designed to assess neurovegetative, affective, behav-
ioral, and cognitive aspects of depression. The range
of possible scores on each individual item is 0 to 6,
thereby providing a total score range of 0 to 60.
PROCEDURE
Primary nurses completed the MADRS within 4 d
of each patient's admission. Primary nurse ratings
were kept in the patients' medica! charts, and a record
of the ratings was kept on a flowchart that served as a
reminder to complete the ratings. All data were en-
tered into the computer on a weekly basis by a re-
search assistant.
RESULTS
The data were submitted to a SAS maximum-likeli-
hood factor analysis (SAS Institute Inc., 1987). Based
on the Scree test (Cattell, 1966), the resulting factor
structure was subjected to a Promax oblique rotation
with four factors. The results of the Promax rotation,
with the factor loadings of all items, are presented in
Table 1. The four factors are conceptually clear and are
consistent, with a multidimensional, biopsychosocial
model of depression. The first factor, cognitive-pessi-
mism, is composed of the suicidal thoughts, pessimis-
tic thoughts, apparent sadness, and reported sadness
items. The second is an affective factor and is com-
posed of the inability to feel, lassitude, and observed
sadness items. The third factor, cognitive-anxiety, is
composed of the concentration difficulties and inner
tension items. The fourth factor, vegetative, is com-
posed of the reduced sleep and reduced appetite items.
Because oblique rotations permit interfactor correla-
tions, these are reported in Table 2.
TABLE 1. Item loadings on MADRS four-factor solution
Factor 1
Item (cognitive-pessimism)
Reported sadness 0.81'
Suicidal thoughts 0.57'
Pessimistic thoughts 0.56'
Apparent sadness 0.53'
Lassitude 0.04
Inability to feel 0.06
Concentration difficulties -0.04
Inner tension 0.37
Reduced appetite -0.07
Reduced sleep 0.18
aF'actor loading > 0.40.
An orthogonal rotation using the varimax (SAS In-
stitute Inc., 1987) procedure produced a factor struc-
ture with virtually the same pattern of significant
loadings obtained with the oblique Promax rotation.
The orthogonal pattern of loadings differed by only
two items. Reported sadness, which loaded on Factor
1 for the oblique rotation, loaded on both Factor 1
and Factor 2 in the varimax rotation. Similarly, inner
tension, which loaded on Factor 3 for the oblique ro-
tation, loaded on both Factor 1 and Factor 3 in the
varimax rotation. Thus, the oblique rotation has the
advantage of containing two fewer items that load on
multiple factors. Furthermore, the oblique rotation is
preferred because of the obtained interfactor correla-
tions. A defensible strategy for choosing between or-
thogonal and oblique rotations may be to first conduct
an oblique rotation (Pedhazur and Schmelkin, 1991). If
the obtained interfactor correlations are negligible,
then an orthogonal rotation would be preferred be-
cause of its relative simplicity. In the present analysis,
the interfactor correlations were substantial; there-
fore, the oblique rotation was retained.
DISCUSSION
The data from the current factor analysis of the
MADRS indicate that the scale is composed of four
factors. The first factor, labeled cognitive-pessi-
mism, is clearly the strongest factor and is com-
posed of the most reliable items on the scale
(Craighead et al., 1996; Davidson et al., 1986).
The other factors, however, also represent a mean-
ingful proportion of the scale's variance. Each of the
four factors has been found to be rated reliably (r] >
0.60) by nurses in this Affective Disorders Inpatient
Unit (Craighead et al., 1996).
Use of the factor scores may provide more specific
tests of treatment outcome effects, thus allowing in-
vestigators to determine the rate and degree of the
therapeutic change across the various domains of de-
pressive disorders. Factor scores may also be useful in
studying the topology of symptoms of various sub-
types of depression. The use of factor scores on clinical
Factor 2 Factor 3 Factor 4
(affective) (cognitive-anxiety) (vegetative)
0.23 -0.10 -0.01
-0.12 0.08 0.13
0.10 0.12 -0.05
0.41 a -0.01 0.05
0.69' 0.17 -0.14
0.65' 0.07 0.04
0.33 0.64' 0.06
-0.04 0.42' 0.04
0.29 -0.07 0.68'
-0.24 0.16 0.45'
 Research Article: Factor Analysis ofthe Montgomery-Asberg Scale
TABLE 2. Interfactor correlations for the MADRS four-factor solution
Factor 1 Factor 2
Factor (cognitive-pessimism) (affective)
1 0.58
2 0.31
3 0.02
4
rating scales will be of value when studying depression
with a multitrait-multimethod paradigm (Campbell
and Fiske, 1959). Factor scores of the MADRS may ulti-
mately be useful in helping the clinician decide on a
particular order or combination of intervention pro-
cedures when choosing from among those that have
been found effective for the treatment of depression.
The factors are consistent with a multifactoral
biopsychosocial model of depression (Craighead,
1990). By the rather stringent requirement of 0.40
necessary for an item to load on a factor, this rather
clear, interpretable factor structure emerged. The first
factor, cognitive-pessimism, reflects the patient's re-
port of sadness, pessimism, guilty thoughts, and vari-
ous levels of suicidal thoughts and plans. The second
factor appears to reflect a cohesion of affectively laden
lack of behaviors. The patient is rated as appearing
sad, dispirited, and unhappy, having lost interest in
things around her and having difficulty getting started
on even routine activities. The cognitive-anxiety fac-
tor reflects the association of concentration and tension
problems, which characterize anxious-depressives. As
might be expected, the vegetative symptoms of sleep
and appetite disturbance constitute Factor 4.
Acknowledgments. This research was supported
in part by grant MH40159, CRC/PE for the Study
of Depression, from the National Institute of Men-
tal Health to the Department of Psychiatry at Duke
University, Durham, NC (Dan G. Blazer II, PI).
Appreciation is expressed to Margaret Ferencik
(Head Nurse) and the nursing staff of the Affective
33
Factor 3 Factor 4
(cognitive-anxiety) (vegetative)
0.34 0.31
0.38
Disorders Program for their efforts in the comple-
tion of the project.
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