What is the Maudsley Staging Method?

What is the Maudsley Staging Method?

The Maudsley Staging Method (MSM) is a multidimensional, points-based tool that quantifies treatment resistance in depression by scoring three core factors: number of failed antidepressant treatments, severity of depressive symptoms, and duration of the current episode, producing a total score ranging from 3 (minimal resistance) to 15 (severe resistance). 1

Core Components of the MSM

The MSM incorporates three distinct dimensions that are scored and summed:

1. Treatment Failure Dimension

• Rated on a 5-point subscale based on the number and types of antidepressant medications that have failed 2
• Includes consideration of augmentation strategies and electroconvulsive therapy (ECT) treatment history 1
• Assessment is performed using the Maudsley Treatment Inventory (MTI), which provides a comprehensive list of medications with dose rating options 3

2. Severity of Illness Dimension

• Ranges from subsyndromal depression (score 1) to severe syndromal depression with psychosis (score 5) 2
• Can be assessed using simple instruments such as the Clinical Global Impression, Psychiatric Status Rating, or standard diagnostic checklists 3
• This is a unique feature that distinguishes the MSM from other staging models like the Thase and Rush or MGH-s models 1

3. Duration of Current Episode

• Rated on a 3-point subscale reflecting how long the current depressive episode has persisted 2
• Longer duration independently predicts worse outcomes and functional impairment 4, 5

Clinical Utility and Validation

The MSM is the only staging model with prospective validation demonstrating good predictive validity, correctly predicting treatment resistance in more than 85% of cases. 1, 6

Predictive Performance

• Higher MSM scores independently predict being in a depressive episode for 50% or longer of follow-up duration (OR = 2.11) 4
• Predicts persistent depression throughout follow-up (OR = 2.01) and functional impairment 4
• Outperforms the Thase and Rush model in predicting future nonresponse 1
• The Dutch extension of the MSM (DM-TRD) showed even better predictive validity than the original MSM for future depressive symptomatology 5

Expert Consensus and Recommendations

The 2022 Delphi consensus guideline recommends the Maudsley Staging Method as the preferred instrument for defining and staging treatment-resistant depression in clinical trials, with 69% expert consensus. 1

• The American Psychiatric Association recommends using structured staging tools like the MSM to confirm treatment resistance in clinical practice 7, 6
• Alternative valid options include the Thase and Rush model and the MGH-s model, though these lack the prospective validation of the MSM 1

Advantages Over Other Staging Models

The MSM differs from competing models in critical ways:

• Unlike the Thase and Rush model, MGH-s, and European Staging Model, the MSM uniquely incorporates disease characteristics (duration and baseline symptom severity) rather than focusing solely on treatment failures 1
• The Antidepressant Treatment History Form has good reliability for ECT outcomes specifically, but the MSM has broader applicability 1, 7
• The MSM produces a continuous score reflecting the level of treatment resistance, allowing for more nuanced assessment than categorical staging 1

Common Pitfalls

• Reliability testing of the MSM has not been formally reported, though inter-rater and intra-rater reliability were excellent in the Dutch extension study 1, 5
• The MSM does not have direct correspondence with the commonly used definition of TRD as "two or more treatment failures" 1
• Proper use requires the Maudsley Treatment Inventory for standardized assessment of the treatment failure dimension 3