Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The Nurses' Global Assessment of Suicide Risk (NGASR) is a tool designed to evaluate the risk of suicide by considering various psychological and situational factors. The assessment involves a series of 15 criteria, each with a binary true/false response. These criteria encompass a range of stressors and psychological states that are weighted differently to reflect their importance in determining suicide risk.

The factors and their respective scores are as follows:

- Presence/influence of hopelessness: 3 points
- Recent stressful events: 1 point
- Persecutory voices/beliefs: 1 point
- Depression/loss of interest or loss of pleasure: 3 points
- Withdrawal from social interactions: 1 point
- Warning of suicidal intent: 1 point
- Evidence of a plan to commit suicide: 3 points
- Family history of mental illness or suicide: 1 point
- Recent bereavement or relationship breakdown: 3 points
- History of psychosis: 1 point
- Widow/widower: 1 point
- Prior suicide attempt: 3 points
- History of socioeconomic deprivation: 1 point
- History of substance use: 1 point
- Terminal illness: 1 point

For each criterion that is true, the corresponding score is added up to generate a total score, which can range from 0 to 25.

Based on this total score, the risk of suicide is interpreted as follows:

- 12 or higher: Risk of suicide is very high
- 9 to 11: Risk of suicide is high
- 6 to 8: Risk of suicide is intermediate
- 5 or below: Risk of suicide is low

This system provides a structured way to evaluate the risk, guiding healthcare providers in identifying individuals who may require urgent interventions or further psychological evaluation.

The Nurses' Global Assessment of Suicide Risk score, or NGASR score, is a clinical calculator used in the field of mental health. It is specifically designed for use by nurses to assess the risk of suicide in patients, particularly those with psychiatric disorders. The NGASR score is a valuable tool in the early identification of patients at high risk of suicide, allowing for timely intervention and management. It includes factors such as previous suicide attempts, depression, hopelessness, and other relevant clinical indicators. This calculator is not recommended for use in patients under the age of 18 or in those without a psychiatric diagnosis, as it may not accurately reflect their suicide risk.

Nurses' Global Assessment of Suicide Risk score (NGASR score)

The Hamilton Depression Scale (HAM-D) is a clinical questionnaire designed to assess the severity of depression in individuals by evaluating a range of emotional and physiological symptoms. The scale involves several categories, with responses scored according to their severity. The total score then provides an overall understanding of the individual's depression level.

To compute the score, respondents choose from predefined options in each category:

- **Depressed Mood**: Ranges from no mood issues ("Absent") scoring 0 to extreme mood symptoms ("Extreme symptoms") scoring 4.
- **Feelings of Guilt**: Begins at "Absent" for 0 and extends to "Hallucinations of guilt" for 4.
- **Suicide**: Scores start at 0 for no suicidal thoughts and increase to 4 for "Attempts at suicide".
- **Initial Insomnia**: Difficulty falling asleep, scored between "Absent" (0) and "Frequent" (2).
- **Insomnia During The Night**: From "Absent" (0) to "Frequent" (2) interruptions during sleep.
- **Delayed Insomnia**: Early morning awakenings, scored 0 to 2.
- **Work and Interests**: Evaluates impact on productivity, with scores ranging from "No difficulty" (0) to "Unable to work" (4).
- **Retardation**: Slowness in thought and activity, scored from 0 for no retardation to 4 for "Complete stupor".
- **Agitation**: Emotional restlessness is measured from 0 to 2.
- **Psychiatric Anxiety**: Ranges from "Absent" (0) to "Fears" (4).
- **Somatic Anxiety**: Physical symptoms of anxiety range from 0 to 4 for "Incapacitating".
- **Gastrointestinal Somatic Symptoms**: Scored from "Absent" (0) to "Severe" (2).
- **General Somatic Symptoms**: Evaluates physical energy, also scored between 0 and 2.
- **Genital Symptoms**: Libido and related issues, scoring 0 to 2.
- **Hypochondriasis**: Relates to health worries, scored from 0 to 4 for "Hypochondriacal delusions".
- **Weight Loss**: Scores 0 for no loss to 2 for "Obvious".
- **Insight**: Self-awareness of illness, scored from 0 for complete insight to 2 for "Loss of insight".

The sum of these scores yields the HAM-D total score, which is interpreted as follows:
- A total score from 0 to 7 is considered "Normal", indicating no significant depression.
- Scores between 8 and 16 suggest "Mild depression".
- Scores from 17 to 23 indicate "Moderate depression".
- A score of 24 or higher signifies "Very severe depression". 

The HAM-D score provides clinicians with a comprehensive view of the depression severity, guiding potential treatment decisions.

The Hamilton Depression Scale, also known as the HAM-D scale, is a clinical calculator used to quantify the severity of depressive symptoms in patients diagnosed with depression. It is widely used in both clinical and research settings. The HAM-D scale assesses a variety of symptoms associated with depression such as mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and somatic symptoms. 

The scale is typically used in adult populations, but can also be used in adolescents with modifications. The clinical utility of the HAM-D scale is to monitor the severity of depression and response to treatment in patients diagnosed with depressive disorder. It is not designed to diagnose depression, but rather to measure the severity of depressive symptoms in individuals already diagnosed with the condition. 

The HAM-D scale should not be used as a diagnostic tool for depression, and it may not be suitable for use in patients with cognitive impairment or severe communication difficulties due to the nature of the questions asked. It also may not capture all aspects of depression, such as atypical symptoms or depression with comorbid anxiety.

Hamilton depression scale (HAM-D scale)

The Major Depression Inventory (MDI) index evaluates the severity of depression by analyzing responses to 12 questions about various emotional and physical symptoms experienced. These questions cover aspects such as mood, interest in activities, energy levels, self-confidence, guilt, perceived worth of life, concentration, restlessness, subdued feelings, sleep disturbances, and changes in appetite.

Each response is scored on a scale from 0 to 5:
- At no time = 0
- Some of the time = 1
- Slightly less than half of the time = 2
- Slightly more than half of the time = 3
- Most of the time = 4
- All the time = 5

These individual scores are summed to generate a total score ranging from 0 to 60. This total score is then interpreted to assess the degree of depression:

- **0 to 19:** No depression
- **20 to 24:** Mild depression
- **25 to 29:** Moderate depression
- **30 to 60:** Severe depression

After gathering all responses, assign each to its corresponding numeric value, sum the scores, and compare this total against the specified score ranges to determine the level of depression. The final evaluation provides both the total score and a verbal interpretation, reflecting the severity of depressive symptoms based on the score.

The Major Depression Inventory (MDI) index is a self-report mood questionnaire developed by the World Health Organization. It is designed to assess the presence and severity of depressive symptoms in individuals, particularly those in a primary care setting or general population. The MDI index is used to identify major depressive disorder, as well as to measure the severity of depressive symptoms. It can be used to monitor changes in symptoms over time, making it a useful tool for evaluating the effectiveness of treatment interventions. The MDI index is not recommended for use in individuals with cognitive impairment or severe mental illness, as these conditions may affect the individual's ability to accurately self-report symptoms.

Major Depression Inventory index (MDI index)

The Patient Health Questionnaire-9 (PHQ-9) is designed to evaluate the severity of depression across nine symptom areas. Each of these symptoms corresponds to a question with four possible answers, each indicating how frequently the symptom is experienced: "Not at all," "Several days," "More than half the days," and "Nearly every day." These responses are converted to numerical values, with "Not at all" scoring 0, "Several days" scoring 1, "More than half the days" scoring 2, and "Nearly every day" scoring 3.

To calculate the depression score:

1. Assign numerical values to each response based on the predefined scale.
2. Sum these values to obtain a total score.

The interpretation of the depression level is based on the total score, categorized as follows:

- Total score 0 – 4: Minimal depression
- Total score 5 – 9: Mild depression
- Total score 10 – 14: Moderate depression
- Total score 15 – 19: Moderately severe depression
- Total score 20 – 27: Severe depression

These categories provide a systematic approach to understanding the severity of depression and help in determining the appropriate level of intervention or further assessment needed.

The Patient Health Questionnaire-9 (PHQ-9) is a clinical calculator used to screen, diagnose, monitor, and measure the severity of depression. It is applicable to patients in a wide range of healthcare settings, including primary care and mental health clinics. The PHQ-9 is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders, and it scores each of the 9 DSM-IV criteria for depression as "0" (not at all) to "3" (nearly every day). 

The clinical utility of the PHQ-9 is to not only screen for the presence of depressive symptoms but also to provide a severity score that can help in treatment decisions. It can be used to monitor the efficacy of treatment over time, providing a quantitative measure of patient progress. 

There are no specific exclusion criteria for the use of the PHQ-9. However, it should be noted that it is a screening tool and not a definitive diagnostic tool. Therefore, a high score should be followed up with a comprehensive psychiatric evaluation. It may also be less accurate in populations with high rates of physical illness due to the somatic nature of several of the questions.

Patient Health Questionnaire-9 for depression severity (PHQ-9)

The Hamilton Anxiety Scale (HAM-A scale) is a tool designed to measure a person's level of anxiety through responses to different categories of symptoms. These symptoms are grouped into 13 categories that reflect various aspects of anxiety:

- Anxious mood
- Tension
- Fears
- Insomnia
- Intellectual difficulties
- Depressed mood
- Somatic symptoms
- Cardiovascular symptoms
- Respiratory symptoms
- Gastrointestinal symptoms
- Genitourinary symptoms
- Autonomic symptoms
- Behavior during an interview

For each category, the respondent chooses among options that range from "None" to "Very severe." These responses are quantitatively scored, with "None" receiving 0 points, "Mild" 1 point, "Moderate" 2 points, "Severe" 3 points, and "Very severe" 4 points. 

The scoring process is simple: add up the scores from all 13 categories. The total score can range from 0 to 52, with higher scores indicating greater severity of anxiety. Once the scores are summed, the total is interpreted as follows:

- A score between 0 and 7 suggests "No or minimal anxiety."
- A score between 8 and 14 reflects "Mild anxiety."
- A score between 15 and 23 indicates "Moderate anxiety."
- A score of 24 or more points to "Severe anxiety."

This method provides a standardized way to assess anxiety levels based on individual self-reports concerning various symptoms.

The Hamilton Anxiety Scale, often abbreviated as HAM-A, is a psychological questionnaire used by clinicians to rate the severity of a patient's anxiety. It is applicable to patients who are suspected of or diagnosed with anxiety disorders. The HAM-A scale is a valuable tool in both clinical and research settings, as it allows for the quantification of anxiety symptoms and can be used to monitor changes in symptom severity over time. It is particularly useful in assessing the efficacy of therapeutic interventions for anxiety disorders. The HAM-A scale is not recommended for use in patients with cognitive impairments or severe mental illness, as these conditions may interfere with the patient's ability to accurately report their symptoms.

Hamilton anxiety scale (HAM-A scale)

The Generalized Anxiety Disorder-7 (GAD-7) score is a simple tool used to assess anxiety levels based on seven key questions about common symptoms. Each question pertains to how often specific feelings or behaviors have been experienced recently, ranging from being nervous to feeling afraid that something awful might happen.

For each of these seven questions, the following answers are possible, each with an associated score that reflects symptom frequency:

| Response Option              | Score |
|------------------------------|-------|
| Not at all                   | 0     |
| Several days                 | 1     |
| More than half the days      | 2     |
| Nearly every day             | 3     |

The questions focus on:

- Feeling nervous, anxious, or on edge
- Inability to stop or control worrying
- Excessive worrying about various things
- Trouble relaxing
- Restlessness that makes it difficult to sit still
- Irritability or annoyance
- Feeling afraid that something bad might happen

By converting each response to its numerical score, the results are then summed to produce a total score ranging from 0 to 21. This score allows individuals and healthcare providers to identify the severity of anxiety in a standardized manner.

The total score is interpreted as follows:
- Scores of 0 to 4 suggest "No anxiety disorder," indicating minimal anxiety symptoms.
- Scores of 5 to 9 indicate "Mild anxiety disorder," reflecting a low level of anxiety that might warrant attention.
- Scores of 10 to 14 denote "Moderate anxiety disorder," suggesting a noticeable impact that could benefit from further evaluation or intervention.
- Scores of 15 or more are categorized as "Severe anxiety disorder," pointing to significant anxiety that likely requires professional help or intervention.

The Generalized Anxiety Disorder-7 score, commonly abbreviated as GAD-7, is a clinical tool used to measure the severity of generalized anxiety disorder in adults. It is a self-reported questionnaire that consists of seven items, each scored from 0 (not at all) to 3 (nearly every day), providing a 0-21 severity scale. The GAD-7 score is used to screen for and assess the severity of generalized anxiety disorder, and it can also be used to monitor treatment response in patients with this disorder. It is not recommended for use in children or adolescents, or for diagnosing other types of anxiety disorders.

Generalized anxiety disorder-7 score (GAD score)

The Patient Safety Screener 3 (PSS-3) measures suicide risk by evaluating responses to three questions related to feelings of depression and thoughts of or attempts at suicide. Each response contributes points to an overall score, which determines the risk level.

The questions assess whether, in the past two weeks, the individual has felt depressed or hopeless, whether they have considered suicide, and whether they have ever attempted suicide in their lifetime. Answers to these questions are scored as follows:

- Feeling down, depressed, or hopeless in the past two weeks:
  - "Yes" scores 1 point
  - "No" and "Refused to answer" score 0 points

- Having thoughts of suicide in the past two weeks:
  - "Yes" scores 1 point
  - "No" and "Refused to answer" score 0 points

- Lifetime suicide attempt:
  - "Yes" scores 1 point
  - "No" and "Refused to answer" score 0 points

To calculate the total score, simply add the scores from each of the responses. The possible scores range from 0 to 3, with higher scores indicating greater risk. Based on the total score:

- A score of 2 or 3 suggests a "Risk of suicide is high".
- A score of 0 or 1 indicates a "Risk of suicide is low".

The Patient Safety Screener 3 (PSS-3) is a clinical calculator used in the field of mental health, specifically for patients who may be at risk for suicide. It is a brief, three-item screening tool designed to identify patients in healthcare settings who may be at risk for suicide or self-harm. The PSS-3 is typically used in emergency departments and inpatient medical/surgical units, but can be applied in any healthcare setting. 

The clinical utility of the PSS-3 is to quickly identify patients who may be at risk for suicide, allowing for immediate intervention and referral to appropriate mental health services. It is not intended to be a comprehensive assessment of suicide risk, but rather a first step in identifying those who may need further evaluation.

There are no specific exclusion criteria for the use of the PSS-3. However, it should be noted that this tool is not designed to predict suicide or to be used as the sole method of assessing suicide risk. It should be used in conjunction with a comprehensive clinical assessment and judgement.

Patient Safety Screener 3 (PSS-3)

Suicidal ideation

Electroconvulsive therapy

Transcranial magnetic stimulation

Screening for borderline personality disorder

Lithium

Cognitive behavioral therapy

Public health measures

Community-based interventions

Indications for screening

Indications for screening (eating disorders)

Indications for screening (depression)

Indications for screening, obesity

Indications for screening, general population

Safety planning

Clozapine

Post-discharge care

Indications for screening (cancer)

Dialectical behavior therapy

Technology-based interventions

Indications for screening (psychiatric disorders)

Choice of screening tool

Risk assessment

Indications for screening (opioid users)

Restricting access to lethal means

As per AACE/ACE/ASA/…/OS 2020 guidelines, 

Indications for screening (Tourette's syndrome)

Ketamine

Collaborative interventions

Updated 2024 VA/DoD guidelines for the assessment and management of suicide risk


Suicidal ideation

Guidelines

Key sources