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    Columbia Suicide Severity Rating Scale (C-SSRS Screener)

    Screens for suicidal ideation and behavior.
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    INSTRUCTIONS

    Note there are several versions of the C-SSRS; this is the screener version, which is a truncated version of the full scale intended for emergency settings.

    When to Use
    Pearls/Pitfalls
    Why Use

    Emergency patients in whom there is concern for suicidality.

    • Often based entirely on patient-reported items, but also allows for integration of information from other sources (e.g. family and friends, healthcare professionals, hospital records, coroner’s report/death certificate).

    • Best validated in emergency settings (i.e., to triage patients in the emergency department) and also has limited validation in the outpatient psychiatry setting (Viguera 2015).

    • Suicide risk assessment is complex, and the C-SSRS can assist clinicians with their evalulation of patients in the ER to predict their overall risk and need for admission.

    • Extensively validated in various patient populations, including children as young as five years old and adolescents.

    • Recommended and adopted by the US Food and Drug Administration for clinical trials (FDA 2012) and Centers for Disease Control to define and stratify suicidal ideation and behavior (Crosby 2011).

    Part 1. Severity of ideation:
    0. No reported suicidal ideation
    1. Wish to be dead
    2. Nonspecific active suicidal thoughts
    3. Active suicidal ideation with any methods (not plan) without intent to act
    4. Active suicidal ideation with some intent to act, without specific plan
    5. Active suicidal ideation with specific plan and intent
    Part 2. Suicidal behavior:
    0. No reported suicidal behavior
    1. Actual attempt (potentially self-injurious act committed with some wish to die as a result; injury/harm not necessary to be considered “attempt”)
    2. Interrupted attempt (if not for outside interruption, actual attempt would have occurred)
    3. Aborted attempt or self-interrupted attempt (takes steps toward suicide attempt but stops self before engaging in actual self-destructive behavior)
    4. Preparatory acts or behavior (anything beyond verbalization or thought, like assembling specific method (e.g. buying pills or gun) or preparing for death by suicide (e.g. giving things away, writing suicide note))
    5. Suicide (death by suicide occurred)

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Protocols vary by institution, but most suggest complete assessment by a psychiatrist and inpatient admission for high risk patients (level 4-5). Low and moderate risk patients should be reassessed by a trained clinician and may not require admission.

    Critical Actions

    Should not replace a complete clinical evaluation; may be employed as an initial screener to guide a clinician’s suicide risk assessment and to help stratify patients into low, moderate, or high risk categories.

    Formula

    Part 1. Severity of ideation (select most severe in the past month):

    Variable

    0. No reported suicidal ideation

    1. Wish to be dead

    2. Nonspecific active suicidal thoughts

    3. Active suicidal ideation with any methods (not plan) without intent to act

    4. Active suicidal ideation with some intent to act, without specific plan

    5. Active suicidal ideation with specific plan and intent

     

    Part 2. Suicidal behavior (select most severe in lifetime):

    Variable

    0. No reported suicidal behavior

    1. Actual attempt

    Potentially self-injurious act committed with some wish to die as a result; injury/harm not necessary to be considered “attempt”

    2. Interrupted attempt

    If not for outside interruption, actual attempt would have occurred

    3. Aborted attempt or self-interrupted attempt

    Takes steps toward suicide attempt but stops self before engaging in actual self-destructive behavior

    4. Preparatory acts or behavior

    Anything beyond verbalization or thought, like assembling specific method (e.g. buying pills or gun) or preparing for death by suicide (e.g. giving things away, writing suicide note)

    5. Suicide*

    Death by suicide occurred

    *Suicide option is listed for research purposes for patients who have died by suicide.

    Facts & Figures

    Interpretation:

    Suicidal ideation (most severe in the past month)

    Risk of suicide

    Management

    1-2

    Low

    Behavioral health referral at discharge

    3, or reported suicidal behavior in lifetime

    Moderate

    Behavioral health consult (psychiatric nurse/social worker) and consider patient safety precautions

    4-5, or reported suicidal behavior within the past three months

    High

    Immediate notification of physician and/or behavioral health and patient safety precautions

    Evidence Appraisal

    The Columbia Suicide Severity Rating Scale (C-SSRS) was originally derived by researchers at Columbia University, the University of Pennsylvania, and the University of Pittsburgh (Posner 2011).

    While suicidal ideation and behavior had previously been conceived one-dimensionally, with passive ideation progressing to active intent and then suicidal behavior, the C-SSRS attempted to separate the two (ideation and behavior) by using four constructs: severity of ideation, intensity of ideation, behavior, and lethality. The constructs were based on factors identified in previous studies found to be predictive of suicide attempts and completed suicide.

    In a study of 3,776 patients who had a baseline C-SSRS and at least one follow-up C-SSRS, sensitivity and specificity of positive reports for identifying suicidal behaviors were found to be 67% and 76%, respectively (Mundt 2013).

    Similar findings have been reproduced by others. In a longitudinal study of 1,055 adults admitted to a psychiatric hospital, the C-SSRS was found to have excellent internal consistency (alpha = 0.95), with the summary score and total score revealing adequate classification for suicide-related behavior within six months (sensitivity 69%, specificity 65-67%) (Madan 2016).

    The C-SSRS has been used in numerous trials and has been extensively validated in several subpopulations, including children as young as five years old (Glennon 2014), veterans with concomitant posttraumatic stress disorder (Legarreta 2015), and outpatients in a psychiatry clinic (Viguera 2015). The C-SSRS has been translated for use to 30+ languages other than English (Gratalup 2013).

    Literature

    Validation

    Research PaperMundt JC, Greist JH, Jefferson JW, Federico M, Mann JJ, Posner K. Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. J Clin Psychiatry. 2013;74(9):887-93.Research PaperGlennon J, Purper-ouakil D, Bakker M, et al. Paediatric European Risperidone Studies (PERS): context, rationale, objectives, strategy, and challenges. Eur Child Adolesc Psychiatry. 2014;23(12):1149-60.Research PaperLegarreta M, Graham J, North L, Bueler CE, Mcglade E, Yurgelun-todd D. DSM-5 posttraumatic stress disorder symptoms associated with suicide behaviors in veterans. Psychol Trauma. 2015;7(3):277-85.Research PaperViguera AC, Milano N, Laurel R, et al. Comparison of Electronic Screening for Suicidal Risk With the Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an Outpatient Psychiatric Clinic. Psychosomatics. 2015;56(5):460-9.Research PaperMadan A, Frueh BC, Allen J, et a. Psychometric Re-evaluation of the Columbia-Suicide Severity Rating Scale: Findings from a Prospective, Inpatient Cohort of Severely Mentally Ill Adults. J Clin Psychiatry 2016;77(7):e867-e873.
    Dr. Kelly Posner

    About the Creator

    Kelly Posner, PhD, is a professor of psychiatry at the Vagelos College of Physicians and Surgeons at Columbia University in New York. She is also the founder and director of the Columbia Lighthouse Project. Dr. Posner’s primary research is focused on depression and suicide risk.

    To view Dr. Kelly Posner's publications, visit PubMed

    Content Contributors
    • Joshua Salvi, MD, PhD
    About the Creator
    Dr. Kelly Posner
    Content Contributors
    • Joshua Salvi, MD, PhD