Assessment Guide  |   Nov 16, 2020  |   2 minute read

Columbia Suicide Severity Rating Scale | C-SSRS

The Columbia Suicide Severity Rating Scale (C-SSRS)

Recommended frequency: Manual
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Summary

The Columbia-Suicide Severity Rating Scale (C-SSRS) is a standardized, self-report measure, intended to be used as a supportive tool to screen for the presence of suicidal ideation or behaviour in an individual. Developed by multiple institutions with support from the National Institute of Mental Health (NIMH), the C-SSRS was the first scale to address the full range of suicidal thoughts and behaviours that indicate increased risk.

While primarily used in acute care settings, the scale has been successfully implemented in many settings, including schools, college campuses, military, fire departments, the justice system, primary care, and for research. The C-SSRS is evidence-based, suitable for all ages, available in over 150 languages, and effectively identifies who needs support and the level of support they need.

About the C-SSRS

The C-SSRS was created in response to a gap in the field identified by a group of researchers from Columbia University, the University of Pennsylvania, and the University of Pittsburgh, who were working together on a NIMH study of treatments to reduce suicide risk among adolescents. The group recognized the need for a singular screening tool that could more precisely assess the full spectrum of thoughts and behaviour associated with suicidality, and identify individuals at risk.

The C-SSRS measures two primary components:

  1. Suicidal Ideation: Assesses thoughts about self-harm or suicide, including severity and frequency.
  2. Suicidal Behaviour: Evaluates past and recent suicidal actions, including attempts, preparatory behaviours, and aborted or interrupted attempts.

The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. The C-SSRS asks users:

  • Whether and when they have thought about suicide (ideation);
  • What actions they have taken, and when, to prepare for suicide;
  • Whether and when they attempted suicide or began a suicide attempt that was either interrupted by another person or stopped of their own volition.

There are several versions of the Columbia Suicide Severity Rating Scale available for use in clinical practice. The Greenspace platform offers the following two:

  • The Lifetime/Recent version to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behaviour.
  • The Since Last Visit version of the scale assesses suicidality since the client’s last visit.

The C-SSRS has an expansive evidence base, with more than 600 published peer-reviewed studies demonstrating it’s validity and use across various populations. It’s use is supported by SAMHSA, the CDC, the FDA, the NIH, the WHO, and many others. In one study, the C-SSRS had 100% specificity and 100% sensitivity in correctly identifying lifetime actual attempts and 99% specificity and 94% sensitivity in correctly identifying lifetime interrupted attempts that were recorded on the Columbia Suicide History Form. Another study from Sweden found that the C-SSRS “robustly” predicted death by suicide over one-week, one month, and one-year periods.

Assessments on Greenspace

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Who is the C-SSRS Assessment For?

Review the list below to determine if this assessment should be used with your client. If you answer YES to both questions, the C-SSRS is likely a good fit to use with your client.

  1. Is your client over the age of 6?
  2. Has your client exhibited signs of suicidal ideation or behaviour?

The Scale

The self-report C-SSRS can be completed independently, without an interview. It consists of a series of yes/no questions about suicidal thoughts and behaviours, typically covering a timeframe ranging from the past month to the individual’s lifetime.

Ideation Assessment

  • Questions assess the presence of suicidal thoughts, ranging from passive wishing to be dead to active planning.
  • Respondents indicate if they have had these thoughts and how frequently they have occurred.

Behaviour Assessment

  • Evaluates past suicide attempts, preparatory actions (e.g., writing a note, acquiring means), and the most severe attempt if applicable.

Risk Interpretation

  • Responses help clinicians determine the level of risk and necessary interventions.

The number and specific questions asked in the assessment will vary based on the individual’s responses. The user responds with “yes” or “no” to indicate whether they have thought about suicide, whether they have attempted suicide or began an attempt, and how recent the thought or behaviour occurred.

The shortest screeners are condensed to a minimum of two and a maximum of six questions, depending on the responses, ensuring a streamlined and efficient way to assess whether a person is at risk and needs further support.

If the patient answers NO to question 2 for suicidal ideation, the assessment skips directly to question 6 to assess whether a recent attempt was made. If the patient answers YES to question 2, they will be asked all 6 questions to assess suicidal behaviour and preparation.

SUICIDE IDEATION DEFINITIONS AND PROMPTS SINCE LAST CONTACT
Ask questions that are bold and underlined YES NO
1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you actually had any thoughts of killing yourself?
If YES to 2, ask questions 3, 4, 5 and 6. If NO to 2, go directly to question 6
3) Have you been thinking about how you might do this?
E.g. “I thought about taking an overdose, but I never made a specific plan as to when, where or how I would actually do it…and I would never go through with it.”
4) Have you had these thoughts and had some intention on acting on them?
As opposed to “I have thoughts, but I definitely will not do anything about them”
5) Have you started to work or worked out the details of how to kill yourself and do you intend to carry out this plan?
6) Have you done anything, started to do anything, or prepared to do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

Scoring the C-SSRS

The C-SSRS does not provide a numerical score but categorizes risk levels based on responses:

  • No or Low Risk: No suicidal ideation or behaviours reported.
  • Moderate Risk: Suicidal thoughts with some intent or planning but no action taken.
  • High Risk: Suicidal ideation with intent, plan, or recent suicidal behaviours.

The patient is at low risk if they answer YES solely to questions 1 or 2. The patient is at moderate risk if they answer YES to question 3. If the patient answers YES to question 4, 5, or 6, they are at high risk of suicidality.

Scoring: The C-SSRS does not provide a numerical score but categorized risk levels based on responses:
No or Low Risk: No suicidal ideation or behaviors reported.
Moderate Risk: Suicidal thoughts with some intent or planning but no action taken.
High Risk: Suicidal ideation with intent, plan, or recent suicidal behaviors.
The patient is at low risk if they answer YES solely to questions 1 or 2. The patient is at moderate risk if they answer YES to question 3. If the patient answers YES to question 4, 5, or 6, they are at high risk of suicidality.

Interpreting the C-SSRS and Determining Next Steps

Results from the C-SSRS Self-Report should be reviewed by a clinician, counsellor, or crisis professional. If responses indicate significant risk:

  • Immediate safety planning may be required.
  • Referral to mental health services should be made.
  • Crisis intervention steps should be taken if urgent risk is identified.

An organization can establish criteria or thresholds that determine what to do next for each client screened. Safety plans to coordinate further care for each risk level should be in place. Be prepared to take immediate action to support a patient if they are assessed as high risk for suicide.

Questions 4-6 indicate a high risk for suicidal behaviour. When this assessment is completed on the Greenspace platform, a flag and date of response are placed on the client profile to highlight suicidality, which indicates that the client has scored high risk on the C-SSRS or another measure that monitors for this risk.

Note: The C-SSRS is a tool to aid in the assessment of suicide risk and should not replace comprehensive clinical evaluations. Always consult with or refer to mental health professionals when significant risk is identified

Copyright Information
Developed by The Columbia Lighthouse Project.

References
About the protocol – the columbia lighthouse project. The Columbia Lighthouse Project – Home of the Columbia-Suicide Severity Rating Scale (C-SSRS): a series of simple, plain-language questions that anyone can use to assess suicide risk. (2024, April 5). https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
Columbia-Suicide severity rating scale (C-SSRS). Columbia University Department of Psychiatry. (2024, March 28). https://www.columbiapsychiatry.org/research-labs/columbia-suicide-severity-rating-scale-c-ssrs
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011, December). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. The American journal of psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC3893686/
Suicide Prevention in Pediatric Populations. Montana DPHHS. (n.d.). https://dphhs.mt.gov/suicideprevention/toolkit/pediatric

Frequently Asked Questions
Is C-SSRS a lifetime screener?

There are several versions of the C-SSRS available for use in clinical practice. The Lifetime/Recent version allows practitioners to gather lifetime history of suicidality as well as any recent suicidal ideation and/or behaviour.

How often should the C-SSRS be administered?

C-SSRS developers recommend administering the Lifetime/Recent version when meeting with a new client and then using the Since Last Visit version at each follow-up appointment.

Is the C-SSRS reliable?

The C-SSRS has an expansive evidence base, with more than 600 published peer-reviewed studies demonstrating it’s validity and use across various populations. Its use is supported by SAMHSA, the CDC, the FDA, the NIH, the WHO, and many others. In one study, the C-SSRS had 100% specificity and 100% sensitivity in correctly identifying lifetime actual attempts and 99% specificity and 94% sensitivity in correctly identifying lifetime interrupted attempts that were recorded on the Columbia Suicide History Form.

In 2011, the Centers for Disease Control and Prevention adopted the protocol’s definitions for suicidal behavior and recommended the use of the Columbia Protocol for data collection. In 2012, the Food and Drug Administration declared the Columbia Protocol the standard for measuring suicidal ideation and behaviour in clinical trials. Today, the Columbia Protocol is used in clinical trials, public settings, and everyday situations, such as in schools, faith communities, hospitals, and the military.

What ages is the C-SSRS applicable for?

The standard version of the C-SSRS is suitable for most children and adults. The standard C-SSRS has been successfully used with children age 6-12. Many younger children can understand the concepts of the questions as they are worded in this standard version.

How should I respond to significant and unexpected score changes?

To use the Columbia Protocol most effectively and efficiently, an organization can establish criteria or thresholds that determine what to do next for each person screened. Decisions about hospitalization, counselling, referrals, and other actions are informed by the “yes” or “no” answers and other factors, such as the recency of suicidal thoughts and behaviours.

If the person answers “Yes” to questions 2 or 3 of the scale, seek behavioural healthcare for further evaluation. If the person answers “Yes” to questions 4, 5, or 6, seek emergency care.

How should I administer the C-SSRS to clients?

The C-SSRS is a self-report measure that clients can complete on their own. The protocol asks 2-6 questions about suicidal ideation and behaviours. Depending on the response to question 2, the assessment will ask question 3-6 if they answered YES to question 2, or skip directly to question 6 if the client answered NO.

How long does it take to complete the C-SSRS?

The C-SSRS takes approximately 2-4 minutes to complete. The patient is asked a minimum of 2 questions and a maximum of 6 questions based on previous answers.

Is the C-SSRS a diagnostic tool?

The C-SSRS is not sufficient on its own as a diagnostic instrument, and is meant to be used as a supportive screening tool. The protocol helps clinicians identify whether someone is at risk and gauge the level of support the client needs.

What does the C-SSRS measure?

The C-SSRS identifies whether someone is at risk for suicide, determines the severity and immediacy of that risk, and gauges the level of support that the person needs.

Through 6 simple questions, the administrator can determine whether someone is at low, medium, or high risk of suicide and decide further actions based on the risk level.

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