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Emerg Med Pract. Author manuscript; available in PMC 2021 Mar 19.
Published in final edited form as:
Emerg Med Pract. 2019 May 1; 21(5): CD3–CD4.
Published online 2019 May 1.
PMCID: PMC7974826
NIHMSID: NIHMS1673432
Joshua Salvi, MD, PhD
Author information Copyright and License information PMC Disclaimer
The publisher's final edited version of this article is available at Emerg Med Pract
Critical Actions
The C-SSRS should not replace a complete clinical evaluation. It may be employed as an initial screening to guide a clinician in suicide risk assessment and to help stratify patients into categories of low, moderate, or high risk.
Evidence Appraisal
The 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 understood as one-dimensional, with passive ideation progressing to active intent and then to suicidal behavior, the C-SSRS attempted to separate ideation and behavior by using 4 constructs (severity of ideation, intensity of ideation, behavior, and lethality), based on factors identified in previous studies as predictive of suicide attempts and completed suicide.
In a study of 3776 patients who had a baseline C-SSRS screening and at least 1 follow-up, positive reports had 67% sensitivity and 76% specificity for identifying suicidal behaviors (Mundt 2013).
Similar findings have been reproduced by others. In a longitudinal study of 1055 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 6 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 5 years of age (Glennon 2014); military veterans with concomitant posttraumatic stress disorder (Legarreta 2015); and outpatients in a psychiatry clinic (Viguera 2015). It has been translated for use in more than 30 languages (Gratalup 2013).
Points & Pearls
The Columbia-Suicide Severity Rating Scale (C-SSRS) score is based on the patient’s responses to screening questions, but it also allows for integration of information from other sources (eg, family and friends, healthcare professionals, hospital records, or coroner’s report).
The C-SSRS has been validated in emergency settings (ie, to triage patients in the emergency department) but also has some validation in the outpatient psychiatry setting (Viguera 2015).
Why to Use
Suicide risk assessment is complex; the C-SSRS can assist clinicians in evaluation of patients in the emergency department to predict overall suicide risk and the need for admission. The C-SSRS has been extensively validated in several subpopulations, including children and adolescents, military veterans with concomitant posttraumatic stress disorder, and psychiatry outpatients.
The C-SSRS is recommended by the United States Food and Drug Administration for clinical trials (United States Food and Drug Administration 2012), and has been adopted by the Centers for Disease Control and Prevention to define and stratify suicidal ideation and behavior (Crosby 2011).
When to Use
The C-SSRS should be used in patients in the emergency department for whom there is a concern for suicidality.
Next Steps
Protocols vary by institution, but most recommend a complete assessment by a psychiatrist and inpatient admission for patients identified as high risk (Level 4 or 5). Patients at low to moderate risk should be reassessed by a trained clinician and may not require admission.
Footnotes
Use the Calculator Now
Click here to access the C-SSRS on MDCalc.
References
Original/Primary Reference
•. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266–1277. DOI: 10.1176/appi.ajp.2011.10111704 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Validation References
•. Mundt JC, Greist JH, Jefferson JW, et al. 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):887–893. https://www.ncbi.nlm.nih.gov/pubmed/24107762 [PubMed] [Google Scholar]
•. Glennon 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):1149–1160. DOI: https://dx.doi.org/10.1007%2Fs00787-013-0498-3 [PMC free article] [PubMed] [Google Scholar]
•. Legarreta M, Graham J, North L, et al. DSM-5 posttraumatic stress disorder symptoms associated with suicide behaviors in veterans. Psychol Trauma. 2015;7(3):277–285. DOI: 10.1037/tra0000026 [PubMed] [CrossRef] [Google Scholar]
•. Viguera 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):460–469. DOI: 10.1016/j.psym.2015.04.005 [PubMed] [CrossRef] [Google Scholar]
•. Madan A, Frueh BC, Allen J, et al. Psychometric reevaluation 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. DOI: 10.4088/JCP.15m10069 [PubMed] [CrossRef] [Google Scholar]
Other References
•. Brent DA, Greenhill L, Compton S, et al. The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry. 2009;48(10):987–996. DOI: 10.1097/CHI.0b013e3181b5dbe4 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
•. Crosby AE, Han B, Ortega LA, et al. Suicidal thoughts and behaviors among adults aged ≥ 18 years--United States, 2008–2009. MMWR Surveill Summ. 2011;60(13):1–22. https://www.ncbi.nlm.nih.gov/pubmed/22012169 [PubMed] [Google Scholar]
•. United States Food and Drug Administration. Guidance for Industry: Suicidal Ideation and Behavior: Prospective Assessment of Occurrence in Clinical Trials. Rockville, MD: United States Department of Health and Human Services; 2012. https://www.fda.gov/downloads/Drugs/Guidances/ucm225130.pdf [Google Scholar]
•. Gratalup G, Fernander N, Fuller DS, et al. Translation of the Columbia Suicide Severity Rating Scale for Use in 33 Countries. Paper presented at: 9th Annual Meeting of the International Society for CNS Clinical Trials and Methodology; February 19–21, 2013; Washington, DC. [Google Scholar]
