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Assessing Suicide Risk Using C-SSRS Clinical Guide

Assessing Suicide Risk Using C-SSRS Overview

This content is intended as a Quick Reference for Assessing Suicide Risk and will cover an overview and nursing considerations utilizing the Columbia Suicide Severity Rating Scale (C-SSRS). 

What is the Columbia-Suicide Severity Rating Scale

Suicide Risk Assessment

Why Screen for Suicide Risk?

Healthcare professionals are positioned to prevent suicide. About half of people who die by suicide meet with a healthcare provider in the month before their death (LeCloux et al., 2021).

In another study, clinicians who screened for depression but not suicide failed to detect risk in one-third of their clients (Horowitz et al., 2021). You must directly ask about suicide to detect risk.

Clinicians who routinely screen for suicide are more likely to (Pumariega et al., 2020):

  • Identify people at risk for suicide.
  • Connect people at risk to the services they need.

What is the Columbia-Suicide Severity Rating Scale?

The Columbia-Suicide Severity Rating Scale (C-SSRS) is considered the “gold standard” of suicide screening and assessment. There are two types of C-SSRS tools:

  • Screeners allow you to quickly identify if a person has any suicide risk.
  • Full scales guide you in a complete assessment of suicidal ideation and behavior.

Why the C-SSRS Assessment?

It is well-established that the C-SSRS effectively identifies suicide risk and helps plan treatment interventions (The Columbia Lighthouse Project, 2022).

The C-SSRS is also accessible. It is free and available in over 100 languages. No mental health training is needed to administer the C-SSRS.

It is important to note that mental health training IS needed to identify a person’s risk level and develop an appropriate treatment plan.

You can select different versions of the C-SSRS based on the client’s:

  • Age group
  • Population
  • Setting
  • Treatment phase

Lastly, the C-SSRS can help you avoid asking vague or leading questions that leave suicide risk undetected. When you ask the “right” questions, you can better understand your client’s suicide risk and get them the help they need (Research Foundation for Mental Hygiene, 2018).

When Should You Screen for Suicide Risk?

You should screen all clients over the age of 12 years old at intake and then at follow-up appointments (The Joint Commission [TJC], 2019).

You should also screen for suicide when you notice risk factors, such as (Jacobs, n.d.):

  • Any sort of crisis
  • Significant loss
  • Major life stressors
  • Recent medical diagnosis
  • Major shift in presentation
  • Suicide-related statements or behaviors

Who Can Administer the C-SSRS?

You do not need specific mental health training to use the C-SSRS. Anyone can administer the C-SSRS.

A person does not need to be in a behavioral health setting to be screened for suicide risk. They can be assessed in:

  • Primary care
  • Inpatient settings
  • Emergency departments
  • Schools
  • Day treatment programs

C-SSRS developers provide free training in administration and scoring through their website. See the Resources section for more information.

What Version Should You Use?

Two steps can help you choose the version of the C-SSRS that will best suit your needs.

Step 1: Setting and Language

Select the version that is the best fit for your setting and client by:

  • Visiting the developer’s website (a link is provided in the resources section)
  • Choosing your setting and language from the drop-down menu

Step 2: Version

Review the options and choose the version that best suits your needs. There are three core versions of the C-SSRS:

  • Screener: To briefly ask about suicidal thoughts and behaviors
  • Lifetime/Recent: To fully assess suicidal thoughts and behaviors in the client’s lifetime and in the last 3 months
  • Since last visit: To follow up on suicidal thoughts and behaviors assessed in a previous appointment

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 (Research Foundation for Mental Hygiene, 2018).

Administering and Scoring the C-SSRS

Administration Basics

The C-SSRS uses an interview format. It is intended to be flexible and conversational. You do not need to ask all questions, such as those the client has already answered.

The C-SSRS encourages you to integrate information gathered from other sources, such as:

  • Caregivers
  • Family members
  • First responders
  • Medical records

Sections of the C-SSRS

There are two main sections of the C-SSRS.

Part I: Suicidal Ideation

In this section, you ask if the person has had thoughts of suicide (i.e., ideation). You should then ask clients with suicidal ideation about:

  • Plans
  • Intent

The full version includes questions about their most severe ideation. Each item is scored on a scale and provides information about:

  • Severity
  • Frequency
  • Duration

You then add the scores to understand the overall intensity of the client’s ideation. Scores range from 2 to 25. Higher scores are associated with greater risk (Research Foundation for Mental Hygiene, 2018).

If the person denies suicidal ideation, you should still ask questions about suicidal behavior.

Part 2: Suicidal Behavior

In the second section, you will ask about prior suicide attempts. A prior suicide attempt is one of the most significant risk factors for suicide (Prabhakar et al., 2021).

The full version of the C-SSRS includes specific questions about:

  • Interrupted attempts: Something or someone stopped the person from dying
  • Aborted attempts: The person stopped themselves while an attempt was in progress
  • Preparatory behaviors: Actions taken with suicide intent (e.g., buying a gun, collecting pills)

The full version also includes questions about the potential lethality of their most serious attempt.

Next Steps

You will then use the results from the C-SSRS to decide the next steps. Clients will need a comprehensive risk assessment with a licensed mental health professional if they:

  • Endorse ideation at a level of 4 or 5 in the past month
  • Engaged in any suicidal behaviors in the past 3 months

Resources

Columbia-Suicide Severity Rating Scale

Training Options

The Columbia Lighthouse Project, designed to support C-SSRS users and to further the science backing this instrument, offers a variety of free training programs. Visit their website at http://cssrs.columbia.edu/training/training-options/

Suicide Hotline (988)

National Suicide Prevention Lifeline Toll-Free / 24 hours / 7 days a week https://988lifeline.org/

  • 988

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Additional Information

Course Contributor

The content for this course was written by Bridgett Ross, PsyD.

Dr. Ross received her bachelor’s degree in Psychology and Philosophy from Boston College and then her doctoral degree in Clinical Psychology from Alliant International University. She is a licensed psychologist in California and was in private practice for 13 years treating various issues including trauma, anxiety and mood disorders, grief/loss, and issues around self-concept, identity, and attachment. Having supervised pre-licensed and licensed clinicians, she maintains an interest in professional issues in the field of psychology. Dr. Ross’ training and work history include Children’s Hospital Chadwick Center for Children and Families, Kaiser Permanente, Alvarado Parkway Institute, and the Department of Veterans Affairs, which informed her focus on providing evidence-based trauma treatment to diverse populations.

Acknowledgment: Monique Kahn, PsyD was the previous author of this educational activity but did not participate in the revision of the current version of this course.

Other Resources

Below are some additional websites that you can go to for more information on suicide and suicide prevention:

References

  • The Columbia Lighthouse Project. (2022). The Columbia Suicide Severity Rating Scale (C- SSRS) supporting evidence. http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/evidence/
  • Horowitz, L. M., Mournet, A. M., Lanzillo, E., He, J. P., Powell, D. S., Ross, A. M., Wharff, E. A., Bridge, J. A., & Pao, M. (2021). Screening pediatric medical patients for suicide risk: Is depression screening enough? The Journal of Adolescent Health, 68(6), 1183–1188. https://doi.org/10.1016/j.jadohealth.2021.01.028
  • Jacobs, D. (n.d.). SAFE-T: Application to Clinical Practice. Retrieved from http://stopasuicide.org/assets/docs/SAFE-T_Application_to_Clinical_Practice.pdf
  • The Joint Commission. (2019). R3 Report: Requirement, rationale, reference. https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/
  • LeCloux, M., Aguinaldo, L. D., Lanzillo, E. C., & Horowitz, L. M. (2021). PCP Opinions of Universal suicide risk screening in rural primary care: Current challenges and strategies for successful implementation. The Journal of Rural Health, 37(3), 554–564. https://doi.org/10.1111/jrh.12508
  • Prabhakar, D., Peterson, E. L., Hu, Y., Chawa, S., Rossom, R. C., Lynch, F. L., Lu, C. Y., Waitzfelder, B. E., Owen-Smith, A. A., Williams, L. K., Beck, A., Simon, G. E., & Ahmedani, B.
  • K. (2021). Serious suicide attempts and risk of suicide death: A case–control study in the US healthcare systems. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 42(5), 343–350. https://doi.org/10.1027/0227-5910/a000729
  • Pumariega, A. J., Good, K., Posner, K., Millsaps, U., Romig, B., Stavaraski, D….Yarger, H. (2020). Systemic suicide screening in a general hospital setting: Process and initial results. World Social Psychiatry, 2(1), 31-42.
  • Research Foundation for Mental Hygiene. (2018). Assessment of suicidal risk using C-SSRS. https://practiceinnovations.org/portals/0/CSSRS/shell.html
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