A Therapist's Guide to the Columbia-Suicide Severity Rating Scale (C-SSRS) Sceening Version 

Talking about suicide can be difficult, but as a therapist, understanding how to assess suicide risk is one of the most important ways you can support your clients. Having the right tools can make this process more manageable and help you provide the care your clients need. That’s where the Columbia-Suicide Severity Rating Scale (C-SSRS) Screening Version comes in. 

The C-SSRS (Screen) is a trusted and widely-used tool that helps you better understand the severity and urgency of a client’s suicidal thoughts or behaviors. By using this tool, you can feel more confident in making decisions about treatment and ensuring your clients get the support they deserve. Let’s take a closer look at the C-SSRS—what it is, how it works, and how to use it effectively. 

What is the Columbia-Suicide Severity Rating Scale Screen Version?

‍The C-SSRS (Screen), sometimes called the Columbia Protocol, is a 6-item screening tool designed to assess suicidal thoughts and actions. It can help identify individuals at risk for suicide and determines the level of severity and immediacy of the risk. It asks respondents to rate whether they have experienced the suicidal thoughts and behaviors listed (e.g., “Have you wished you were dead or wished you could go to sleep and not wake up?”) in the past month on a scale of “Yes” and “No.” It also asks about lifetime and recent (past three months) suicide planning.

The C-SSRS has been validated in age groups six and up, although there is a version available for very young children aged 4-5. It has also been extensively validated in several subpopulations, including children and adolescents, military veterans with noncomitant post-traumatic stress disorder, and psychiatry outpatients. Clinicians commonly use the C-SSRS to quantify the severity of suicidal ideation and behavior and determine the level of support a person needs. It can assist clinicians in evaluating suicide risk as an initial screening, but should not replace a complete clinical evaluation. 

What do you learn from the Columbia-Suicide Severity Rating Scale (Screen)?

‍The C-SSRS (Screen) offers important insights into an individual's risk of suicide, helping you make informed treatment decisions. It is scored on a binary Yes/No scale, but a total score is not used. Instead, it is helpful to look at the items endorsed to determine risk level. When you administer the screener, it identifies the presence and severity of suicidal thoughts and behaviors, categorizing risk into low, medium, and high levels:

• Low Risk: Answers to Questions 1 or 2 indicate suicidal thoughts without intent or plan, suggesting a lower level of risk that still requires further evaluation.
• Medium Risk: "Yes" responses to Questions 3 or 6 (lifetime question) point to significant suicidal ideation, possibly with some intent or plan, indicating a moderate risk level that needs a comprehensive risk assessment.
• High Risk: Affirmative answers to Questions 4, 5, or 6 (past 3 months question) show suicidal intent, plan, or recent attempts, signaling a high-risk situation that demands immediate intervention and a thorough safety assessment, possibly including a crisis reponse center or emergency department. These individuals should not be left alone until they can be further evaluated.

Using the C-SSRS (Screen) repeatedly over time gives you additional valuable information, allowing you to:

• Track changes in suicidal thoughts and behaviors, helping you assess treatment effectiveness and adjust interventions as necessary.
• Identify patterns or triggers that may increase suicide risk, enabling you to develop targeted prevention strategies.
• Evaluate the impact of life events, stressors, or treatment milestones on an individual's suicidal thoughts and behaviors.
• Make informed decisions about resource allocation, ensuring those at highest risk receive the most intensive support and intervention.

It should be noted that the C-SSRS (Screen) 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 risk. 

‍Research and Evidence behind the Columbia-Suicide Severity Rating Scale (Screen)

‍The C-SSRS builds on research and collaboration among leading institutions. Researchers from Columbia University, the University of Pennsylvania, the University of Pittsburgh, and New York University developed it with support from the National Institute of Mental Health (NIMH), giving the scale a strong scientific basis:

• Origins: The C-SSRS originated from a 2007 NIMH study focused on reducing suicide risk among adolescents with depression, emphasizing the need for a standardized tool to identify individuals at risk.
• Scientific Foundation: Its development stemmed from over 20 years of research in suicidology and earlier instruments like the Columbia Suicide History Form.
• Validation: Various studies have confirmed the C-SSRS's effectiveness, showing good convergent and divergent validity, high sensitivity, and specificity for categorizing suicidal behavior.

The C-SSRS is widely recognized and adopted:

• In 2011, the CDC incorporated the scale's definitions for suicidal behavior and suggested its use for data collection.
• The FDA endorsed the C-SSRS in 2012 as a standard for measuring suicidal ideation and behavior in clinical trials.
• It is now employed globally in different environments, including clinical trials, public spaces, schools, faith communities, hospitals, and the military, across 45 nations on six continents.

Despite its advantages, the C-SSRS has certain limitations:

• It depends on self-reporting, which can be affected by factors like stigma or reluctance to disclose suicidal thoughts.
• The scale does not cover all potential suicide risk factors, such as substance use or access to lethal means.
• The C-SSRS is not a standalone diagnostic tool and should be used alongside a comprehensive clinical assessment.

Frequently Asked Questions (FAQ)

Who can administer the C-SSRS (Screen)?

Anyone can administer the C-SSRS (Screen); no mental health training is required, although some training is recommended for best results. Online training sessions as short as 20 minutes are available.

‍When and where should the C-SSRS (Screen) be used?

The C-SSRS (Screen) finds its place in various settings, such as healthcare facilities, schools, community organizations, research, military and corrections. It suits most ages and special populations and is available in over 150 country-specific languages. The scale can be part of a comprehensive suicide risk assessment, during initial evaluations, and for ongoing monitoring of at-risk individuals.

‍How are the C-SSRS (Screen) questions phrased?

The C-SSRS (Screen) uses straightforward, direct language to elicit clear responses. The screener version consists of seven "yes" or "no" questions addressing different aspects of suicidal ideation and behavior, ranging from a wish to be dead to specific suicidal thoughts and past suicidal actions.

‍What do the C-SSRS (Screen) scores mean?

Responses to the C-SSRS (Screen) questions help identify an individual's level of suicide risk and the immediacy of the risk. A "yes" answer to any question may indicate the need for referral to a mental health professional. Affirmative responses to questions 4, 5, or 6 signal high risk and require immediate intervention and a thorough safety assessment.

‍Is the C-SSRS (Screen) an effective tool for assessing suicide risk?

The C-SSRS (Screen) is an evidence-based tool with extensive research (please see the “research and evidence” section above for specific citations) supporting its effectiveness in assessing suicide risk. It has proven to help prevent suicide in real-world settings by accurately identifying at-risk individuals and efficiently allocating resources to those who need them most.

‍Is the C-SSRS (Screen) only available in English? ‍

No, it has been translated in more than 150 country-specific languages. Many of these translations have been linguistically validated. 

‍Other Assessment Similar to the Columbia-Suicide Severity Rating Scale to Consider

‍While the C-SSRS is a widely-used and effective tool for assessing suicide risk, there are several other assessments that can provide valuable insights and complement the C-SSRS in your clinical practice. For example, here’s one to consider:

• Suicide Cognitions Scale-Revised (SCS-R): This 16-item self-report measure evaluates thoughts, perceptions, and beliefs often experienced by individuals who have attempted suicide. The SCS-R offers a way to identify and track suicide risk over time, making it a useful tool for monitoring treatment progress and informing risk assessments.

Using additional assessments in your clinical practice can help you gain a more nuanced understanding of your clients' suicide risk and inform your treatment decisions. However, it's important to remember that no single assessment can provide a complete picture of an individual's risk. Always use these tools as part of a comprehensive suicide risk assessment that considers multiple sources of information and your clinical judgment.