When to Use the Columbia-Suicide Severity Rating Scale (C-SSRS)
Use the C-SSRS as a validated screening tool to identify patients at risk for suicide-related behavior in both general populations and populations at increased risk, particularly in mental health specialty care settings where suicide risk screening has become standard practice. 1
Primary Screening Applications
Deploy the C-SSRS Screener version in psychiatric emergency departments as an initial screening step before conducting a full clinical assessment of suicide risk. 2
Apply the C-SSRS in general population screening programs when selecting a validated measure to identify patients at risk for suicide-related behavior, as it has sufficient evidence among both general and increased-risk populations. 1
Use the C-SSRS in mental health specialty care settings where suicide risk screening has become part of standard care, though evidence for screening programs reducing suicide attempts or deaths remains insufficient. 1
Specific Clinical Contexts
Screen patients presenting to psychiatric emergency services after self-harm episodes, as the C-SSRS can predict short-term suicide risk within 1 week, 1 month, and 1 year. 2
Assess adolescents and adults in treatment studies for suicide prevention interventions, as the C-SSRS demonstrates good convergent validity and sensitivity to change over time. 3
Monitor patients during clinical trials assessing suicidal ideation and behavior, particularly when tracking treatment response. 3
Important Caveats and Limitations
Do not rely exclusively on the C-SSRS for risk stratification, as no specific tool has sufficient evidence to determine level of suicide risk, and misclassification can lead to inappropriate care recommendations. 1
Recognize the C-SSRS has limited predictive accuracy - while it performs somewhat better than chance (AUC 0.62-0.65), it can miss many combinations of suicidal ideation and behavior that present in clinical practice. 4, 5
Be aware that the C-SSRS has been criticized for psychometric flaws, including not addressing the full spectrum of suicidal ideation or behavior and having ambiguous wording that can lead to misclassifications. 5
Combine the C-SSRS with other assessment methods including clinical interviews, self-reported measures, and collateral information from loved ones, rather than using it as a standalone tool. 1, 6
Optimal Cut-Off Points
In psychiatric emergency settings, use an ideation severity cut-off that identifies patients with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7). 2
Pay particular attention to the highest levels of ideation severity (intent or intent with plan), as these predict higher odds of suicide attempts during follow-up. 3
Focus on specific C-SSRS items including frequency, duration, and deterrents, which show stronger associations with elevated short-term risk than controllability and reasons items. 4