What are MSPS (Modified Somatic Perception Scale) and CSSRS (Columbia-Suicide Severity Rating Scale) in the context of a patient with a history of overdose and Major Depressive Disorder (MDD) being treated with escitalopram?

Understanding MSPS and C-SSRS in Clinical Practice

Modified Somatic Perception Scale (MSPS)

The Modified Somatic Perception Scale (MSPS) is a risk stratification tool derived from the SAD PERSONS scale, designed to predict suicide attempts in emergency psychiatric settings. 1

Key Characteristics

• The MSPS was evaluated in a large study of 4,019 consecutive psychiatric emergency referrals over 2 years. 1
• Despite widespread use, the MSPS demonstrates poor predictive ability for future suicide attempts, with a sensitivity of only 40.0% and positive predictive value of just 7.4% for high-risk scores. 1
• High-risk MSPS scores at baseline fail to accurately identify patients who will attempt suicide within the next 6 months. 1

Clinical Implications

• The MSPS should not be relied upon as a standalone tool for suicide risk stratification, as it cannot sufficiently determine risk level and may lead to misclassification. 2, 1
• Using the MSPS exclusively can result in inappropriate care recommendations, either exposing patients to unnecessary interventions or failing to provide adequate treatment. 2

Columbia-Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a validated screening instrument that quantifies the severity of suicidal ideation and behavior through structured assessment of thoughts, plans, intent, and actions. 3, 4, 5

Primary Applications

• The American College of Physicians recommends the C-SSRS as a validated screening tool for identifying patients at risk for suicide-related behavior in both general populations and high-risk groups, particularly in mental health specialty care settings. 3
• The C-SSRS demonstrates good convergent validity with other suicidal ideation scales and high sensitivity/specificity for classifying suicidal behaviors. 5
• The scale is sensitive to change over time, making it useful for tracking treatment response. 5

Assessment Components

• The C-SSRS evaluates suicidal ideation through intensity measures including frequency, duration, controllability, deterrents, and reasons for ideation. 6, 5
• Behavioral assessment captures the full spectrum from preparatory acts to actual suicide attempts and completed suicide. 2, 5
• The highest severity levels (intent or intent with plan) at baseline predict higher odds of subsequent suicide attempts. 5

Critical Limitations and Proper Use

• The American College of Physicians explicitly advises against relying exclusively on the C-SSRS for risk stratification, as no single tool has sufficient evidence to determine level of suicide risk. 2, 3
• The C-SSRS must be combined with other assessment methods including clinical interviews, self-reported measures, and collateral information from family members. 3
• In Swedish adult psychiatric populations with recent self-harm, the C-SSRS showed limited ability to correctly predict future suicidal behavior (AUC 0.65), only somewhat better than chance. 6
• The 2019 VA/DoD guidelines note that too few studies exist to assess the accuracy of the C-SSRS, and it is not recommended as a standalone screening tool for suicide risk. 2

Specific Predictive Items

• Among individual C-SSRS items, frequency, duration, and deterrents were associated with elevated short-term risk in adult psychiatric cohorts. 6
• Controllability and reasons for ideation did not significantly predict future attempts. 6
• The suicidal ideation intensity score, when adjusted for previous suicide attempt history, significantly predicts non-fatal or fatal suicide attempts (OR 1.08). 6

Context for Your Patient with MDD and Overdose History

For a patient with Major Depressive Disorder and previous overdose being treated with escitalopram, the C-SSRS should be used as part of a comprehensive suicide risk assessment strategy, not as the sole determinant of risk level. 2, 3

• Combine C-SSRS screening with structured clinical interviews focusing on current ideation intensity, access to means, protective factors, and treatment adherence. 2, 3
• Obtain collateral information from family members about observed mood changes and behavioral patterns. 7
• Monitor particularly closely during the first year following any psychiatric hospitalization, as this represents the highest-risk period for patients with major depression. 2
• Avoid using the MSPS for risk stratification in this patient, given its poor predictive validity. 1