Nicohwilliam

COLUMBIA-SUICIDE SEVERITY

RATING SCALE (C-SSRS)

Risk Assessment (Lifeline crisis center version)

Columbia-Suicide Severity Rating Scale (C-SSRS)

The Columbia-Suicide Severity Rating Scale (C-SSRS) is a questionnaire used for suicide assessment

developed by multiple institutions, including Columbia University, with NIMH support. The scale is

evidence-supported and is part of a national and international public health initiative involving the

assessment of suicidality. Available in 103 different languages, the scale has been successfully

implemented across many settings, including schools, college campuses, military, fire departments,

the justice system, primary care and for scientific research.

Several versions of the C-CCRS have been developed for clinical practice. The Risk Assessment

version is three pages long, with the initial page focusing on a checklist of all risk and protective

factors that may apply. This page is designed to be completed following the client (caller) interview.

The next two pages make up the formal assessment. The C-SSRS Risk Assessment is intended to help

establish a person’s immediate risk of suicide and is used in acute care settings.

In order to make the C-SSRS Risk Assessment available to all Lifeline centers, the Lifeline collaborated

with Kelly Posner, Ph.D., Director at the Center for Suicide Risk Assessment at Columbia

University/New York State Psychiatric Institute to slightly adjust the first checklist page to meet the

Lifeline’s Risk Assessment Standards. The following components were added: helplessness, feeling

trapped, and engaged with phone worker.

The approved version of the C-SSRS Risk Assessment follows. This is one recommended option to

consider as a risk assessment tool for your center. If applied, it is intended to be followed exactly

according to the instructions and cannot be altered.

Training is available and recommended (though not required for clinical or center practice) before

administering the C-SSRS. Training can be administered through a 30-minute interactive slide

presentation followed by a question-answer session or using a DVD of the presentation. Those

completing the training are then certified to administer the C-SSRS and can receive a certificate,

which is valid for two years.

To complete the C-SSRS Training for Clinical Practice, visit http://c-ssrs.trainingcampus.net/

For more general information, go to http://cssrs.columbia.edu/

Any other related questions, contact Gillian Murphy at [email protected].

Lifeline Version 1/2014

COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

Posner, Brent, Lucas, Gould, Stanley, Brown, Fisher, Zelazny, Burke, Oquendo, & Mann © 2008 The Research Foundation for Mental Hygiene, Inc.

RISK ASSESSMENT VERSION

(* elements added with permission for Lifeline centers)

Instructions: Check all risk and protective factors that apply. To be completed following the patient interview, review of medical

record(s) and/or consultation with family members and/or other professionals.

Suicidal and Self-Injury Behavior (Past week) Clinical Status (Recent)

Actual suicide attempt Lifetime Hopelessness

Interrupted attempt Lifetime Helplessness*

Aborted attempt Lifetime Feeling Trapped*

Other preparatory acts to kill self Lifetime Major depressive episode

Self-injury behavior w/o suicide intent Lifetime Mixed affective episode

Suicide Ideation (Most Severe in Past Week) Command hallucinations to hurt self

Wish to be dead Highly impulsive behavior

Suicidal thoughts Substance abuse or dependence

Suicidal thoughts with method (but without specific

plan or intent to act) Agitation or severe anxiety

Suicidal intent (without specific plan) Perceived burden on family or others

Suicidal intent with specific plan Chronic physical pain or other acute medical problem

(AIDS, COPD, cancer, etc.)

Activating Events (Recent) Homicidal ideation

Recent loss or other significant negative event Aggressive behavior towards others

Describe: Method for suicide available (gun, pills, etc.)

Refuses or feels unable to agree to safety plan

Pending incarceration or homelessness Sexual abuse (lifetime)

Current or pending isolation or feeling alone Family history of suicide (lifetime)

Treatment History Protective Factors (Recent)

Previous psychiatric diagnoses and treatments Identifies reasons for living

Hopeless or dissatisfied with treatment Responsibility to family or others; living with family

Noncompliant with treatment Supportive social network or family

Not receiving treatment Fear of death or dying due to pain and suffering

Other Risk Factors Belief that suicide is immoral, high spirituality

Engaged in work or school

Engaged with Phone Worker *

Other Protective Factors

Describe any suicidal, self-injury or aggressive behavior (include dates):

SUICIDAL IDEATION Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is “yes”, complete “Intensity of Ideation” section below.

Lifetime: Time He/She Felt

Most Suicidal

Past 1 month

1. Wish to be Dead Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up. Have you wished you were dead or wished you could go to sleep and not wake up?

If yes, describe:

Yes No

□ □

Yes No

□ □

2. Non-Specific Active Suicidal Thoughts General non-specific thoughts of wanting to end one’s life/commit suicide (e.g., “I’ve thought about killing myself”) without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period. Have you actually had any thoughts of killing yourself?

If yes, describe:

Yes No

□ □

Yes No

□ □

3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a specific plan). Includes person who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it…and I would never go through with it.” Have you been thinking about how you might do this?

If yes, describe:

Yes No

□ □

Yes No

□ □

4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to “I have the thoughts but I definitely will not do anything about them.” Have you had these thoughts and had some intention of acting on them?

If yes, describe:

Yes No

□ □

Yes No

□ □

5. Active Suicidal Ideation with Specific Plan and Intent Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

If yes, describe:

Yes No

□ □

Yes No

□ □

INTENSITY OF IDEATION The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe). Ask about time he/she was feeling the most suicidal.

Lifetime - Most Severe Ideation: _______ ________________________________________ Type # (1-5) Description of Ideation

Recent - Most Severe Ideation: _______ ________________________________________ Type # (1-5) Description of Ideation

Most Severe

Most Severe

Frequency How many times have you had these thoughts?

(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day

____

____

Duration When you have the thoughts how long do they last?

(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day (2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous (3) 1-4 hours/a lot of time

____ ____

Controllability Could/can you stop thinking about killing yourself or wanting to die if you want to?

(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty (2) Can control thoughts with little difficulty (5) Unable to control thoughts (3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts

____ ____

Deterrents Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of committing suicide?

(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you (2) Deterrents probably stopped you (5) Deterrents definitely did not stop you (3) Uncertain that deterrents stopped you (0) Does not apply

____ ____

Reasons for Ideation What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both?

(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on (2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling) (3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go on and to end/stop the pain living with the pain or how you were feeling) (0) Does not apply

____

____

© 2008 Research Foundation for Mental Hygiene, Inc.            C‐SSRS—Lifetime Recent - Clinical (Version 1/14/09)                                 Page 1 of 2 

SUICIDAL BEHAVIOR (Check all that apply, so long as these are separate events; must ask about all types)

Lifetime Past 3

months

Actual Attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results, this is considered an attempt. Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred. Have you made a suicide attempt? Have you done anything to harm yourself? Have you done anything dangerous where you could have died?

What did you do? Did you______ as a way to end your life? Did you want to die (even a little) when you_____? Were you trying to end your life when you _____? Or Did you think it was possible you could have died from_____?

Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)? (Self-Injurious Behavior without suicidal intent) If yes, describe:

Has subject engaged in Non-Suicidal Self-Injurious Behavior?

Yes No

□ □

Total # of Attempts

______

Yes No

□ □

Yes No

□ □

Total # of Attempts

______

Yes No

□ □ Interrupted Attempt: When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred). Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so. Has there been a time when you started to do something to end your life but someone or something stopped you before you actually did anything? If yes, describe:

Yes No

□ □

Total # of interrupted

______

Yes No

□ □

Total # of interrupted

______

Aborted or Self-Interrupted Attempt: When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self- destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else. Has there been a time when you started to do something to try to end your life but you stopped yourself before you actually did anything? If yes, describe:

Yes No

□ □

Total # of aborted or

self- interrupted

______

Yes No

□ □

Total # of aborted or

self- interrupted

______

Preparatory Acts or Behavior: Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a suicide note). Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)? If yes, describe:

Yes No

□ □

Total # of preparatory

acts

______

Yes No

□ □

Total # of preparatory

acts

______

Most Recent Attempt Date:

Most Lethal Attempt Date:

Initial/First Attempt Date:

Actual Lethality/Medical Damage: 0. No physical damage or very minor physical damage (e.g., surface scratches). 1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains). 2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree

burns; bleeding of major vessel). 3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes

intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures). 4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree

burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area). 5. Death

Enter Code

______

Enter Code

______

Enter Code

______

Potential Lethality: Only Answer if Actual Lethality=0 Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before run over).

0 = Behavior not likely to result in injury 1 = Behavior likely to result in injury but not likely to cause death 2 = Behavior likely to result in death despite available medical care

Enter Code

______

Enter Code

______

Enter Code

______

© 2008 Research Foundation for Mental Hygiene, Inc.           C‐SSRS—Lifetime Recent - Clinical (Version 1/14/09)                             Page 2 of 2