Proof Positive: The Evidence Supports Using the C-SSRS to Assess Risk

An unprecedented amount of research has validated the relevance and effectiveness of the questions used in the Columbia-Suicide Severity Rating Scale (C-SSRS) to assess suicide risk, making it the most evidence-based tool of its kind. Research validates the questions — and the way they are structured and categorized — for assessing the likelihood that someone will make a suicide attempt. And research on the scale’s reliability confirms that the C-SSRS effectively identifies who is most at risk.

“The research shows that this tool will help organizations focus on folks who are at highest risk.”

– Anne Bauer, MD, field director, Accreditation and Certification Operations, The Joint Commission

Psychometric Properties and Clinical Outcomes

Numerous studies support the psychometric properties of the C-SSRS. These studies attest to the scale’s divergent, convergent, predictive, and incremental validity, as well as to its sensitivity to change, internal consistency, inter-rater reliability, cross-cultural and multi-lingual application, and more. Evidence also supports the effectiveness of the C-SSRS as an intervention tool for preventing suicides, as well as a measurement tool for treatment response.

The Columbia Lighthouse Project has compiled a “Supporting Evidence” document that provides the details on this research, as well as a long list of published studies that involved use of the C-SSRS. This list of studies is categorized in several ways, including by population group (age, psychiatric condition, etc.) and setting.

Ideation and Behavior as Risk Factors: Select Studies

The C-SSRS consists of questions for asking people whether and when they have thought about suicide (ideation) and what actions they have taken — and when — to attempt or prepare to take their own lives (behavior). We ask about both ideation and behavior because research has shown that, independent of each other, they are predictive of suicide attempts.

  • Suicidal ideation and a history of suicidal behavior are among the most salient short- and long-term risk factors for suicide risk.
    • Nordström, P., Samuelsson, M., & Åsberg, M. (1995). Survival analysis of suicide risk after attempted suicide. Acta Psychiatrica Scandinavica, 91(5), 336–340.
    • Beck, A.T., Brown, G. K., Steer, R. A., et al. (1999). Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide and Life-Threatening Behavior, 29(1), 1–9.
    • Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. Journal of Consulting and Clinical Psychology, 68(3), 371–377.
    • Kuo, W.-H., Gallo, J. J., & Tien, A. (2001). Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychological Medicine, 31(7), 1181–1191.
  • Suicidal ideation is predictive of or a precursor to suicidal behavior.
    • Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56(7), 617–626.
    • Posner, K., Brown, G. K., Stanley, B., et al. (2011). The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277.
  • Suicidal ideation and behavior do not always occur together.
    • Fawcett, J. (1992). Suicide risk factors in depressive disorders and in panic disorder. Journal of Clinical Psychiatry. 53 (Suppl), 9–13.

Types of Behavior: Select Studies

Suicide attempts are strong predictors of additional attempts. But other behaviors that stop short of an attempt also are strongly predictive. That’s why the scale includes questions about aborted attempts, interrupted attempts, and preparations for suicide.

  • A suicide attempt is a potent risk factor for additional suicide attempts or death by suicide.
    • Steer, R. A., Beck, A., Garrison, B., & Lester, D. (1988). Eventual suicide in interrupted and uninterrupted attempters: a challenge to the cry-for-help hypothesis. Suicide and Life-Threatening Behavior, 18 (2), 119–128.
    • Fawcett, J., Scheftner, W., Fogg, L., & Clark, D. (1990). Time-related predictors of suicide in major affective disorder. The American Journal of Psychiatry, 147(9), 1189–1194.
    • Malone, K. M., Szanto, K., Corbitt, E. M., & Mann, J. J. (1995). Clinical assessment versus research methods in the assessment of suicidal behavior. American Journal of Psychiatry, 152(1), 1601.
    • Harris, E. C., & Barraclough, B. (1997) Suicide as an outcome for mental disorders. A meta-analysis. The British Journal of Psychiatry, 170(3), 205–228.
    • Brown et al., 2000.
  • Aborted attempts are highly associated with future suicide attempts.
    • Marzuk, P., Tardiff, K., Leon, A., Portera, L., & Weiner, C. (1997). The prevalence of aborted suicide attempts among psychiatric inpatients. Acta Psychiatrica Scandinavica,. 96(6), 492–496.
    • Barber, M. E., Marzuk, P., Leon, A., & Portera, L. (1998). Aborted suicide attempts: a new classification of suicidal behavior. American Journal of Psychiatry, 155(3), 385–389.
  • Interrupted attempts are predictive of suicide.
    • Steer R.A., & Beck, A. (1988). Use of the Beck Depression Inventory, Hopelessness Scale, Scale for Suicidal Ideation, and Suicidal Intent Scale With Adolescents. Advances in Adolescent Mental Health, 3, 219–231.
  • Some suicidal behaviors that are more prevalent than previous suicide attempts are just as, or more, predictive of risk.
  • Mundt, J. C., Greist, J. H., Jefferson, J. W., Federico, M., Mann, J. J., & Posner, K. (2013). Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. The Journal of Clinical Psychiatry, 74(9), 887-893.
  • People who have prepared for a suicide attempt are more likely to die by suicide than those who do not report such behavior.
    • Steer et al., 1988.
    • Marzuk et al., 1997.
    • Beck et al., 1999
  • It is recommended that screening instruments assess any, or “nonzero,” intent to die, because people who engage in suicidal behavior frequently have mixed motives.
    • Andriessen, K. (2006). On “intention” in the definition of suicide. Suicide and Life-Threatening Behavior, 36(5), 533–538.
    • Marzuk et al., 1997.
    • Silverman, M.M. (2006). The language of suicidology. Suicide and Life-Threatening Behavior, 36(5), 519–532.
    • Posner et al., 2011.

Types of Ideation: Select Studies

The C-SSRS contains questions about suicidal thoughts — focusing on their intensity, duration, and frequency — because research shows the importance of those factors. The wording of the questions, such as the scale’s question about “wish to die,” are evidence-based, too.

  • Patients with a wish to die are five to six times more likely than the general public to die by suicide.
    • Brown, G. K., Steer, R. A., Henriques, G. R., & Beck, A. T. (2005). The internal struggle between the wish to die and the wish to live: a risk factor for suicide. American Journal of Psychiatry. 162(10), 1977–1979.
  • The best reference point to use to quantify ideation is “the time the person felt most suicidal,” which has been shown to be the most predictive of suicide.
    • Beck et al., 1999.
  • Ideation with the intent to act is a distinct type of suicidal ideation.
    • Hawton, K. (1987). Assessment of suicide risk. British Journal of Psychiatry, 150, 145–153.
    • Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale and methodology. Suicide and Life-Threatening Behavior, 37(3), 248–263.
    • Posner et al., 2011.
  • The presence of the intent to act confers a higher risk for suicidal behavior.
    • Posner et al., 2011.
    • Mundt et al., 2013.
  • The duration of adolescents’ suicidal thoughts may be particularly important to the risk for suicidal behavior.
  • Gipson, P. Y., Agarwala, P., Opperman, K. J., Horwitz, A., & King, C. A. (2014). Columbia-Suicide Severity Rating Scale: Predictive Validity With Adolescent Psychiatric Emergency PatientsPediatric Emergency Care, 31(2), 88-93.

C-SSRS Reliability and Validity: Select Studies

Research on the use of the C-SSRS has confirmed the scale’s reliability and validity for assessing risk. Studies also have supported its use by nonmental health staff, in electronic form, and in non-English language translations.

“Having a proven method to assess suicide risk is a huge step forward in our efforts to save lives.”

– Michael Hogan, Former Commissioner, New York State Office of Mental Health

  • The C-SSRS determined clinically meaningful points at which a person may be at risk for a suicide attempt.
    • Posner et al., 2011.
  • The C-SSRS intensity scale score was a significant predictor of a suicide attempt for 178 adolescents seeking psychiatric emergency services.
    • Gipson et al., 2014.
  • In emergency department follow-up assessments, a phone-administered C-SSRS increased suicide attempt detection by more than 40 percentage points compared with chart reviews.
    • Arias, S. A., Zhang, Z., Hillerns, C., et al. (2014). Using structured telephone follow-up assessments to improve suicide-related adverse event detection. Suicide and Life-Threatening Behavior. doi: 10.1111/sltb.12088.

Feasibility and Reliability in Nonmental Health Settings and Administered by Nonmental Health Staff

  • Various nonclinicians using the C-SSRS in a juvenile justice system all classified suicidal behaviors in the same way, demonstrating strong interrater reliability.
    • Kerr, D.C., Gibson, B., Leve, L.D., & DeGarmo, D.S. (2014). Young adult follow-up of adolescent girls in juvenile justice using the Columbia Suicide Severity Rating Scale. Suicide and Life-Threatening Behavior, 44 (2), 113–129.
  • Phone and in-home assessments by nonpsychiatric subspecialty staff using the C-SSRS reached conclusions that matched the conclusions of mental health professionals who followed up with participants.
    • Lucas, M. S., Brawner, B. M., Hardie, T. L., Beacham, B., Paidipati, C., Diaz, M., Lauer, A, Hobbie, W. L., & Deatrick, J. A. Assessing Suicidal Ideation and Behaviors among Survivors of Childhood Brain Tumors and Their Mothers During Sociobehavioral Research. Oncology Nursing Forum, 42(5): E319 – E329.

Feasibility and Validation of the eC-SSRS (electronic form of the C-SSRS)

  • The eC-SSRS is an effective means for prospectively monitoring suicidality in clinical trial research and practice.
    • Mundt, J.C., Greist, J.H., Gelenberg, A.J., Katzelnick, D.J., Jefferson, J.W. & Model, J.G. (2010). Feasibility and Validation of a Computer-Automated Columbia-Suicide Severity Rating Scale Using Interactive Voice Response Technology. Journal of Psychiatric Research, 44, 1224–1228.

Cross-cultural Validation

  • The versions of the C-SSRS in 45 languages (a total of over 100 translations now exist) were established according to a rigorous methodology to ensure conceptual equivalence and cultural relevance across languages.
    • Gratalup, G., Fernander, N., Fuller,D.S., & Posner, K (2013). Translation of the Columbia Suicide Severity Rating Scale for Use in 33 Countries. International Society for CNS Clinical Trial Methodology, 9th Annual Scientific Meeting, Washington, D.C.
  • The Korean version of the C-SSRS is a reliable and valid tool for the prediction of suicidal risk in a clinical setting.
    • Pai, D., Woo, J. M., Son, M. H., & Lee, C. (2015). The Reliability and Validity of the Korean Version of Columbia-Suicide Severity Rating Scale in Alcohol Dependent Patients. Journal of Korean Neuropsychiatric Association, 54(2), 222–227.
  • The Turkish version of the C-SSRS is a reliable and valid instrument that can be used for adolescents across inpatient and outpatient psychiatric and nonpsychiatric settings.
    • Gunes A., Kilincaslan, A., & Eskin, M. (2015). Psychometric Properties of the Turkish Version of Columbia-Suicide Severity Rating Scale Among 12–18 year-old adolescents in Turkey. American Academy of Child and Adolescent Psychology, 62nd Annual Meeting, San Antonio, Texas.