Columbia Suicide Severity Rating Scale

The Columbia Suicide Severity Rating Scale is a structured instrument for assessing suicidal ideation and behaviour. A screening version asks a short sequence of questions, and a full version records the severity and intensity of ideation and the details of any behaviour.

It is used in emergency departments, primary care, mental health services and research. It structures the questions and supports triage decisions, but it does not predict who will make an attempt.

Usage. It is used when a patient discloses thoughts of death or self-harm, in routine mental health assessment, and after a positive depression screen.

Indications. Any patient with a positive item on a depression screen related to suicidal thoughts, patients presenting after self-harm, and routine screening in settings where the risk is higher.

Preparation and technique. The interview is conducted in private and in a calm manner. The screening version asks about the wish to be dead, non-specific active suicidal thoughts, thoughts with a method, intent, plan, and suicidal behaviour in the preceding 3 months.

Contraindications and precautions. The instrument is used with patients who are able to engage. Patients who are acutely intoxicated or agitated are assessed with attention to safety first.

Interpretation.

• Positive responses to the first two questions (wish to be dead, non-specific thoughts) are usually low risk, with supportive follow up.
• A positive response to the question about thoughts with a method is moderate risk and prompts a same day clinical assessment.
• A positive response to the questions about intent or plan, or suicidal behaviour within the last 3 months, is high risk.

Causes of a positive screen. Depression, bipolar disorder, psychosis, substance misuse, personality disorder, acute loss or stress, and chronic illness or pain.

Critical values and findings needing immediate action.

• High risk responses require immediate safety measures: not leaving the patient alone, removing access to means, and urgent psychiatric assessment.
• Moderate risk responses require same day assessment by a trained clinician and a documented safety plan.

Limitations and artefacts. A negative screen does not rule out risk, because risk changes quickly. Patients may under report from fear of consequences. The instrument informs risk assessment but does not replace clinical judgement.

Follow up tests. A full psychiatric assessment, collateral history from family, assessment of access to means, toxicology screen where intoxication is suspected, and review of medicines.

Special groups. Children and adolescents are assessed using adapted language. Older adults often have fewer warning signs and higher lethality, so risk is assessed carefully.