Columbia Suicide Severity Rating Scale (C-SSRS)

1) Wish to be dead: Patient has a wish to be dead or to fall asleep and not wake up. (Have you wished you were dead or wished you could sleep and not wake up?) {Yes/No:21365}

2) Suicidal thoughts: Patient has general, non-specific thoughts of wanting to end their life/commit suicide. (Have you actually had any thoughts of killing yourself?) {Yes/No:21365}

Did the patient answer "yes" to question #2 above? {Yes/No:21365} (if "no", indicate "not applicable" for questions 3-5, then go to question 6)

3) Suicidal thoughts with method (without specific plan or intent to act):

Patient has thoughts of suicide and has thought of at least one method, but has no specific plan and no intent to act. (Have you been thinking about how you might kill yourself?) {YES_NO:21033}

4) Suicidal intent without specific plan: Patient has active thoughts of killing themselves and has some intent to act. (Have you had thoughts of killing yourself and had some intention of acting on them?) {YES_NO:21033}

5) Suicide intent with specific plan: Thoughts of killing oneself with details of plan fully or partially worked out and with some intent. (Have you started to work out how you might kill yourself? Do you intend to carry out this plan?) {YES_NO:21033}

------

6) Suicide behavior question:"Have you ever done anything, started to do anything, or prepared to do anything to end your life?" (examples: collected pills, obtained a gun, gave away valuables, wrote a will or a suicide note, started a suicide attempt but changed their mind, actually attempted suicide, etc). {Yes/No:21365}

Was the behavior over 3 months ago? {YES_NO:21033}

Between 3 months and 1 week ago? {YES_NO:21033}

Within the last week? {YES_NO:21033}

Based upon the C-SSRS, the patient's acute suicide risk is {Desc; low/moderate/high:110033}

Notes on how scale is used at MaineMedicalCenter:

Risk level (3rd column below) is determined by one of two ways:

  1. By the highest number question with a positive response in questions 1 thru 5 (1st column below). For example, if pt answered yes to question 2 but no to questions 3-5, risk would be low. If they answered yes to question 3 but no to 4 and 5, risk would be moderate. Etc.
  1. By the most recent time grouping to receive a positive response in question 6 (2ND column below). For example, if pt answered yes to “less than 3 months and greater than 1 week,” but no to “less than 1 week,” the risk is would be moderate. If yes to “less than 1 week,” the risk would be high.

The final risk level is the higher of the two. For example, if the pt was high risk as determined by questions 1-5, but low as determined by question 6, the final risk level is high.

Note that the 4th column below contains disposition considerations. This means that the clinician should consider those dispositions that correspond to the assessed risk. The final plan is based not only on the C-SSRS, but also on other elements of the evaluation. If I were to recommend a final plan that did not correspond to the C-SSRS risk level (eg, discharging home without follow-up a patient who is high risk according to the scale), I would acknowledge that in my documentation and explain my reasons for doing so.