psychiatry & behavioral healthquestionnaire

Columbia-Suicide Severity Rating Scale (C-SSRS)

The Columbia-Suicide Severity Rating Scale is a structured assessment of suicidal ideation severity and behaviour. It progresses from passive ideation (wishing to be dead) through active ideation with increasing specificity (method, intent, plan) to suicidal behaviour (attempts, preparation). It is the most widely used structured suicide risk assessment tool worldwide.

questionnaire

✓ when to use

Use for any patient where suicidal risk needs to be assessed: psychiatric emergencies, positive PHQ-9 item 9, post-self-harm presentations, depression, substance use, and any clinical concern about suicide risk. The C-SSRS provides a structured framework that ensures key questions are asked systematically. Can be used in ED, inpatient, outpatient, and primary care settings.

✗ when not to use

The C-SSRS is an assessment tool, not a prediction tool — no instrument can reliably predict who will die by suicide. A 'low-risk' C-SSRS result does not guarantee safety. Clinical judgement, collateral history, and the therapeutic relationship remain essential. The C-SSRS should be administered by trained staff who can respond appropriately to positive responses. It should not be used in isolation from a broader clinical assessment.

clinical pearls

  • The C-SSRS is hierarchical: questions progress from less severe (Q1: passive ideation) to most severe (Q5: plan with intent, Q6: behaviour). A positive response at a higher level supersedes lower levels in risk categorisation.
  • Question 2 is the key branch point: 'Have you actually had any thoughts of killing yourself?' This separates passive ideation (Q1 only) from active suicidal ideation (Q2+). Active ideation requires more intensive assessment and follow-up.
  • Questions 4 and 5 (intent and plan) are the strongest predictors of near-term suicide attempt. Intent WITHOUT plan (Q4) and plan WITH intent (Q5) both require urgent assessment, but Q5 represents the highest ideation severity.
  • Question 6 assesses BEHAVIOUR, not just thoughts. This includes actual attempts, interrupted attempts (stopped by external circumstance), aborted attempts (stopped by self), and preparatory behaviour (writing a note, giving away possessions, acquiring means).
  • Safety planning should accompany any positive C-SSRS assessment. A safety plan includes: warning signs, coping strategies, people to contact for distraction, people to contact for help, professionals/agencies to contact in crisis, and means restriction steps. The Stanley-Brown Safety Plan is the most widely used format.

related tools

phq-9Item 9 positive → consider C-SSRS for detailed assessmentgad-7Anxiety assessment — anxiety increases suicide riskaudit-cAlcohol screening — intoxication and alcohol misuse increase acute suicide risk