Using the Columbia Suicide Severity Rating Scale As a Cheat Sheet

I’ve been looking over the Columbia Suicide Severity Rating Scale (CSSRS). See my previous post about this at short link http://wp.me/p1glcu-1BO. You can also look at the web link http://cssrs.columbia.edu/index.html. You can get training in the use of the instrument at link http://c-ssrs.trainingcampus.net/uas/modules/trees/windex.aspx.

You can view any of the pdf forms of the scales but please remember–they’re all copyrighted and you would need to request permission to use any of them as is. But anyone can view them as a sort of cheat sheet. They’re not behind a firewall, and you don’t have to pay to peek for a refresher as to what questions are important for clinicians to ask in any suicide risk assessment.

You can also read the original paper by Posner and colleagues about the CSSRS [1].

One section of the web site could lead to believing that prediction of suicide is possible and that’s the media/press section. Although I confess I didn’t read any of the news stories, the titles are a little ambitious, e.g. Can Suicide be Really Predicted? Study Says Yes. We don’t teach residents in psychiatry that suicide can be “predicted”, per se, and in my opinion, the idea is at least debatable. The same could be said about preventing suicide [2, 3].

But I don’t think there’s anything to stop professionals from trying nor to stop us from viewing ourselves as all being on the same team, generous enough to share resources that could help save lives. And in the interest of continuous quality improvement, I have shared with our Assistant Resident Director the Competency Assessment Instrument for suicide risk assessment (CAI-S), which we’ve been given permission to use by the authors, Hung and colleagues [4].

1. Posner, K., Ph.D., and e. al (2011). “The Columbia-Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults.” The American Journal of Psychiatry 168(12): 1266-1277.
Objective: Research on suicide prevention and interventions requires a standard method for assessing both suicidal ideation and behavior to identify those at risk and to track treatment response. The Columbia-Suicide Severity Rating Scale (C-SSRS) was designed to quantify the severity of suicidal ideation and behavior. The authors examined the psychometric properties of the scale.
Method: The C-SSRS’s validity relative to other measures of suicidal ideation and behavior and the internal consistency of its intensity of ideation subscale were analyzed in three multisite studies: a treatment study of adolescent suicide attempters (N=124); a medication efficacy trial with depressed adolescents (N=312); and a study of adults presenting to an emergency department for psychiatric reasons (N=237).
Results: The C-SSRS demonstrated good convergent and divergent validity with other multi-informant suicidal ideation and behavior scales and had high sensitivity and specificity for suicidal behavior classifications compared with another behavior scale and an independent suicide evaluation board. Both the ideation and behavior subscales were sensitive to change over time. The intensity of ideation subscale demonstrated moderate to strong internal consistency. In the adolescent suicide attempters study, worst-point lifetime suicidal ideation on the C-SSRS predicted suicide attempts during the study, whereas the Scale for Suicide Ideation did not. Participants with the two highest levels of ideation severity (intent or intent with plan) at baseline had higher odds for attempting suicide during the study.
Conclusions: These findings suggest that the C-SSRS is suitable for assessment of suicidal ideation and behavior in clinical and research settings.

2. Bleich, A., Y. Baruch, et al. (2011). “Management of the suicidal patient in the era of defensive medicine: focus on suicide risk assessment and boundaries of responsibility.” Isr Med Assoc J 13(11): 653-656.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist’s responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.

3. Szmukler, G. (2012). “Risk assessment for suicide and violence is of extremely limited value in general psychiatric practice.” Australian and New Zealand Journal of Psychiatry 46(2): 173-174.

4. Hung, E. K., R. L. Binder, et al. (2012). “A method for evaluating competency in assessment and management of suicide risk.” Acad Psychiatry 36(1): 23-28.

OBJECTIVE: Although health professionals increasingly are expected to be able to assess and manage patients’ risk for suicide, few methods are available to evaluate this competency. This report describes development of a competency-assessment instrument for suicide risk-assessment (CAI-S), and evaluates its use in an objective structured clinical examination (OSCE). METHOD: The authors developed the CAI-S on the basis of the literature on suicide risk-assessment and management, and consultation with faculty focus groups from three sites in a large academic psychiatry department. The CAI-S structures faculty ratings regarding interviewing and data collection, case formulation and presentation, treatment-planning, and documentation. To evaluate the CAI-S, 31 faculty members used it to rate the performance of 31 learners (26 psychiatric residents and 5 clinical psychology interns) who participated in an OSCE. After interviewing a standardized patient, learners presented their risk-assessment findings and treatment plans. Faculty used the CAI-S to structure feedback to the learners. In a subsidiary study of interrater reliability, six faculty members rated video-recorded suicide risk-assessments. RESULTS: The CAI-S showed good internal consistency, reliability, and interrater reliability. Concurrent validity was supported by the finding that CAI-S ratings were higher for senior learners than junior learners, and were higher for learners with more clinical experience with suicidal patients than learners with less clinical experience. Faculty and learners rated the method as helpful for structuring feedback and supervision. CONCLUSION: The findings support the usefulness of the CAI-S for evaluating competency in suicide risk-assessment and management.

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