Scale assessing suicidal ideation saves lives through high predictive validity and use of common language

November 9, 2011

(Medical Xpress) -- Work to advance suicide prevention and increase the reliability of suicide risk assessment received a significant boost this week through findings of a new study of the Columbia Suicide

Severity Rating Scale (C-SSRS). The collective results of three national studies (one National Institute of Mental Health-funded and one American Foundation of Prevention-funded) add more evidence to the value of the Columbia-Suicide Severity Rating Scale (C-SSRS) as a tool for assessing and predicting the risk of .

strategies depend on establishing the frequency and severity of and identifying risk and protective factors. Data collection to support these aims must employ valid and reliable assessment. In a report appearing online November 8 and in the December issue of The American Journal of Psychiatry, Kelly Posner, Ph.D., and colleagues evaluated the psychometric properties of the C-SSRS in three studies that used it along with other instruments for suicide assessment.

The C-SSRS was designed to assess the full range of suicidal ideation and behavior and more precisely identify their types. Four constructs are measured: the severity of ideation, the intensity of ideation, behavior, and lethality. The scale uses different assessment periods for suicidal ideation, including a lifetime period to assess suicidal ideation at its worst point, since research has indicated that this may be a stronger predictor of subsequent suicide than current ideation. Other important characteristics of the scale are its differentiation of suicidal behavior and nonsuicidal self-injurious behavior, and its user-friendly format, a critical feature that enhances its appeal to clinicians. The C-SSRS is unique among rating instruments in meeting the essential criteria.

The C-SSRS was intended to assess and behavior across clinical and research settings where it addressed two major problems in suicide prevention. The first was whether any assessment could discriminate between those who will go on to attempt to take their lives from those who will not---identifying those at greatest risk. Typically any mention of suicide triggers a cascade of events in a hospital, often for people who are unlikely to attempt suicide. In this study, operationalized thresholds (a specific answer on the

C-SSRS) for triggering next steps were predictively supported. More accurate predictions of risk and associated triggers for next steps or referrals would cut down on false positives and lower this unnecessary burden.

The second problem is the need for a precise, meaningful common language agreed upon by researchers and clinicians. Suicide research is hampered by a lack of uniform definitions and inaccurate reporting of events.

The Institute of Medicine noted in 2002 the lack of definitions and standardization as one of the major impediments to suicide prevention. The C-SSRS is the only scale that provides definitions, which have been adopted by the Centers for Disease Control and Prevention, and corresponding probes to facilitate easy identification “Prevention depends on appropriate identification of phenomena,” said Posner. “If we can’t identify something, it limits our ability to understand, manage, and treat illness. That limits our confidence in drug trials and epidemiological findings. Fifty percent of suicides see their primary care doctor the month before they die; we should be asking these questions the way we monitor for blood pressure.”

Findings from the three studies showed initial promising data for the C-SSRS on convergent and divergent validity, predictive validity, sensitivity, specificity, sensitivity to change, and identification of those at highest risk. The greater precision led to a greater number of correctly identified suicide-related behaviors, which in turn resulted in a lower number of actual attempts. From a public health perspective, implementation of the CSSRS could lead to significant reductions in suicide over time.

The report will be published online on November 8, 2011, at AJP in Advance, the advance edition of The , the official journal of the American Psychiatric Association.

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