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Printed on 6/29/2026
For informational purposes only. This is not medical advice.
The Columbia Suicide Severity Rating Scale (C-SSRS) screener is a brief, structured assessment tool designed to identify the presence and severity of suicidal ideation and behavior. It uses six yes/no questions arranged in a hierarchical order of increasing severity, from passive wish for death to active suicidal ideation with specific plan and intent. The C-SSRS is endorsed by the FDA, CDC, WHO, and numerous clinical guidelines as a standard suicide risk screening tool. It is used in emergency departments, primary care, schools, military settings, and research worldwide.
Formula: Risk level based on highest 'Yes' response. Q1-2: ideation. Q3-5: ideation with method/intent/plan. Q6: suicidal behavior.
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The C-SSRS screener assesses five levels of suicidal ideation in a hierarchical structure. Type 1: passive wish to be dead ('I wish I could go to sleep and not wake up'). Type 2: non-specific suicidal ideation ('I have thoughts of killing myself'). Type 3: suicidal ideation with a method but no intent or plan. Type 4: suicidal ideation with some intention to act. Type 5: suicidal ideation with a specific plan and intent to carry it out. Each type builds on the previous — clinicians identify the highest type present and document it as the current ideation level.
Beyond ideation, the C-SSRS assesses four categories of suicidal behavior: actual suicide attempt (self-injurious act with intent to die), interrupted attempt (stopped by external circumstance before beginning), aborted attempt (stopped by the individual before beginning), and preparatory acts (gathering means, writing a note, giving away possessions). Behaviors are assessed both over the individual's lifetime and in the past 3 months, as recent behavior carries greater acute risk weight.
Any ideation type 4 or 5, or any suicidal behavior in the past 3 months, constitutes high acute risk and requires immediate safety assessment and likely psychiatric evaluation. Ideation types 1-3 without behavior represent lower but clinically meaningful risk requiring close monitoring, safety planning, and follow-up. No ideation and no behavior in the past 3 months indicates low current risk. Document both the risk level and protective factors, access to lethal means, and any acute stressors identified during assessment.
Emergency Psychiatrists
The C-SSRS is the standard suicide risk assessment tool in emergency psychiatric settings. Its hierarchical structure rapidly distinguishes passive death wishes from active suicidal ideation with plan and intent, enabling triage decisions about disposition (discharge, voluntary admission, involuntary hold).
Therapists and Psychiatrists
In outpatient mental health care, the 'since last visit' version of C-SSRS enables clinicians to systematically track suicidal ideation between sessions. Any escalation from type 1-2 to type 4-5 between visits signals urgent need for safety reassessment.
Clinical Researchers
The FDA's 2012 guidance recommends C-SSRS for all CNS drug clinical trials to monitor treatment-emergent suicidal ideation and behavior. Its standardized scoring enables cross-trial comparisons and regulatory safety dossier preparation.
Inpatient Psychiatric Teams
On inpatient psychiatry units, the C-SSRS is administered at admission and before discharge to document risk trajectory. A patient admitted with ideation type 5 who discharges with type 1-2 demonstrates measurable improvement that supports the clinical decision for discharge.
Primary Care Physicians
Primary care providers frequently encounter patients with depression who may harbor suicidal ideation. The screener version of C-SSRS enables non-psychiatric clinicians to conduct a structured, documented suicide risk assessment and determine when mental health referral is urgent.
Pharmaceutical Researchers
Black-box warnings on antidepressants require monitoring of treatment-emergent suicidal ideation, particularly in pediatric and young adult populations. C-SSRS provides the standardized behavioral endpoint that satisfies FDA post-marketing safety requirements.
The Columbia Suicide Severity Rating Scale is recognized by the FDA, CDC, WHO, and SAMHSA as the preferred suicide risk assessment tool for both clinical practice and research. The FDA's 2012 guidance explicitly recommends C-SSRS for all clinical trials involving CNS drugs, making it the most widely required suicide assessment tool in pharmaceutical research.
C-SSRS ideation types 4 and 5 represent active suicidal ideation with intent — where the individual has some intention (type 4) or a specific plan and intent (type 5) to act on suicidal thoughts. These always require immediate intervention: safety planning, means restriction counseling, and determination of appropriate level of care. Do not discharge or end a session without a documented safety plan when types 4-5 are present.
A history of prior suicide attempt increases the risk of future attempt approximately 30-fold compared to individuals with no attempt history. Always ask about lifetime attempts (Question 6 on the screener) and document attempt method, lethality, and rescue circumstances. Prior attempts with high medical lethality or low rescue likelihood carry the highest future risk.
Means restriction — particularly firearm safety and secure storage of medications — is one of the strongest evidence-based suicide prevention interventions. A patient with suicidal ideation who has access to a loaded firearm at home is at substantially higher acute risk than one without access. Ask about and document access to all lethal means, and involve family members in means restriction counseling when possible.
The Stanley-Brown Safety Planning Intervention (SPI) combines C-SSRS-based risk stratification with a personalized written safety plan identifying warning signs, coping strategies, social supports, and crisis resources. Evidence from multiple studies shows that SPI combined with C-SSRS-guided monitoring significantly reduces suicide attempts in high-risk populations compared to treatment as usual.
The C-SSRS score alone is not sufficient documentation. Document the clinical context that informed your risk assessment: access to lethal means, protective factors (children, religious beliefs, therapeutic relationship), acute stressors (recent loss, legal problems, relationship crisis), substance use status, and any prior attempts with method and lethality. This narrative context is as important as the ideation type for medicolegal documentation.
The C-SSRS exists in multiple validated versions for different settings: the screener (6 questions, rapid administration), the full clinical version (detailed intensity ratings), the 'since last visit' version (for serial monitoring in outpatient care), and the lifetime/recent version (for initial assessments). Using the version appropriate for your context improves both clinical efficiency and measurement accuracy.
In the US, the 988 Suicide and Crisis Lifeline (call or text 988) provides 24/7 free and confidential support. The Crisis Text Line (text HOME to 741741) is available for those who prefer text-based communication. These resources should be provided to any patient with positive C-SSRS ideation and included in written safety plans.
Inpatient psychiatric admission is generally indicated when a patient has: active plan with access to means, inability to commit to a safety plan, active intoxication, lack of social support, history of high-lethality prior attempt, or imminent decompensation in mental status. A high C-SSRS ideation type alone (without these contextual factors) may be managed safely on an outpatient basis with intensive safety planning and close follow-up.
Patients with borderline personality disorder (BPD) frequently experience chronic passive suicidal ideation (types 1-2) as a baseline feature of their illness. The clinical priority is identifying acute escalation above the individual's baseline — from passive to active ideation, emergence of a plan, or new high-lethality behavior. Dialectical behavior therapy (DBT) is the evidence-based treatment for reducing suicidal behavior in BPD.
Columbia Suicide Severity Rating Scale (C-SSRS) developed by Posner et al. (Am J Psychiatry 2011) from patients in psychiatric research. Sensitivity 89%, specificity 75% for prospective suicide attempt at ideation type 4-5. FDA 2012 guidance recommends C-SSRS for all clinical trials involving CNS drugs. C-SSRS has been validated in 50+ languages. SAMHSA recommends C-SSRS for clinical and research use. Training available at cssrs.columbia.edu. Stanley-Brown Safety Planning Intervention evidence: Stanley and Brown (J Clin Psychol 2012).
The C-SSRS screener result is determined by the highest-numbered question answered 'Yes,' reflecting the most severe level of suicidal ideation or behavior endorsed. If only Question 1 is positive (wish to be dead), this indicates passive suicidal ideation and warrants further monitoring and clinical follow-up. If Question 2 is positive (thoughts of killing yourself), active suicidal ideation is present and requires a more thorough risk assessment.
Positive responses to Questions 3 through 5 indicate progressively more severe active suicidal ideation: Question 3 positive means the person has thought about a method, Question 4 positive means there is some intent to act, and Question 5 positive means there is a specific plan with intent. These escalating levels of ideation require increasingly urgent clinical intervention, safety planning, and consideration of higher levels of care.
A positive response to Question 6 indicates suicidal behavior — the person has made a prior attempt, started to carry out a plan, or made preparations. This is the highest risk category on the screener and warrants immediate safety assessment, means restriction counseling, and determination of the appropriate level of care. Any positive response on the C-SSRS should trigger a comprehensive clinical evaluation and documentation of the safety plan.
The C-SSRS screener should be used whenever there is a clinical need to assess for suicidal ideation and behavior. It is appropriate for universal screening in emergency departments, inpatient psychiatric admissions, primary care visits where depression or risk factors are identified, and as part of intake assessments in mental health settings. Many health systems now mandate universal suicide screening using the C-SSRS or similar validated tools.
This tool is also indicated when a patient presents with depression, hopelessness, recent psychosocial stressors, substance use, or any clinical concern for self-harm. It can be used by non-clinical staff after brief training, making it suitable for schools, crisis hotlines, military settings, and community organizations. The C-SSRS screener is designed for rapid administration and can be completed in one to two minutes.
The C-SSRS screener is a brief screening version and does not capture the full detail of the complete C-SSRS clinical assessment, which includes intensity ratings for ideation (frequency, duration, controllability, deterrents, reasons) and detailed behavior assessment. A positive screener should prompt a more comprehensive evaluation by a qualified clinician.
Like all suicide risk assessment tools, the C-SSRS cannot predict with certainty whether an individual will attempt suicide. Suicide risk is dynamic and can change rapidly based on circumstances, access to means, and protective factors. A negative screen does not eliminate risk, and clinical judgment must always be applied alongside structured screening.
The screener relies on honest self-disclosure, and individuals who are determined to conceal suicidal ideation may deny symptoms. Cultural factors, stigma, and the clinical environment can all influence willingness to disclose. The C-SSRS should be administered in a private, supportive setting and should be considered one component of a comprehensive risk assessment rather than a standalone decision-making tool.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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