A clinician in a red sweater sits in a therapist's office talking with a client about the results of her C-SSRS questionnaire.

What Is the Columbia-Suicide Severity Rating Scale (C-SSRS)?

March 20, 2024

4 min.

Here’s how suicidal risk assessment tools are used to connect people with appropriate resources and treatments.

By: Elizabeth Kroll

Clinically Reviewed By: Dr. Don Gasparini

Learn more about our Clinical Review Process


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Table of Contents

Trigger warning: Suicide. If you’re experiencing suicidal thoughts or are in danger of harming yourself, this is a mental health emergency. Contact The Suicide & Crisis Lifeline 24/7 by calling or texting 988.

Suicidal ideation encompasses a wide range of thoughts, wishes, and preoccupation with suicide and death. These ideations can range anywhere from simply believing it would be best to not exist anymore (passive suicidal ideation) to developing a plan to end your life (active suicidal ideation).

Because there is such a wide range of suicidal thoughts, it’s important to understand how a person is thinking about suicide and how their suicidal ideations change over time in order to provide them with appropriate resources and treatment. That’s where suicide risk assessment tools come into play. Below, we delve into how these suicidal ideation screening tools are used in research and clinical settings—including Charlie Health’s virtual Intensive Outpatient Program (IOP).

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What are the tools for measuring suicidal ideation?

There are several tools commonly used by healthcare professionals and researchers to measure suicidal ideation and people’s risk of suicide. At Charlie Health, we use the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Ask Suicide-Screening Questions (ASQ-5) toolkit. Both of these screening tools ensure that we have robust data and an effective response system to help clients who are struggling with suicidal thoughts. Below, we break down each screening measure. 

The Columbia-Suicide Severity Rating Scale (C-SSRS)

Also known as the Columbia Protocol, the C-SSRS is a set of three mandatory questions and three follow-up questions implemented depending on previous answers. It was developed in 2007 in a partnership between Columbia University, the University of Pennsylvania, and the University of Pittsburgh. Unlike the ASQ-5, the C-SSRS is administered by a practitioner or clinician and lends itself to starting conversations around suicidal ideation. It is free to use and very brief, making it easy to implement in a clinical setting. 

The Ask Suicide-Screening Questions (ASQ-5)

This toolkit is a standardized set of 5 yes-or-no questions that ask about differing levels of suicidal ideation in quick and easy-to-understand language. It was developed in 2008 by the National Institute of Mental Health (NIMH) to screen for suicidal ideation in people ages 8 and up. Generally, this tool is presented on intake forms or surveys for clients to complete confidentially before an appointment. Similar to the C-SSRS, the ASQ-5 is free to use and very brief.

The Columbia-Suicide Severity Rating Scale (C-SSRS)

The Ask Suicide-Screening Questions (ASQ-5)

A set of three questions (and three follow-up questions) used by clinicians to start conversations about suicidal ideation.

Five yes-or-no questions often used on intake forms to screen for suicidal ideation in people over the age of 8.

How are these scales used? 

Asking about suicide doesn’t make it more likely to happen. In fact, research shows that talking about suicidal ideation or plans can prevent suicides from taking place. That’s why these scales are used to assess suicidality and connect people with necessary support and treatment. 

In healthcare contexts, these scales are used either as a screening method prior to an appointment (think: the forms you fill out before a primary care doctor visit) or to start a conversation during an appointment as part of a larger mental health assessment. 

In research, these scales are used to measure, track, and predict behaviors based on levels of suicidal ideation. Also, these scales are used to evaluate the success of programs meant to reduce suicidal ideation. Because the ASQ is generally presented in a survey and the C-SSRS is usually presented as a conversation, the ASQ-5 is used in research more often than the C-SSRS.

How does Charlie Health use these scales?

These scales are used at different points in time during care at Charlie Health. 

The ASQ-5 is presented to clients in their intake, discharge, and post-discharge surveys so that we can track shifts in suicidal behaviors and thoughts. When used at intake, we focus on the questions that help determine if a person is at a higher risk of active suicidal ideation or passive suicidal ideation in order to determine the best course of treatment for them. Whenever you see data regarding reductions in suicidal ideation through Charlie Health’s program, those results are based on the ASQ-5 questions — here are some of those findings: 

  • Before treatment, about two in five clients (37%) had thoughts of completing suicide in the past week. 
  • After discharging from Charlie Health’s virtual IOP, 71% of young people who reported active suicidal ideation at intake were no longer suicidal.
  • There were no significant differences or reductions in suicidal ideation outcomes between those with public and private health insurance.

Charlie Health clinicians use the C-SSRS as a suicide risk assessment tool during an initial conversation with a new client. This conversation allows clinicians to determine risk levels and create a safety plan, if necessary, to help clients cope with their suicidal ideation. The C-SSRS is also used by our crisis team whenever a client in treatment needs additional crisis support. Again, it’s used to facilitate a conversation with a crisis clinician and either create or review a safety plan. Because this scale is used as a prompt for conversations, no additional data is collected during this process. 

A person sits on a grey couch in a therapist's office answering C-SSRS questions.

Treatment for suicidal ideation at Charlie Health 

If you or a loved one are struggling with thoughts of suicide, Charlie Health is here to help. Charlie Health’s virtual Intensive Outpatient Program (IOP) provides more than once-weekly mental health treatment for young people dealing with complex mental health conditions, including suicidal ideation. Our expert clinicians incorporate evidence-based therapies into individual counseling, family therapy, and group sessions. With treatment, managing your mental health is possible. Fill out the form below or give us a call to start healing today. 

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