The Screen Version of the Columbia-Suicide Severity Rating Scale (C-SSRS) is a six-question triage tool for suicide risk. Five questions step through increasing severity of suicidal ideation over the past month - from a passive wish to be dead, through active thoughts of killing oneself, to ideation with a method, with intent, and with a specific plan. The sixth question asks about suicidal behaviour: whether the person has ever done, started to do, or prepared to do anything to end their life, and if so whether that was within the past three months.
The Screener does not produce a total score. It sorts people into low, moderate or high risk according to which questions are endorsed, and its purpose is to decide what happens next - routine follow-up, a behavioural-health referral, or an immediate safety response and full assessment. It is a structured way of asking, not a prediction instrument, and it can be administered by staff without mental-health training.
02 - Origin & purpose
Where it comes from.
The C-SSRS was developed by Kelly Posner and colleagues at Columbia University, with the University of Pennsylvania and the University of Pittsburgh, for the NIMH-funded Treatment of Adolescent Suicide Attempters (TASA) study. The full scale, published in the American Journal of Psychiatry in 2011, was designed to give clinical trials a single, consistent way of classifying suicidal ideation and behaviour, using definitions adapted from the Columbia Suicide History Form. Its behaviour definitions were adopted by the US Centers for Disease Control in 2011, and in 2012 the US Food and Drug Administration named it the standard for prospective suicidality assessment in trials.
The Screen Version distils the full scale's ideation-severity ladder and behaviour question into six yes/no items with skip logic, so that a receptionist, nurse or emergency clinician can screen in a few minutes. It is now embedded in emergency-department, inpatient and primary-care pathways in many countries and is distributed, with free training, by the Columbia Lighthouse Project.
03 - Scoring & cutoffs
How scoring works.
There is no summed total. Risk triage follows the response pattern rather than a score.
Ideation at the level of method, intent or plan (questions 4-5), or suicidal behaviour in the past three months, indicates high risk requiring an immediate clinical response. Earlier-level ideation (questions 1-3) indicates moderate or low risk warranting clinical follow-up. Any positive response merits a fuller risk assessment.
The table below is interpretation guidance for a completed administration; it is not a scorable form.
Score
Severity
Interpretation
1–3
Moderate / low risk
Ideation at questions 1-3 (wish to be dead, non-specific active thoughts, thoughts of method without intent). Clinical follow-up and a fuller risk assessment are warranted.
4–5
High risk
Ideation at questions 4-5 (active ideation with some intent, or with a specific plan and intent). Immediate clinical response required.
6–6
High risk - behaviour
Any suicidal behaviour, with behaviour in the past three months indicating high risk. Immediate clinical response required.
This content is intended for use by healthcare professionals and is not a self-diagnosis or risk-prediction tool. If you or someone you know is in immediate danger, contact emergency services (999 in the UK, 112 in the EU) or a crisis line such as the Samaritans on 116 123. A score never replaces a clinical risk assessment and safety planning conversation.
04 - Validation evidence
How well it performs.
The 2011 validation of the full C-SSRS across three multisite studies showed that its behaviour classifications matched the Columbia Suicide History Form with 100% sensitivity and 99-100% specificity for actual, interrupted and aborted attempts, and that baseline ideation severity predicted later attempts in adolescent re-attempters (odds ratio 1.45 per severity level). Ideation severity correlated with the Scale for Suicide Ideation (r = 0.52-0.69), and the intensity subscale had an alpha of 0.94 in the adolescent sample. Inter-rater reliability could not be examined in those studies.
Evidence for the six-item Screener itself comes mainly from emergency settings. In 18,684 consecutive psychiatric-emergency patients in Stockholm, the ideation ladder predicted death by suicide with an AUC of 0.72 at one week and 0.69 at one month; a threshold at question 3 or higher gave a sensitivity of 54% and specificity of 76% for suicide within a month, with a very low positive predictive value (<=1.2%) and a high negative predictive value (Bjureberg et al., 2021). In a general emergency department of 92,643 patients the Screener had a sensitivity of only 18% for death by suicide within 30 days, at 99% specificity, and 53% for a self-harm visit within 30 days (Simpson et al., 2021). Among 15,373 US veterans, the Screener had an AUC above 0.80 for a suicide attempt in the following three months (Katz et al., 2020). A 2025 meta-analysis found that prior suicidal behaviour on the C-SSRS predicted future non-fatal attempts (pooled odds ratio about 3) more strongly than ideation did (Daray et al., 2025).
0.72
AUC, SUICIDE WITHIN 1 WEEK
54%
SENSITIVITY (>=Q3, 1 MONTH)
76%
SPECIFICITY (>=Q3, 1 MONTH)
100%
BEHAVIOUR VS CSHF, SENSITIVITY
05 - How it compares
How it compares to the alternatives.
Instrument
Items
Time
When to reach for it
C-SSRS Screener
6
~2 min
Structured yes/no triage of ideation severity and behaviour with skip logic and built-in risk bands. Free for clinical use; electronic reproduction needs permission.
Ask Suicide-Screening Questions - NIMH's public-domain screen for young people aged 10-24 in medical and emergency settings. Reach for it in paediatrics.
Suicidal Behaviors Questionnaire-Revised - gives a graded 3-18 total covering lifetime ideation, past-year frequency, disclosure and likelihood. Free with attribution; useful for adults.
Passive thoughts of death or self-harm in the past two weeks. A prompt for further questions, not a risk stratifier - follow a positive answer with the C-SSRS.
C-SSRS full scale
-
~5-10 min
The clinician-rated Lifetime/Recent version grades ideation severity and intensity and classifies behaviour in detail. Use after a positive screen or in research.
BSS
21
~10 min
Beck Scale for Suicide Ideation - a self-report severity scale for current ideation, useful for monitoring in specialist care. Licensed.
06 - When to use it
Right tool, wrong tool.
The Screener is intended for universal or targeted screening of suicide risk in emergency departments, inpatient and outpatient mental-health services, primary care, schools and community settings, in adults and adolescents. Columbia describes the standard scale as suitable for most children from about six years and adults; adaptations exist for very young children, autism, intellectual disability and dementia, and for military and veteran populations. Its validation evidence is strongest in adult psychiatric and general emergency departments and in US veterans' services; evidence in young children and in cognitive impairment is limited.
Reach for it when
-Universal or targeted screening at emergency, inpatient or primary-care intake where a structured, consistent question set is needed.
-Following up a positive PHQ-9 item 9 or a spontaneous disclosure with a defined triage pathway.
-Settings where non-clinical staff carry out the first screen and need clear rules for escalation.
-Documenting ideation severity and recent behaviour in a common language across a service.
Reach for something else when
-Predicting who will die by suicide - a negative screen does not rule out risk and most deaths after emergency discharge follow a negative screen.
-Grading the severity of ideation numerically or tracking change - use the full C-SSRS, the BSS or the SBQ-R.
-Children under about six, or people unable to report their own thoughts; use an adapted version and collateral history.
-Replacing a clinical risk formulation: the Screener tells you what to do next, not why the person is at risk.
07 - Confidence & precision
Reading the score with care.
The Screener yields a category, not a score, so measures such as the standard error of measurement and minimal clinically important difference do not apply. Its precision should instead be read from its predictive values. Because suicide is rare even in high-risk services, the positive predictive value for death is very low - about 1% or less in a psychiatric emergency department - while the negative predictive value is high. That asymmetry means a positive screen mainly identifies people who warrant a fuller assessment, not people who will act, and a negative screen lowers but does not remove concern. In a general emergency department, four out of five people who died by suicide within 30 days had screened negative. Use the Screener to structure the conversation and the response, and rely on clinical judgement, collateral information and prior behaviour for the overall formulation.
08 - Limitations
What it cannot tell you.
The Screener depends entirely on disclosure. People who conceal ideation, who are intoxicated, or who have decided to act may screen negative, and in general emergency populations sensitivity for subsequent death by suicide has been as low as 18%. Conversely, in services where chronic ideation is common a large proportion of patients will screen high, with a positive predictive value near 1%, which can overload pathways if the response is not proportionate.
Most of the validation evidence concerns the full clinician-rated scale or the ideation ladder in adult emergency samples; formal validation of the Screener's specific triage bands is limited, inter-rater reliability for the Screener has not been established, and evidence in children under twelve and in people with cognitive impairment is sparse. The instrument is copyrighted: it is free to use in clinical and community care, but reprints and electronic implementations require permission, and an exclusive licence for electronic versions is held by a commercial vendor.
09 - Licensing, explained
How licensing works.
The C-SSRS is copyrighted by Columbia University and The Research Foundation for Mental Hygiene. It is available free of charge for use in community and healthcare settings and for nonprofit research through the Columbia Lighthouse Project (cssrs.columbia.edu), which also provides free training.
Reprints and electronic reproduction or integration require permission from the developers (Kelly Posner's office, New York State Psychiatric Institute). That is why this page explains the instrument and its interpretation rather than reproducing the questions.
[5]Daray FM, Grendas LN, Neupane SP, et al. Prediction of fatal and non-fatal suicide attempts by the Columbia-Suicide Severity Rating Scale (C-SSRS): systematic review and meta-analysis. British Journal of Psychiatry. 2025 (2025) ↩
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