The Columbia Suicide Severity Rating Scale (C-SSRS): Improved Risk Assessment and the Positive Impact on Suicide Prevention Jeffrey Garbelman, Ph.D.

Suicide prevention efforts
depend upon appropriate identification & screening

Dilemmas: What Can’t We Rely On? ‘Standard Risk Factors’
Quantity Utility (Fowler, 2012; Fawcett, 1990;Bush, 2003; Goldstein, 1991; Porkorny, 1983) Predictive/Postdictive (Kennedy, 1994) Low Incident behavior with ‘obvious’ indicators…. after Suicide

Dilemmas: What Can’t We Rely On? Presumptions of Clinical Contact
The trouble with ‘contact’ is not the lack of it (Friedlander, 2012; Liu, 2012). Inpatient chart review of 76 suicides indicated that 78% had documented denial of suicidal thoughts just prior to event (Jobes, 2012; Busch, 2003; Fawcett, 1990). Approximately 2/3 of completed suicides occur on the first attempt (Goldblatt, 2011)

A deeper fundamental problem….
Wait, let’s back up…. A deeper fundamental problem….

What are we talking about?
Manipulative Suicidal ideation SEROIOUS Deliberate self-harm SUICIDE ATTEMPT Suicide gesture Self destructive behavior Parasuicide Suicide acts Suicide attempt Self-inflicted injury Self mutilation e Intrapersonal violence (Brown, 2002)

Severity of Ideation Subscale

Annually in the United States
225 Million Adults 8.3 Million (3.7%) Seriously Consider Suicide 2.2 million (1%) Make a Suicide Plan 1 million (0.5%) Attempt Suicide 500,000 (0.25%) Seen in ER 38,000 (0.017%) Die Who are they?

Plan to Attempt 72 % Fowler, 2012;
Transition Data Cumulative Probabilities of transition: Ideation to Plan 34 % Plan to Attempt 72 % Fowler, 2012;

C-SSRS Standard Training
4/9/2017

4/9/2017 Suicidal Behavior 24

Suicide Attempt Definition
C-SSRS Standard Training 4/9/2017 Suicide Attempt Definition A self-injurious act committed with at least some intent to die, as a result of the act There does not have to be any injury or harm, just the potential for injury or harm (e.g., gun failing to fire) Any “non-zero” intent to die – does not have to be 100% Intent and behavior must be linked People have mixed motives so 99% make someone angry and 1% wants to die. Used to be we asked “did you want to kill yourself” answer “no” and we move on. Often with that next question “did any part of you want to kill yourself” we get a very different answer. 25

Total Number of Behaviors Matters!
Number of Different Lifetime Suicidal Behaviors Predict Suicidal Behavior Patients not prospectively reporting suicidal behavior N =3577 Patients prospectively reporting suicidal behavior N =201 Odds ratio of prospective suicidal behavior report (95% CI; ***p-values < .001) No Behaviors Reported at BL 2791 (97.3%) 76 (2.7%) 4.56 (3.40 – 6.11)*** One Behavior 345 (91.5 %) 32 (8.5%) 3.41 (2.22 – 5.23)*** Two Behaviors 214 (84.3 %) 40 (15.7%) 6.86 (4.57 – 10.32)*** Three Behaviors 172 (81.5 %) 39 (18.5 %) 8.33 (5.50 – 12.62)*** Four Behavior 55 (79.7 %) 14 (20.3 %) 9.35 (4.98 – 17.54)*** Any type of Lifetime behavior increases likelihood of behavior during trial by ~ 3.4 times; increases proportionally with increased number of different behaviors reported 28

Data Supports Importance of Full Range: Lifetime Different Suicidal Behaviors Predict Suicidal Behavior Baseline Reports Patients not prospectively reporting suicidal behavior N =3577 Patients prospectively reporting suicidal behavior N =201 Odds ratio of prospective suicidal behavior report (95% CI; ***p-values < .001) Actual Attempt 522 (85.6 %) 88 (14.4 %) 4.56 (3.40 – 6.11)*** BL Interupted Attempt 349 (82.7 %) 73 (17.3 %) 5.28 (3.88 – 7.18)*** BL Aborted Attempt 461 (84.7 %) 83 (15.3 %) 4.75 (3.53 – 6.40)*** BL Preparatory Behavior 177 (81.2 %) 41 (18.8 %) 4.92 (3.38 – 7.16)*** A person reporting any one of the lifetime behaviors at baseline is ~ 4.5 to 5 times more likely to prospectively report a behavior during subsequent follow-up 29

4/9/2017 This is the C-SSRS Screener  Combined Behaviors Question 30

6) Suicide Behavior Question
"Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. If YES, ask: How long ago did you do any of these? ・ Over a year ago? ・ Between three months and a year ago? ・ Within the last three months?

4/9/2017 Lethality (Compilation of Beck Medical Lethality Rating Scale) What actually happened in terms of medical damage? For example if there was a cut, did it require a Band-Aid or a bandage? Did it bleed a little bit or profusely? 32

4/9/2017 Why Potential Lethality? Likely lethality of attempt if no medical damage. Examples of why this is important are cases in which there was no actual medical damage but the potential for very serious lethality Laying on tracks with an oncoming train but pulling away before run over Put gun in mouth and pulled trigger but it failed to fire – Both 2 33

Intensity of Ideation C-SSRS Standard Training 4/9/2017 Once types of ideation are determined, few follow-up questions about most severe thought Frequency Duration Controllability Deterrents Reasons for ideation (stop the pain or make someone angry—stop the pain is worse) Gives you a 2-25 score that will help inform clinical judgment about risk All these items significantly predictive of suicide (on SSI)/minimum amount of info needed for tracking and severity All the areas predictive of suicide from Beck’s data 34

4/9/2017 INTENSITY OF IDEATION The following features should be rated with respect to the most severe type of ideation (i.e.,1-5 from above, with 1 being the least severe and 5 being the most severe ). Ask about time he/she was feeling the most suicidal. Most Severe Ideation: _____ _________________________________________________ Type # (1-5) Description of Ideation Most Severe Frequency How many times have you had these thoughts? (1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day ____ Duration When you have the thoughts, how long do they last? (1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day (2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous (3) 1-4 hours/a lot of time Controllability Could /can you stop thinking about killing yourself or wanting to die if you want to? (1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty (2) Can control thoughts with little difficulty (5) Unable to control thoughts (3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts Deterrents Are there things - anyone or anything (e.g. family, religion, pain of death) - that stopped you from wanting to die or acting on thoughts of committing suicide? (1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you (2) Deterrents probably stopped you (5) Deterrents definitely did not stop you (3) Uncertain that deterrents stopped you (0) Does not apply Reasons for Ideation What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were feeling) or was it to get attention, revenge or a reaction from others? Or both? (1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on (2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling). (3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go on and to end/stop the pain living with the pain or how you were feeling). (0) Does not apply 35

4/9/2017 Clinical Monitoring Guidance For Intensity of Ideation, risk is greater when: Thoughts are more frequent Thoughts are of longer duration Thoughts are less controllable Fewer deterrents to acting on thoughts Stopping the pain is the reason Duration found to be predictive in adolescents (King, 2010) 40

Once I score everything, how do I interpret? As in, what’s considered worrisome? 41

Advantages….Operationalized Criteria for Next Steps
Clinical Practice About Advantages….Operationalized Criteria for Next Steps Allows for setting parameters for triggering next steps whatever they may be (e.g. referral to mental health, one-to-one, etc.) 4 or 5 on recent ideation item to indicate need for immediate action Decreases unnecessary referrals, interventions, etc. Walk to an ER or put on 1:1 *In the past, people didn’t know what to manage, so they would hear any wish to die and intervene… 42 42 42 42 42

Flexible Approach to Triage Points
With the C-SSRS screen versions (standard and since last visit)- We can use as little information as a positive score of a 4 or a 5 to make our decision We can include scores of 1,2, and 3 (without intent or plan) We can include question #6 regarding suicidal behaviors With the more thorough Lifetime/Recent and Clinical Since Last Visit Versions we also include- Lifetime Severity Ideation Scores or ‘worst point assessment’ Intensity of Ideation Scores Number of suicidal behaviors Lethality scores

4/9/2017 Clinical Monitoring Guidance: Threshold for Next Steps Difference between a 3 and a 4 being a 3 “I could…” a 4 “I can’t tell you I’m not going to…” Indicates Need for Next Step 45

Streamlining Care in Hospital Policies
Thresholds facilitate identification of those at highest, triage, and care delivery 4/5  Psych consult 3  Consult to Care team Example: Streamlining Care in Hospital Policies (Reading Hospital Policy)

New York State EMR 4/5 past month OR behavior past 3 months = highest level “SUICIDE WARNING” 4/5 OR behavior ever = “SUICIDE HISTORY” – suicidal risk elevated 47 47

Yes to question … And … Or … Negative endorsement, relative to the past 90 days, of “Suicide Behavior” (item #6: presence of ANY suicidal behavior [suicide attempt, interrupted attempt, aborted attempt, and preparatory behavior]) Positive endorsement, relative to the past 90 days, of “Suicide Behavior” (item #6: presence of ANY suicidal behavior [suicide attempt, interrupted attempt, aborted attempt, and preparatory behavior]) 3: Suicidal Thoughts with Method (without specific plan or intent to act) Standard Accountability Procedures 15-minute checks on patient location and safety/security 5-minute checks (voice contact) during toileting/showering/bathroom use Mild Suicide Precautions potentially harmful objects removed from patient’s environment patient restricted to day room during waking hours patient is escorted to bathroom for toileting, w/5-minute checks (voice contact) during toileting/showering/bathroom use 15-minutes checks while in bedroom patient remains in view when escorted off unit (e.g., medical clinic, treatment activities) patient remains on grounds except for medically necessary appointments

Mild Suicide Precautions
4: Suicidal Intent (without specific plan) Mild Suicide Precautions potentially harmful objects removed from patient’s environment patient restricted to day room during waking hours patient is escorted to bathroom for toileting, w/5-minute checks (voice contact) during toileting/showering/bathroom use 15-minutes checks while in bedroom patient remains in view when escorted off unit (e.g., medical clinic, treatment activities) patient remains on grounds except for medically necessary appointments Moderate Suicide Precautions patient restricted from wearing clothing that presents a tying hazard patient is escorted to bathroom for toileting patient must sleep in view of monitor 15-minutes checks while in bedroom, insuring exposure of face, neck, and arms

5: Suicidal Intent (with specific plan)
Moderate Suicide Precautions potentially harmful objects removed from patient’s environment patient restricted from wearing clothing that presents a tying hazard patient restricted to day room during waking hours patient is escorted to bathroom for toileting patient must sleep in view of monitor 15-minutes checks while in bedroom, insuring exposure of face, neck, and arms patient remains in view when escorted off unit (e.g., medical clinic, treatment activities) patient remains on grounds except for medically necessary appointments Severe Suicide Precautions patient must wear clothing issued by hospital with no tying hazard patient assigned 1:1 monitoring monitor remains within arm’s reach of the patient at all times patient remains in view during toileting, with appropriate limitation-of-right documentation monitor remains within arm’s reach in bedroom, insuring exposure of face, neck, and arms patient is restricted to the unit; patient remains on grounds except for medically necessary appointments

Dilemmas: False-Positives
Porkorny 1983: 4,800 psychiatric inpatients were followed for 4-6 years using ‘standard risk factors’ The Good… Identified 56% of suicide completers The Not So Good… False positives? Out of the 4,800 followed? .... 1,206

Screening…a critical opportunity for prevention
C-SSRS Standard Training Clinical Practice About Hershey Grand Rounds 4/9/2017 Screening…a critical opportunity for prevention Primary Care: Opportunity for Prevention Many who die by suicide see their doctor in the month prior to their death 45% of adults 70% of older adults 90% adolescents in the year prior A significant proportion of adolescent attempters in the ER did not present for psychiatric reasons NEED TO SCREEN! 55 55

Screening Programs are Successful
Clinical Practice About C-SSRS Full About 4/9/2017 Screening Programs are Successful High-school screening programs associated with 2x in detection of at-risk individuals (Scott et al., 2009) Meta-analysis concluded that screening results in lower suicide rates in adults (Mann et al., JAMA 2005) Columbia Teen-Screen demonstrated 88% sensitivity and 76% specificity College Screening Project - data suggest that screening brings high-risk students into treatment Only 1 suicide in 4 years post-screening vs. 3 suicides in 4 years pre-screening program (Haas et al., 2008) Adult primary care screenings - 47% increase in rates of detection and diagnosis of depression 56 56 56 56 56

National Action Alliance for Suicide Prevention, 2012
“Screening for suicide risk should be a universal part of Primary Care, Hospital Care (especially emergency department care), Behavioral Health Care, and Crisis Response intervention… Other than during the treatment for a medical emergency, every person contacting medical and behavioral health care should be screened for suicide using a standardized, simple tool.” Screening also recommended by: American Academy of Child and Adolescent Psychiatry American Academy of Pediatrics American Medical Association American College of Emergency Physicians The Joint Commission

Clinical Practice About NCDEU (6/16/10) C-SSRS Standard Training Hershey Grand Rounds 4/9/2017 Why it’s good to do one thing… Science and the Public Health Demand Uniformity (Gibbons, NCDEU 2010) Moving away from a single instrument inherently degrades the precision of the signal The impact of imprecision grows when incidence rates are low Multiple measures increase noise, decrease precision and weaken rigor of epidemiological and research data Imprecise information and poor communication “It should be noted that the use of different instruments is likely to increase measurement variability…decreasing the opportunity to identify potential signals in future meta-analyses…this type of imprecision is particularly problematic in dealing with events that have a low incidence, as is the case for suicidal ideation and behavior occurring in clinical trials.” –2012 FDA Guidance 58 58 58

Improved Identification with Decreased False Positives
PHQ-9 Suicide Item: Thoughts that you would be better off dead or of hurting yourself in some way Outpatient Psychiatry Pilot – Self Report Computer Version (523 Encounters) 6.2% positive screen on C-SSRS vs. 23.8% endorsed item #9 of PHQ-9 Most, but not all, of the positive Columbia screen patients endorsed #9 of PHQ9 e.g. Cases were missed

Reduction in Unnecessary Interventions/ Redirecting Scarce Resources
Hospital system: steadily decreased one-to-ones (27,000 screened) Reading Hospital - “allowed us to identify those at risk and better direct limited resources in terms of psychiatric consultation services and patient monitoring and it has also given us the unexpected benefit of identification of mental illness in the general hospital population which allows us to better serve our patients and our community.” Corrections: California corrections department spent approx. $20 million in 2010 on a suicide-watch program, which they believe could be cut in half by these methods Policy: Discussed during the Rhode Island Senate Commission Hearing to address ER overuse and ER diversion. Senators aim to have frontline responders use scale - specifically EMS and community police 62

Rhode Island Senate Commission Hearing Report for State Wide Implementation: Recommendation: “Support the state wide coordination and implementation of an evidence based suicide/mental health assessment tool and training for Rhode Island healthcare providers and first responders for determination of placement in emergency department or alternative settings.” “…this recommendation would be critical in assisting those in the field with an additional tool for everyday use.” Testimony by a Pawtucket police officer: “…the officer highlighted the important and timely decisions that law enforcement must make…the limited training that law enforcement often receives outside of the police academy was discussed and the importance of providing our first responders with the appropriate tools to assess an individual was identified as a necessary tool.”

The Problem in Schools: Who Do We Refer?
Four hospitals: 61-97% of referrals did not require hospitalization. NYC DOE: “The great majority of children & teens referred by schools for psych ER evaluation are not hospitalized & do not require the level of containment, cost & care entailed in ER evaluation.” “Evaluation in hospital-based psych ER’s is costly, traumatic to children & families, and may be less effective in routing children & families into ongoing care.” One Student sat 9 hours in a principal’s office waiting for EMT! New York City No one persons fault – doing what know to do to keep kids safe

4/9/2017 The Solution… “City schools expand suicide training” (C-SSRS): “This enhanced service has made more appropriate referrals for students to see support staff in the school and referrals to community agencies as needed…”– Crain’s, NY 7/20/12 -38 middle schools/nurse delivery: an estimated 100+ students were identified that would have otherwise been missed, while dramatically reducing unnecessary referrals. 9 yo aborted attempt Tennessee School (2 weeks post- training): “Their use of the C-SSRS may have already saved a life”

Potential Liability Protection
“If a practitioner asked the questions... It would provide some legal protection” –Bruce Hillowe, mental health attorney specializing in malpractice litigation (Crain’s NY, 11/8/11) Implemented by national risk managers of The Doctor’s Company, a medical malpractice insurance company to be used by physician members “I believe it sets the standard…we take a proactive position in patient safety” – Patient Safety Risk Manager Policies now place more burden on universities to implement interventions to protect students from self-harm (Franke, 2004; Lake et al., 2002)

Jeffrey Garbelman, Ph. D. jeffrey. garbelman@va. gov jeffrey
Jeffrey Garbelman, Ph.D.

The Columbia Suicide Severity Rating Scale (C-SSRS): Improved Risk Assessment and the Positive Impact on Suicide Prevention Jeffrey Garbelman, Ph.D.

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The Columbia Suicide Severity Rating Scale (C-SSRS): Improved Risk Assessment and the Positive Impact on Suicide Prevention Jeffrey Garbelman, Ph.D.

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