the columbia suicide severity rating scale (c-ssrs): improved risk assessment and the positive...

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

SSRS): Improved Risk SSRS): Improved Risk Assessment and the Assessment and the

Positive Impact on Suicide Positive Impact on Suicide PreventionPrevention

Jeffrey Garbelman, Ph.D.Jeffrey Garbelman, Ph.D.

Suicide prevention effortsdepend upon appropriateidentification & screening

Dilemmas: What Can’t We Rely Dilemmas: What Can’t We Rely On?On?‘Standard Risk Factors’‘Standard Risk Factors’ QuantityQuantity

Utility (Fowler, 2012; Fawcett, 1990;Bush, Utility (Fowler, 2012; Fawcett, 1990;Bush, 2003; Goldstein, 1991; Porkorny, 1983)2003; Goldstein, 1991; Porkorny, 1983)

Predictive/Postdictive (Kennedy, 1994)Predictive/Postdictive (Kennedy, 1994)

Low Incident behavior with ‘obvious’ Low Incident behavior with ‘obvious’ indicators…. after Suicideindicators…. after Suicide

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Dilemmas: What Can’t We Rely Dilemmas: What Can’t We Rely On? Presumptions of Clinical On? Presumptions of Clinical ContactContact

The trouble with ‘contact’ is not the lack of it The trouble with ‘contact’ is not the lack of it (Friedlander, 2012; Liu, 2012). (Friedlander, 2012; Liu, 2012).

Inpatient chart review of 76 suicides Inpatient chart review of 76 suicides indicated that 78% had documented denial indicated that 78% had documented denial of suicidal thoughts just prior to event of suicidal thoughts just prior to event (Jobes, 2012; (Jobes, 2012;

Busch, 2003; Fawcett, 1990).Busch, 2003; Fawcett, 1990).

Approximately 2/3 of completed suicides Approximately 2/3 of completed suicides occur on the first attemptoccur on the first attempt (Goldblatt, 2011) (Goldblatt, 2011)

Wait, let’s back up….Wait, let’s back up….

A deeper A deeper fundamental fundamental problem….problem….

What are we talking What are we talking about?about?

ManipulativeManipulative Suicidal ideationSuicidal ideation SEROIOUSSEROIOUS Deliberate self-harmDeliberate self-harm SUICIDE ATTEMPTSUICIDE ATTEMPT

Self destructive behavior

Suicide attempt

e

Suicide gesture

Suicide actsParasuicide

Self-inflicted injury

Intrapersonal violence

Self mutilation

(Brown, 2002)

Severity of Ideation Severity of Ideation SubscaleSubscale

Annually in the United StatesAnnually in the United States

1919Who are they?

Transition DataTransition Data

Cumulative Probabilities of transition:Cumulative Probabilities of transition:

Ideation to Plan 34 %Ideation to Plan 34 %

Plan to Attempt Plan to Attempt 72 % 72 % Fowler, 2012; Fowler, 2012;

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Suicidal BehaviorSuicidal Behavior

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Suicide Attempt Suicide Attempt DefinitionDefinition

There does not have to be any injury or There does not have to be any injury or harm, just the harm, just the potential potential for injury or for injury or harm (e.g., gun failing to fire)harm (e.g., gun failing to fire)

Any “non-zero” intent to die – does not Any “non-zero” intent to die – does not have to be 100%have to be 100%

Intent and behavior Intent and behavior mustmust be linked be linked

A self-injurious A self-injurious actact committed committed with with at least at least somesome intent to die, intent to die, as a result ofas a result of the actthe act

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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

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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

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CombinedCombinedBehaviorsBehaviorsQuestionQuestion

This is theThis is the

C-SSRSC-SSRS

ScreenerScreener

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?

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Actual Lethality/Medical Damage: 0. No physical damage or very minor physical damage (e.g. surface scratches).1. Minor physical damage (e.g. lethargic speech; first-degree burns; mild bleeding; sprains).2. Moderate physical damage; medical attention needed (e.g. conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g. comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures).4. Severe physical damage; medical hospitalization with intensive care required (e.g. comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).5. Death

Answer for Actual Attempts OnlyActual Lethality/Medical Damage: 0. No physical damage or very minor physical damage (e.g. surface scratches).1. Minor physical damage (e.g. lethargic speech; first-degree burns; mild bleeding; sprains).2. Moderate physical damage; medical attention needed (e.g. conscious but sleepy, somewhat responsive; second-degree burns; bleeding of major vessel).3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g. comatose with reflexes intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures).4. Severe physical damage; medical hospitalization with intensive care required (e.g. comatose without reflexes; third-degree burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).5. Death

Answer for Actual Attempts Only

Lethality(Compilation of Beck Medical Lethality Rating Scale)

What actually happened in terms of medical damage?

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Why Potential Lethality?Why Potential Lethality?Likely lethality of attempt if Likely lethality of attempt if no medical damageno medical damage. Examples . Examples of why this is important are cases in which there was no of why this is important are cases in which there was no actual medical damage but the potential for very serious actual medical damage but the potential for very serious lethalitylethality– Laying on tracks with an oncoming train but pulling away Laying on tracks with an oncoming train but pulling away

before run overbefore run over– Put gun in mouth and pulled trigger but it failed to fire – Put gun in mouth and pulled trigger but it failed to fire –

Both 2Both 2

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Intensity of IdeationIntensity of Ideation Once types of ideation are determined, few follow-up Once types of ideation are determined, few follow-up

questions about most severe thoughtquestions about most severe thought– FrequencyFrequency– DurationDuration– ControllabilityControllability– DeterrentsDeterrents– Reasons for ideation (stop the pain or make someone Reasons for ideation (stop the pain or make someone

angry—stop the pain is worse)angry—stop the pain is worse) Gives you a 2-25 score that will help inform clinical Gives you a 2-25 score that will help inform clinical

judgment about riskjudgment about risk

All these items significantly predictive of suicide (on All these items significantly predictive of suicide (on SSI)/minimum amount of info needed for tracking SSI)/minimum amount of info needed for tracking and severityand severity

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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

MostSevere

FrequencyHow 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

____

DurationWhen 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

____

ControllabilityCould /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

____

DeterrentsAre 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 IdeationWhat 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

____

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MostSevere


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MostSevere


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MostSevere


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MostSevere


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____

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For Intensity of Ideation, risk is greater For Intensity of Ideation, risk is greater when:when:– Thoughts are Thoughts are moremore frequent frequent– Thoughts are of Thoughts are of longerlonger duration duration– Thoughts are Thoughts are lessless controllable controllable– FewerFewer deterrents to acting on thoughts deterrents to acting on thoughts– Stopping the pain is the reason

Duration found to be predictive in adolescents (King, 2010)

Clinical Monitoring Clinical Monitoring GuidanceGuidance

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Once I score everything, how do I

interpret? As in, what’s considered worrisome?

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Advantages….OperationalizAdvantages….Operationalized Criteria for Next Stepsed Criteria for Next Steps

Allows for setting parameters for Allows for setting parameters for triggering next steps whatever triggering next steps whatever they may be they may be (e.g. referral to mental health, (e.g. referral to mental health, one-to-one, etc.)one-to-one, etc.)

– 4 or 5 on recent ideation item to 4 or 5 on recent ideation item to indicate need for immediate actionindicate need for immediate action

– Decreases unnecessary referrals, Decreases unnecessary referrals, interventions, etc.interventions, etc.

*In the past, people didn’t know what to manage, so they would hear any wish to die and intervene…

Flexible Approach to Triage Flexible Approach to Triage PointsPoints With the C-SSRS screen versions (standard and With the C-SSRS screen versions (standard and

since last visit)-since last visit)- We can use as little information as a positive score of a 4 We can use as little information as a positive score of a 4

or a 5 to make our decisionor a 5 to make our decision We can include scores of 1,2, and 3 (without intent or We can include scores of 1,2, and 3 (without intent or

plan)plan) We can include question #6 regarding suicidal behaviorsWe can include question #6 regarding suicidal behaviors ---------------------- With the more thorough Lifetime/Recent and With the more thorough Lifetime/Recent and

Clinical Since Last Visit Versions we also include-Clinical Since Last Visit Versions we also include- Lifetime Severity Ideation Scores or ‘worst point Lifetime Severity Ideation Scores or ‘worst point

assessment’assessment’ Intensity of Ideation ScoresIntensity of Ideation Scores Number of suicidal behaviorsNumber of suicidal behaviors Lethality scoresLethality scores

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IndicateIndicates Need s Need

for for Next Next StepStep

Clinical Monitoring Guidance: Clinical Monitoring Guidance: Threshold for Next StepsThreshold for Next Steps

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Thresholds facilitate identification of those at highest, triage, and care delivery

4/5 Psych consult3 Consult to Care team

(Reading Hospital Policy)

Example: Streamlining Care in Hospital Policies

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New York State EMR 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

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 Procedures15-minute checks on patient location and safety/security5-minute checks (voice contact) during toileting/showering/bathroom use

Mild Suicide Precautionspotentially harmful objects removed from patient’s environmentpatient restricted to day room during waking hourspatient is escorted to bathroom for toileting, w/5-minute checks (voice contact) during toileting/showering/bathroom use15-minutes checks while in bedroompatient remains in view when escorted off unit (e.g., medical clinic, treatment activities)patient remains on grounds except for medically necessary appointments

4: Suicidal Intent (without specific plan)

Mild Suicide Precautionspotentially harmful objects removed from patient’s environmentpatient restricted to day room during waking hourspatient is escorted to bathroom for toileting, w/5-minute checks (voice contact) during toileting/showering/bathroom use15-minutes checks while in bedroompatient remains in view when escorted off unit (e.g., medical clinic, treatment activities)patient remains on grounds except for medically necessary appointments

Moderate Suicide Precautionspotentially harmful objects removed from patient’s environmentpatient restricted from wearing clothing that presents a tying hazardpatient restricted to day room during waking hourspatient is escorted to bathroom for toiletingpatient must sleep in view of monitor15-minutes checks while in bedroom, insuring exposure of face, neck, and armspatient remains in view when escorted off unit (e.g., medical clinic, treatment activities)patient remains on grounds except for medically necessary appointments

5: Suicidal Intent (with specific plan)

Moderate Suicide Precautionspotentially harmful objects removed from patient’s environmentpatient restricted from wearing clothing that presents a tying hazardpatient restricted to day room during waking hourspatient is escorted to bathroom for toiletingpatient must sleep in view of monitor15-minutes checks while in bedroom, insuring exposure of face, neck, and armspatient remains in view when escorted off unit (e.g., medical clinic, treatment activities)patient remains on grounds except for medically necessary appointments

Severe Suicide Precautionspotentially harmful objects removed from patient’s environmentpatient must wear clothing issued by hospital with no tying hazardpatient assigned 1:1 monitoringmonitor remains within arm’s reach of the patient at all timespatient remains in view during toileting, with appropriate limitation-of-right documentationpatient must sleep in view of monitormonitor remains within arm’s reach in bedroom, insuring exposure of face, neck, and armspatient is restricted to the unit; patient remains on grounds except for medically necessary appointments

Dilemmas: False-Dilemmas: False-PositivesPositives Porkorny 1983: 4,800 psychiatric inpatients were Porkorny 1983: 4,800 psychiatric inpatients were

followed for 4-6 years using ‘standard risk factors’followed for 4-6 years using ‘standard risk factors’ The Good…The Good… Identified 56% of suicide completersIdentified 56% of suicide completers The Not So Good…The Not So Good… False positives? Out of the 4,800 followed? False positives? Out of the 4,800 followed?

.... .... 1,2061,206

Screening…a critical Screening…a critical opportunity for preventionopportunity for prevention Primary Care: Opportunity for PreventionPrimary Care: Opportunity for Prevention

– Many who die by suicide see their doctor Many who die by suicide see their doctor in the in the monthmonth prior to their death prior to their death 45% of adults45% of adults 70% of older adults70% of older adults

– 90% adolescents in the year prior90% adolescents in the year prior– A significant proportion of adolescent A significant proportion of adolescent

attempters in the ER did not present for attempters in the ER did not present for psychiatric reasonspsychiatric reasons

NEED TO SCREEN!NEED TO SCREEN!

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Screening Programs are Screening Programs are SuccessfulSuccessful

High-school screening programs associated with 2x High-school screening programs associated with 2x in detection of at-risk individuals in detection of at-risk individuals (Scott et al., 2009)(Scott et al., 2009)

Meta-analysis concluded that Meta-analysis concluded that screening results screening results in lower suicide rates in adultsin lower suicide rates in adults (Mann et al., JAMA (Mann et al., JAMA 2005)2005)

Columbia Teen-Screen demonstrated 88% Columbia Teen-Screen demonstrated 88% sensitivity and 76% specificity sensitivity and 76% specificity

College Screening Project - data suggest that College Screening Project - data suggest that screening brings high-risk students into treatmentscreening brings high-risk students into treatment– Only 1 suicide in 4 years post-screening vs. 3 suicides in 4 Only 1 suicide in 4 years post-screening vs. 3 suicides in 4 years pre-screening program years pre-screening program (Haas et al., 2008) (Haas et al., 2008)

Adult primary care screenings - Adult primary care screenings - 47% increase in 47% increase in rates of detection and diagnosis of rates of detection and diagnosis of depressiondepression

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“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

National Action Alliance for Suicide Prevention, 2012

Why it’s good to do one thing…Why it’s good to do one thing…Science and the Public Health Demand Science and the Public Health Demand

UniformityUniformity(Gibbons, NCDEU 2010)(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

“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

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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 Reduction in Unnecessary Interventions/Interventions/

Redirecting Scarce Redirecting Scarce ResourcesResources

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Hospital systemHospital system: steadily decreased one-to-ones (27,000 : steadily decreased one-to-ones (27,000 screened)screened)– Reading Hospital - “allowed us to identify those at risk and Reading Hospital - “allowed us to identify those at risk and better direct limited better direct limited

resources in terms of psychiatric consultation services and patient resources in terms of psychiatric consultation services and patient monitoring monitoring and it has also given us the and it has also given us the unexpected benefit of identification of unexpected benefit of identification of mental illness in the general hospital population mental illness in the general hospital population which allows us to better serve which allows us to better serve our patients and our community.”our patients and our community.”

Corrections:Corrections:– California corrections department spent approx. California corrections department spent approx. $20 million in 2010 $20 million in 2010 on a suicide-on a suicide-

watch program, which they believe watch program, which they believe could be cut in half by these methodscould be cut in half by these methods

PolicyPolicy: : – Discussed during the Rhode Island Discussed during the Rhode Island Senate Commission HearingSenate Commission Hearing to to address ER address ER

overuse and ER diversionoveruse and ER diversion.. Senators aim to have frontline responders use scale - Senators aim to have frontline responders use scale - specifically EMS and community policespecifically EMS and community police

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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.”

Rhode Island Senate Commission Hearing Report for State Wide Implementation:

The Problem in Schools: The Problem in Schools: Who Do We Refer?Who Do We Refer?

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– Four hospitals: Four hospitals: 61-97% of referrals did not require 61-97% of referrals did not require hospitalizationhospitalization. .

– NYC DOE:NYC DOE: ““The great majority of children & teens referred by schools The great majority of children & teens referred by schools

for psych ER evaluation are not hospitalized &for psych ER evaluation are not hospitalized & do not do not require the level of containment, cost & carerequire the level of containment, cost & care entailed entailed in ER evaluation.”in ER evaluation.”

““Evaluation in hospital-based psych ER’s is Evaluation in hospital-based psych ER’s is costly, costly, traumatic traumatic to children & families, and may be to children & families, and may be less less effective effective in routing children & families into ongoing care.”in routing children & families into ongoing care.”

One Student sat 9 hours in a principal’s office One Student sat 9 hours in a principal’s office waiting for EMT!waiting for EMT!

New York City

The Solution…The Solution…

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Tennessee School (2 weeks post- Tennessee School (2 weeks post- training): training):

““Their use of the C-SSRS may have Their use of the C-SSRS may have already saved a life”already saved a life”

“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.

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Potential Liability Protection

• Policies now place more burden on universities to implement interventions to protect students from self-harm (Franke, 2004; Lake et al., 2002)

“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

Jeffrey Garbelman, Ph.D.Jeffrey Garbelman, [email protected]@[email protected]@att.net

the columbia suicide severity rating scale (c-ssrs): improved risk assessment and the positive...

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suicidal behavior n

likelihood of behavior

suicide behavior question

lifetime behaviors

low incident behavior

suicidal behaviora person

denial of suicidal thoughts

attempt goldblatt