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C-SSRS Initial Validity and Internal Consistency Findings Three Multisite Studies With Adolescents and Adults

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A r t ic le
1 2 6 6 ajp.psychiatryonline.o rg Am J Psychiatry 168 :12 , Decem ber 2011
exclusion of individuals with suicidal ideation and behav-
ior from clinical trials has resulted in a dearth of evidence
for interventions for these populations, and the methods
for determining which patients will be excluded have been
variable, making it even more difficult to conduct analyses
of these populations on suicide-related questions (4, 5).
Studies of risk factors predicting suicide consistently sug-
gest that suicidal ideation and a history of suicide attempts
are among the most salient risk factors for suicide (6–9).
Moreover, a structured assessment of suicidal ideation and
behavior significantly improves identification of high-risk
patients relative to a routine clinical interview (10). How-
ever, to date, the field has lacked a single standard measure
that assesses both suicidal ideation and behavior (10).
To address inconsistencies in nomenclature, the impact
of such inconsistencies on accurate identification, and
the need for a single measure to assess the severity of and
track changes in suicidal ideation and behavior, a team of
investigators from Columbia University, the University of
Pennsylvania, and the University of Pittsburgh developed
the Columbia–Suicide Severity Rating Scale (C-SSRS).
(Am J P sych ia try 2 011 ; 1 68 :1266–1277 )
the Co lum b ia–Su ic id e Se ve rity R a ting Sca le :
In itia l Va lid ity and In te rna l Con sisten cy F ind ing s From
th ree M u ltis ite S tud ie s W ith A do le scen ts and A du lts
Kelly Posner, Ph.D.
Gregory K. Brown, Ph.D.
Barbara Stanley, Ph.D.
David A. Brent, M.D.
Kseniya V. Yershova, Ph.D.
Maria A. Oquendo, M.D.
Glenn W. Currier, M.D., M.P.H.
Glenn A. Melvin, Ph.D.
Laurence Greenhill, M.D.
Sa Shen, Ph.D.
J. John Mann, M.D.
O b je c t iv e : Research on suicide preven-
tion and interventions requires a stan-
dard method for assessing both suicidal
ideation and behavior to identify those at
risk and to track treatment response. The
Columbia–Suicide Severity Rating Scale
(C-SSRS) was designed to quantify the se-
verity of suicidal ideation and behavior.
The authors exam ined the psychometric
properties of the scale.
M e tho d : The C-SSRS’s validity relative to
other measures of suicidal ideation and
behavior and the internal consistency
of its intensity of ideation subscale were
analyzed in three multisite studies: a
treatment study of adolescent suicide at-
tempters (N=124); a medication efficacy
trial w ith depressed adolescents (N=312);
and a study of adults presenting to an
emergency department for psychiatric
reasons (N=237).
R e su lts : The C-SSRS demonstrated good
convergent and divergent validity w ith
other multi-informant suicidal ideation
and behavior scales and had high sensi-
tivity and specificity for suicidal behavior
classifications compared w ith another
behavior scale and an independent sui-
cide evaluation board. Both the ideation
and behavior subscales were sensitive to
change over time. The intensity of ide-
ation subscale demonstrated moderate
to strong internal consistency. In the ado-
lescent suicide attempters study, worst-
point lifetime suicidal ideation on the
C-SSRS predicted suicide attempts during
the study, whereas the Scale for Suicide
Ideation did not. Participants w ith the
two highest levels of ideation severity (in-
tent or intent w ith plan) at baseline had
higher odds for attempting suicide during
the study.
Co n c lu s io n s : These findings suggest that
the C-SSRS is suitable for assessment of
suicidal ideation and behavior in clinical
and research settings.
Suicide prevention strategies outlined by the Centers
for Disease Control and Prevention (CDC), the U.S. Depart-
ment of Health and Human Services, and the National In-
stitutes of Health depend on establishing the frequency and
severity of suicidal behavior and identifying risk and pro-
tective factors (1, 2). Data collection to support these aims
must employ valid and reliable assessment tools that allow
comparison at local, national, and international levels.
A lack of uniformity in assessment stems in part from
the variability of terms referring to similar or even iden-
tical behavior. Without a common language for report-
ing and communicating occurrences of suicidal behav-
ior and ideation, prevention research is undermined in
several key areas, including the establishment of reli-
able incidence and prevalence rates; comparison of data
across studies, time periods, and locations; development
of adequate tools for identifying and screening patients
in primary and other care settings; measurement of risk
and benefit in drug trials and postmarketing surveys; and
training of health care workers, gatekeepers, and first re-
sponders in suicide risk detection (3). Furthermore, the
This article is featured in this month’s AJP A ud io , is discussed in an editorial by Dr. Hughes (p. 1233)
and is an article that provides C lin ica l G u idance (p. 1277)

PO SneR , bROW n, StAnley, et A l .
Am J Psychiatry 168 :12 , Decem ber 2011 a jp.psychiatryonline.o rg 1 2 6 7
spectrum of suicidal ideation and suicidal behavior and
gauge their severity over specified periods; 3) distinguish
suicidal behavior and nonsuicidal self-injurious behavior;
and 4) employ a user-friendly format that allows integra-
tion of information from multiple sources (e.g., direct pa-
tient interview, family and other interviews, and medical
records). As reviewed by Meyer et al. (27), these criteria are
considered essential for judging the utility of scales assess-
ing suicide-related phenomena, and the scale is unique
among rating instruments in meeting all of these criteria.
The C-SSRS (available at www.cssrs.columbia.edu) in-
cludes definitions of suicidal behavior adapted from the
Columbia Suicide History Form (28). The definitions of
ideation and behavior were also used in the Columbia
Classification Algorithm for Suicide Assessment, commis-
sioned by the U.S. Food and Drug Administration to clas-
sify retrospective reports of potentially suicidal adverse
events and to provide interpretable data to inform pivotal
drug safety questions (29). These definitions were subse-
quently adopted by the CDC (2).
In this study, we evaluated the C-SSRS’s convergent, di-
vergent, and predictive validity, its sensitivity and speci-
ficity, and its sensitivity to change, as well as the internal
consistency of the intensity subscale, based on use of the
scale in three multisite studies. Other indices of reliability
could not be examined because of the study design, al-
though interrater reliability has been demonstrated else-
where (30–32).
M ethod
The studies used in the analyses are described below. More de-
tailed descriptions of the studies and the relevant scales are in-
cluded in a data supplement that accompanies the online edition
of this article. Convergent validity, divergent validity, sensitivity,
specificity, sensitivity to change, predictive and incremental va-
lidity, and internal consistency, as defined in Table 1, were ana-
lyzed as shown in Table 2. Rates of suicidal ideation at study entry
and lifetime actual suicide attempts for the three studies are pre-
sented in Figure 1.
Stud ie s U sed in the A na ly se s
S tud y 1. The Treatment of Adolescent Suicide Attempters study
was a National Institute of Mental Health multisite feasibility
study designed to develop and evaluate treatments to prevent
suicide reattempts in adolescents. Participants were 124 male and
female patients 12–18 years of age with a suicide attempt or in-
terrupted attempt during the 90 days before enrollment (34–36).
Participants were evaluated at baseline and at treatment weeks 6,
12, 18, and 24, as well as during intervening unscheduled visits.
Evaluations included the C-SSRS, the Columbia Suicide History
Form, the Scale for Suicide Ideation, and Beck’s Lethality Scale.
All instruments were administered by independent evaluators,
who were Ph.D.-, R.N.-, or master’s-level clinicians. Assessment
of participants also included the self-report Beck Depression In-
ventory (BDI) at the same visits, as well as ratings by the treating
psychopharmacologist (who was not the independent evaluator)
on the Montgomery-Åsberg Depression Rating Scale (MADRS).
Any potential suicidal events in the study were rated by the sui-
cide evaluation board, which was an independent panel of suici-
dology experts uninvolved in the day-to-day management of the
Suicidal ideation and behavior have traditionally been
conceived as a unidimensional construct, with passive
ideation, active intent, and behavior existing along a con-
tinuum (11, 12). The C-SSRS, however, was designed to
distinguish the domains of suicidal ideation and suicidal
behavior. Four constructs are measured. The first is the
severity of ideation (hereafter referred to as the “severity
subscale”), which is rated on a 5-point ordinal scale in
which 1=wish to be dead, 2=nonspecific active suicidal
thoughts, 3=suicidal thoughts with methods, 4=suicidal
intent, and 5=suicidal intent with plan. The second is the
intensity of ideation subscale (hereafter referred to as the
“intensity subscale”), which comprises 5 items, each rated
on a 5-point ordinal scale: frequency, duration, controlla-
bility, deterrents, and reason for ideation. The third is the
behavior subscale, which is rated on a nominal scale that
includes actual, aborted, and interrupted attempts; pre-
paratory behavior; and nonsuicidal self-injurious behav-
ior. And the fourth is the lethality subscale, which assesses
actual attempts; actual lethality is rated on a 6-point ordi-
nal scale, and if actual lethality is zero, potential lethality
of attempts is rated on a 3-point ordinal scale.
The items for assessing severity of ideation (e.g., a spe-
cific plan or method) and intensity (e.g., frequency, du-
ration) of ideation were based on factors predicting at-
tempts and suicide identified in previous studies (13–20).
The C-SSRS uses different assessment periods, depending
on research or clinical need; the lifetime period assesses
the worst-point ideation, which research has suggested
may be a stronger predictor of subsequent suicide than
current ideation (7, 21).
Item selection for the scale was influenced by research
on what aspects of past suicidal ideation and behavior pre-
dict the risk of future suicidal behavior, including severity
of worst-point ideation and intent and medical damage
or lethality of past suicide attempts (7). Items assessing
suicidal behavior were expanded to encompass not only
actual attempts but also interrupted attempts, because
these are predictive of suicide (22), and aborted attempts,
because they are associated with actual attempt behavior
(23). Preparatory activity was included in the assessments
because analyses suggest that individuals who engage in
preparatory behavior are more likely to commit suicide
than those who do not report such behavior (7, 23, 24).
Neurobiological research suggests that the degree of sui-
cide intent and the degree of medical lethality are related
to serotonin indices in the brain (25), which prompted the
inclusion of items on the scale related to preparation for
suicide attempt and to scoring the severity of medical dam-
age. The more medically damaging or potentially lethal but
nonfatal suicide attempts show serotonin abnormalities
analogous to those found in postmortem examination of
brain tissue from people who died by suicide (26).
The C-SSRS was designed to 1) provide definitions of sui-
cidal ideation and behavior and nonsuicidal self-injurious
behavior and corresponding probes; 2) quantify the full

tHe CO lUM b IA –SU IC Id e SeV eR Ity R At InG SCA le
1 2 6 8 ajp.psychiatryonline.o rg Am J Psychiatry 168 :12 , Decem ber 2011
pressive disorder (37). Participants were 312 adolescents 11–17
years of age with a diagnosis of major depressive disorder. The
study excluded patients who were considered a “suicide risk” by
the investigators, including those who had suicidal ideation or
had made a suicide attempt, although approximately 5.5% re-
ported some level of ideation at study entry (Figure 1).
The self-report Suicidal Ideation Questionnaire–Junior (the ver-
sion for grades 7–9) (38) and the C-SSRS were administered by the
study clinicians at initial screening, at baseline, and at weeks 4,
8, 16, and 24 (or on early termination). Patients who completed
at least one postbaseline assessment were included in the pres-
ent analysis (N=259). The characteristics of the validation sample
were similar to the baseline characteristics of the total sample (37).
S tud y 3 . Study 3, funded by the American Foundation for Sui-
cide Prevention, evaluated the identification and classification of
recent suicide attempts and nonsuicidal self-injurious behavior
by emergency department providers at three sites. Participants
(N=237) were at least 18 years of age and presented to an emer-
gency department for psychiatric reasons. They were categorized
as having made a suicide attempt prior to the emergency evalua-
tion, having engaged in nonsuicidal self-injurious behavior in the
week prior to the evaluation, or reporting psychiatric symptoms
without a suicide attempt or nonsuicidal self-injurious behavior
prior to the evaluation. Study clinicians administered measures
in the emergency department, including the C-SSRS, the Scale for
Suicide Ideation, Beck’s Lethality Scale, and the Columbia Suicide
History Form.
Data A na ly se s
Analyses of data from studies 1 and 2 were conducted with SAS,
version 9.1 (SAS Institute, Cary, N.C.). Analyses of data from study
3 were conducted with SPSS, version 19 (SPSS, Chicago).
Conve rgen t and d ive rgen t v a lid it y. In study 1, to examine the
convergent and divergent validity of the ideation and behavior
components of the C-SSRS, associations between the scale and
other instruments measuring corresponding constructs were ini-
tially tested using Pearson’s r. Effect sizes were computed (Cohen’s
d=2r/sqrt[1–r
2
]) in order to compare the magnitude of the cor-
relations. A mixed-effects regression model was used to adjust for
the effect of repeated assessments over the course of the study.
The C-SSRS ideation scores were entered as dependent variables
and the scores from corresponding scales as independent vari-
ables. Unstructured covariance structure was specified.
The choice of random effects was based on the following as-
sumption: each participant has his or her own systematic base-
line on the measures, and each starting point is treated as the re-
sult of a random deviation from some mean intercept. This model
captures both the repeated-measures effect and random-inter-
cept effect in individuals when the correlation between measures
is assessed. Intercept and time (days in treatment) were included
trial. The board, which was blind to original event classifications,
treatment status, and other potentially biasing information, rated
narratives according to predetermined criteria and definitions of
potential suicidal events. Unanimous consensus was reached in
cases where there was any initial disagreement.
Most participants (N=96, 77.4%) were assessed at week 12; 87
(70.2%) were evaluated at week 18, and 83 (66.9%) at week 24. At-
trition between the study visits was due to participants refusing
to continue study treatment or assessments. Participants who re-
fused treatment but continued with assessments were included in
the analyses. There was one death by suicide in the study during
the follow-up period. As previously reported (36), participants who
remained in the study for longer than the median duration were
similar to those who were followed for less than the median dura-
tion on all baseline predictors of suicidal events except income.
S tud y 2 . Study 2 was an industry-sponsored multisite, double-
blind, placebo-controlled, parallel-group, fixed-dose clinical trial
to evaluate the efficacy of the selective serotonin reuptake inhibi-
tor escitalopram relative to placebo in the treatment of major de-
tA ble 1 . d efin ition s o f M easu re s U sed in P sychom e tric A na ly se s o f the Co lum b ia–Su ic id e Se ve rity R a ting Sca le
a
Measure Definition
Convergent validity The covariance between scores from assessment instruments that measure the same or similar constructs
Divergent validity The degree to which scores from an instrument are not related to scores on unrelated constructs
Predictive validity The extent to which a score on the instrument predicts an outcome
Incremental validity The degree to which data from a new instrument increase power, sensitivity, specificity, and predictive efficacy
of judgments beyond those from comparable instruments
Sensitivity The probability that a subject with an event will be so identified by the assessment instrument
Specificity The probability that a subject without an event will be so identified by the assessment instrument
Sensitivity to change The degree to which data from an instrument reflect small changes in the targeted construct
Internal consistency The magnitude of covariance between items of multi-item measures, reflecting their conceptual integrity
a
Definitions are based on Haynes et al. (33).
FIGURe 1 . base line R a te s o f Su ic ida l Id ea tion and l ife tim e
A c tua l A ttem p ts in th ree S tud ie s
a
a
Study 1 was a treatment study of adolescent suicide attempters
(N=124); study 2 was a medication efficacy trial in depressed ado-
lescents (N=312); study 3 was a study of adults presenting to an
emergency department for psychiatric reasons (N=237). In study 1,
ideation data for “last week” were missing for 17 (13%) subjects. In
study 2, ideation data at baseline were missing for 97 (31%) subjects.
b
In study 1, among patients with lifetime actual attempts, 46.8%
had multiple actual attempts.

PO SneR , bROW n, StAnley, et A l .
Am J Psychiatry 168 :12 , Decem ber 2011 a jp.psychiatryonline.o rg 1 2 6 9
Other types of reliability (e.g., interrater) could not be examined
because of the design of the studies.
Re su lts
Conve rgen t Va lid ity
At baseline, the C-SSRS severity subscale and the Scale
for Suicide Ideation assessment of worst-point ideation
both capture the most suicidal period during the patient’s
lifetime; at all subsequent assessments, the since-last-visit
and worst-point assessments both measure the most se-
vere suicidal ideation since the last assessment.
The C-SSRS severity subscale was moderately corre-
lated with the worst-point score on the Scale for Suicide
Ideation (r=0.52, p<0.001; effect size=1.22, N=472). The
C-SSRS intensity subscale containing the frequency, dura-
tion, controllability, certainty, and deterrents items for the
most severe ideation was moderately correlated with the
worst-point ideation total score on the Scale for Suicide
Ideation (r=0.56, p<0.001; effect size=1.36, N=487). For the
since-last-visit assessments, there was a strong relation-
ship between the C-SSRS severity subscale and the MADRS
suicidal ideation item (r=0.63, p<0.001; effect size=1.61) as
well as the BDI suicide item, which asks subjects to rate on
a 4-point scale their thoughts of killing themselves (r=0.80,
p<0.001; effect size=2.66) (Table 3). For the since-last-visit
assessments, there was also a strong relationship between
the C-SSRS intensity subscale and the MADRS suicidal
ideation item (r=0.69, p<0.001; effect size=1.93) as well as
the BDI suicide item (r=0.51, p<0.001; effect size=1.19).
In study 2, the convergent validity of the C-SSRS with
the self-report Suicidal Ideation Questionnaire–Junior to-
tal score over the course of the study was moderate for the
C-SSRS severity subscale (r=0.36, p<0.01; effect size=0.77)
and low for the C-SSRS intensity subscale (r=0.23, p<0.001,
effect size=0.47) based on pair correlations at multiple
time points across the study (total number of pairs=234).
In study 3, the correlation between the C-SSRS severity
subscale and the Scale for Suicide Ideation total score was
moderate (r=0.69, p<0.001, N=211). The C-SSRS intensity
subscale total score correlated modestly with the Scale for
Suicide Ideation total score (r=0.34, p<0.001; N=193).
In study 1, the C-SSRS’s sensitivity and specificity of
behavior classifications relative to the behavior classifica-
tions on the Columbia Suicide History Form and those by
the evaluation board were examined. A total of 15 study
subjects had at least one actual, interrupted, or aborted
attempt. The total number of these three behaviors in the
study based on all visits was 24, including unscheduled
(emergency) visits. Relative to the Columbia Suicide His-
tory Form, the C-SSRS had 99.4% specificity and 100%
sensitivity in correctly identifying aborted attempts and
100% sensitivity and specificity for both interrupted and
actual attempts (Figure 2). Two aborted attempts were
identified by the behavior subscale that were not identi-
fied using the Columbia Suicide History Form. The C-SSRS
as random-effect variables. A Steiger’s z test for comparison of
correlated correlations evaluated whether the severity and inten-
sity subscales were more related to the suicidal ideation item than
items measuring somatic features of depression on the MADRS
and the BDI.
In study 2, the analysis was parallel to that in study 1 except
that the self-report Suicidal Ideation Questionnaire–Junior total
score was used as the criterion measure for the convergent validi-
ty of the intensity subscale. The convergent and divergent validity
of the C-SSRS behavior subscale and the lethality subscales were
not examined in study 2 because no other behavior measure was
available for comparison.
In study 3, the convergent validity of the severity subscale, in-
tensity subscale, and behavior subscale was evaluated with the
phi coefficient.
S en s itiv it y /sp e c ifi c it y and se n s itiv it y to ch ange . Analysis of
specificity in studies 1 and 3 examined the rate of true negatives
on the C-SSRS behavior subscale relative to behavior ratings on
the Columbia Suicide History Form and, in study 1, also to the
suicide evaluation board ratings. The rate of true positives rela-
tive to the ratings on the Columbia Suicide History Form and the
suicide evaluation board ratings was used to show the sensitivity
of the behavior subscale.
In studies 1 and 2, mixed-effects linear regression was used to
test sensitivity to change of the severity and behavior subscales
over the study period as measured by criterion scales. The C-SSRS
scores were entered as dependent variables, and the scores from
the Scale for Suicide Ideation (study 1) or the Suicidal Ideation
Questionnaire–Junior (study 2) were entered as independent
variables. Unstructured covariance structure was specified, and
intercept and time (days in treatment) were included as random-
effect variables.
P re d ic tive and in c rem en ta l v a lid it y. In study 1, the predictive
validity of the worst-point lifetime ideation on the severity sub-
scale for 1) actual attempts and 2) actual, interrupted, and aborted
attempts combined as reported on the Columbia Suicide History
Form between weeks 1 and 24 was examined using logistic regres-
sion. Similarly, the predictive validity of the severity subscale was
tested for the actual attempts classified by the evaluation board.
The C-SSRS severity scores were entered as a continuous variable,
and suicidal behavior, including multiple attempts, as a dichoto-
mous variable. The average length of time between the baseline
administration of the C-SSRS and the week 24 Columbia Suicide
History Form ratings was 134.63 days (SD=65.48), as some sub-
jects had their week 24 visit beyond 168 days. This variability was
addressed in the model by including time as a covariate.
Incremental validity was evaluated by comparing the predic-
tive validity of the lifetime worst-point ideation (including past
week) on the C-SSRS severity subscale to the predictive validity
of 1) the total score and 2) the suicidal intent items on the Scale
for Suicide Ideation for the same time period. Because intent to
die appears to confer heightened risk for suicide (14, 15, 39), it
was hypothesized a priori that presence of ideation with at least
some intent (the two most severe levels of ideation on the C-
SSRS) would confer greater risk than presence of ideation without
intent. Logistic regression was used to test whether a history of
ideation with at least some intent in contrast to levels of ideation
on the C-SSRS without intent resulted in a greater risk of suicide
attempts or combined ratings of aborted, interrupted, and actual
attempts classified on the Columbia Suicide History Form and ac-
tual attempts classified by the evaluation board.
In te rn a l co n s is te n c y. The internal consistency of the C-SSRS
ideation subscale in all three studies was tested with Cronbach’s
alpha. The severity and behavior subscales use an ordinal scale
and are therefore not subject to internal consistency analysis.

tHe CO lUM b IA –SU IC Id e SeV eR Ity R At InG SCA le
1 2 7 0 ajp.psychiatryonline.o rg Am J Psychiatry 168 :12 , Decem ber 2011
The actual lethality subscale was robustly correlated
with the Beck’s Lethality Scale score from the Columbia
Suicide History Form (r=0.79, p<0.001; N=237). The lethal-
ity subscale is rated on a 6-point scale (running from 0 to
5) using general anchors for lethality, whereas the Colum-
bia Suicide History Form lethality subscale is rated on a
10-point scale (running from 0 to 9) using anchors that
correspond to the method of injury.
D ive rgen t Va lid ity
In study 1, the divergent validity of the C-SSRS severity
subscale was examined by correlating raw scores on the
fatigue, sleep, appetite, and loss of energy items on the
self-report BDI and similar items on the MADRS, admin-
istered by the psychopharmacologist, with the C-SSRS’s
most severe ideation since last visit, administered by a dif-
ferent clinician. Effect sizes using Cohen’s d were comput-
ed to evaluate the strength of the significant correlations.
As in the analyses of convergent validity, mixed-effects
regression was used to adjust for the effect of multiple as-
sessments over time (Table 3).
For the since-last-visit assessments, weak or moderate
correlations were observed between the C-SSRS severity
and intensity subscales and the BDI and MADRS somatic
depression items. A much stronger association with the
BDI and MADRS suicidal ideation items, in contrast to the
weak relationship with nonsuicidal items demonstrated
by the Steiger’s z test for comparison of correlated correla-
demonstrated 100% sensitivity and 96% specificity relative
to the evaluation board ratings using the combined classi-
fications of actual and interrupted attempts. Five cases of
behavior were identified on the behavior subscale but not
by the evaluation board. Because the board did not clas-
sify aborted attempts (of which two were identified by the
C-SSRS), the total number of attempts analyzed here is 22,
not 24.
In study 2, the convergent validity of behavior classifi-
cations was not examined because no parallel measure of
suicidal behavior was available.
In study 3, the degree of association regarding the iden-
tification of lifetime (including past week) actual, inter-
rupted, and aborted attempts using the C-SSRS and the
Columbia Suicide History Form was high (phi values, 0.99,
0.92, and 0.94, respectively; all p values <0.001; N=237). The
C-SSRS had 100% specificity and 100% sensitivity in cor-
rectly identifying lifetime actual attempts and 99% speci-
ficity and 94% sensitivity in correctly identifying lifetime
interrupted attempts that were recorded on the Columbia
Suicide History Form. Two lifetime interrupted attempts
were identified on the Columbia Suicide History Form that
were not identified using the C-SSRS. The scale had 99%
specificity and 93% sensitivity in correctly identifying life-
time aborted attempts that were recorded on the Colum-
bia Suicide History Form. Four lifetime aborted attempts
were identified on the Columbia Suicide History Form that
were not identified using the C-SSRS.
tA ble 2 . Va lid ity M easu re s U sed in A na ly se s o f Item s in the Co lum b ia–Su ic id e Se ve rity R a ting Sca le (C -SSR S ) U sing d a ta
From th ree S tud ie s
Subscale and Study
a
Measure Rater
Convergent
Validity
Divergent
Validity
Predictive
Validity
Incremental
Validity
Sensitivity to
Change
Internal
Consistency
Sensitivity and
Specificity
Severity of ideation subscale
Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation;
items 4 and 5 for predictive validity)
Independent evaluator P P P
Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for conver-
gent validity; items 4, 5, 7, 11, and 12 for divergent validity)
Study psychopharmacologist P P
Study 1 Beck Depression Inventory (item 9 for convergent validity;
items 15, 16, 18, and 20 for divergent validity)
Self-report P P
Study 2 Suicidal Ideation Questionnaire–Junior (total score) Self-report P P
Study 1 Columbia Suicide History Form Independent evaluator P P P P
Study 1 Suicide evaluation board Suicide evaluation board (consensus of
three suicidology experts)
P P P P
Intensity of ideation subscale
Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation) Independent evaluator P P
Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for conver-
gent validity; items 4, 5, 7, 11, and 12 for divergent validity)
Study psychopharmacologist P P
Study 1 Beck Depression Inventory (item 9 for convergent validity;
items 15, 16, 18, and 20 for divergent validity)
Self-report P P
Study 2 Suicidal Ideation Questionnaire–Junior Self-report P P
Studies 1, 2, 3 C-SSRS (intensity of ideation subscale, for most severe ideation) Clinician and independent evaluators P
Suicidal behavior subscale
Studies 1, 3 Columbia Suicide History Form Independent evaluator P P P
Suicidal behavior lethality
Study 3 Columbia Suicide History Form Independent evaluator P
a
Study 1 was a treatment study of adolescent suicide attempters (N=124); study 2 was a medication efficacy trial in depressed adolescents
(N=312); study 3 was a study of adults presenting to an emergency department for psychiatric reasons (N=237).

PO SneR , bROW n, StAnley, et A l .
Am J Psychiatry 168 :12 , Decem ber 2011 a jp.psychiatryonline.o rg 1 2 7 1
tA ble 2 . Va lid ity M easu re s U sed in A na ly se s o f Item s in the Co lum b ia–Su ic id e Se ve rity R a ting Sca le (C -SSR S ) U sing d a ta
From th ree S tud ie s
Subscale and Study
a
Measure Rater
Convergent
Validity
Divergent
Validity
Predictive
Validity
Incremental
Validity
Sensitivity to
Change
Internal
Consistency
Sensitivity and
Specificity
Severity of ideation subscale
Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation;
items 4 and 5 for predictive validity)
Independent evaluator P P P
Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for conver-
gent validity; items 4, 5, 7, 11, and 12 for divergent validity)
Study psychopharmacologist P P
Study 1 Beck Depression Inventory (item 9 for convergent validity;
items 15, 16, 18, and 20 for divergent validity)
Self-report P P
Study 2 Suicidal Ideation Questionnaire–Junior (total score) Self-report P P
Study 1 Columbia Suicide History Form Independent evaluator P P P P
Study 1 Suicide evaluation board Suicide evaluation board (consensus of
three suicidology experts)
P P P P
Intensity of ideation subscale
Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation) Independent evaluator P P
Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for conver-
gent validity; items 4, 5, 7, 11, and 12 for divergent validity)
Study psychopharmacologist P P
Study 1 Beck Depression Inventory (item 9 for convergent validity;
items 15, 16, 18, and 20 for divergent validity)
Self-report P P
Study 2 Suicidal Ideation Questionnaire–Junior Self-report P P
Studies 1, 2, 3 C-SSRS (intensity of ideation subscale, for most severe ideation) Clinician and independent evaluators P
Suicidal behavior subscale
Studies 1, 3 Columbia Suicide History Form Independent evaluator P P P
Suicidal behavior lethality
Study 3 Columbia Suicide History Form Independent evaluator P
a
Study 1 was a treatment study of adolescent suicide attempters (N=124); study 2 was a medication efficacy trial in depressed adolescents
(N=312); study 3 was a study of adults presenting to an emergency department for psychiatric reasons (N=237).
on the Scale for Suicide Ideation corresponded to a de-
crease of 0.106 units in the C-SSRS severity subscale score
(p<0.001). Similarly, change in the Scale for Suicide Ide-
ation worst-point ideation corresponded to a significant
change on the C-SSRS intensity subscale for since-last-
visit assessments (beta=0.071, p<0.001). Figure 3 dem-
onstrates that the mean severity subscale scores and the
mean intensity subscale scores responded similarly to the
change on the Scale for Suicide Ideation. All unscheduled/
emergency visits (N=39) occurring between baseline and
week 24 were excluded from these analyses.
To assess the behavior subscale’s sensitivity to change,
three types of suicidal behaviors (aborted, interrupted,
and actual attempts) identified by the independent evalu-
ators were plotted against those identified by the Colum-
bia Suicide History Form at weeks 6, 12, 18, and 24 (Figure
2) and against interrupted, actual, and one completed
attempt combined, as classified by the evaluation board.
There was full agreement for interrupted and actual at-
tempts and moderate agreement for aborted attempts rel-
ative to the Columbia Suicide History Form classifications
(kappa=0.66, 95% confidence interval [CI]=0.23–1.00) and
high agreement (kappa=0.88, 95% CI=0.77–0.98) with the
attempt and interrupted attempt classifications made by
the evaluation board (Figure 4). Only cases in which both
the C-SSRS and Columbia Suicide History Form ratings
(N=364) from the same assessments were available were
included in the analysis. All unscheduled/emergency vis-
tions, further supports the divergent validity of the C-SSRS
(Table 3). When adjusted for the effect of multiple assess-
ments, the findings were similar—for example, a one-unit
increase in the severity subscale score for the since-last-
visit assessments correlated (on average) with 0.278 units
on the BDI sleep disturbance item (Table 3).
The relationship of the C-SSRS intensity subscale to-
tal score to somatic symptoms of depression on the BDI
and MADRS was also examined. As seen in Table 3, cor-
relations between the intensity subscale and the BDI and
MADRS items were generally small to moderate, in con-
trast to larger correlations with the C-SSRS severity sub-
scale. Effect sizes for these associations varied from small
to large. When adjusted for the effect of repeated assess-
ments, a one-unit change on the BDI and MADRS scores
expressed in standard deviation units corresponded to
measurable changes in the intensity subscale, indicated
by the beta coefficients.
The divergent validity of the C-SSRS severity and inten-
sity subscales in studies 2 and 3 was not examined.
Sen sitiv ity to Change
In study 1, results from the random-effects mixed lin-
ear regression that tested sensitivity to change of the C-
SSRS on the criterion scales over the study period showed
that the scale’s ideation and behavior ratings were relat-
ed to other measures over time. In the linear regression,
a one-unit decrease in the “total current” ideation score

tHe CO lUM b IA –SU IC Id e SeV eR Ity R At InG SCA le
1 2 7 2 ajp.psychiatryonline.o rg Am J Psychiatry 168 :12 , Decem ber 2011
its occurring between baseline and week 24 were excluded
from the analysis. All potential events on the C-SSRS were
later classified by the evaluation board and included in the
analyses. One suicide rated by the board after the study
was completed was not rated on the scale.
In study 2, linear regression showed that a one-unit
decrease in total score on the Suicidal Ideation Question-
naire–Junior corresponded to an average decrease of 0.31
units in the C-SSRS severity subscale score (p=0.01) and to
a decrease of 0.17 units in the intensity of ideation scores
(p<0.001).
P red ic tive and In c rem en ta l Va lid ity
The predictive validity of the C-SSRS was evaluated us-
ing the Columbia Suicide History Form and the suicide
evaluation board classifications; the severity subscale was
examined continuously and categorically (with or with-
out intent). The results were comparable with either ap-
proach.
In study 1, baseline C-SSRS ratings (based on worst-
point lifetime suicidal ideation and conducted before
patients received any treatment) significantly predicted
suicide attempts during treatment (odds ratio=1.45, 95%
CI=1.07–1.98, p=0.02) as well as actual, interrupted, and
aborted attempts combined on the Columbia Suicide His-
tory Form between week 1 and week 24 (odds ratio=1.34,
95% CI=1.05–1.70, p=0.02) and classifications made by
the suicide evaluation board. In the parallel analyses pre-
dicting the behavior classifications made by the suicide
evaluation board from the baseline severity of ideation
ratings, for a one-standard-deviation increase in the life-
time (including past week) severity of ideation on the C-
SSRS, the odds of actual attempts increased by 43% (odds
ratio=1.43, 95% CI=0.99–2.05, p=0.05). Analyses included
all 124 participants who were assessed at baseline, using
intent-to-treat model.
For every one-standard-deviation increase in the level
of lifetime suicidal ideation reported at study entry, the
odds of attempting suicide during the study increased by
45%. The odds of actual, interrupted, or aborted suicide
attempts combined as assessed by the Columbia Suicide
History Form increased by 34% for every one-standard-
deviation increase in lifetime severity of ideation score.
Predictive validity was also evaluated using a lifetime his-
tory of the most severe ideation with and without intent on
the C-SSRS severity subscale. The odds of suicide attempts
scored on the Columbia Suicide History Form during fol-
low-up were compared in participants who endorsed a
lifetime history of the two most severe levels of ideation
(where at least some intent to die was present) reported at
baseline and those who endorsed a history of less severe
ideation (types 0–3) (odds ratio=3.26, 95% CI=1.02–10.45,
p=0.047). The lifetime history of the two highest severity
levels of ideation reported on the C-SSRS at baseline were
also associated with higher odds of actual, interrupted,
and aborted attempts combined on the Columbia Sui-
FIGURe 2 . num be r o f Ca se s in S tudy 1 Id en tified on the
Co lum b ia–Su ic id e Se ve rity R a ting Sca le (C -SSR S ) behav io r
Sub sca le and the Co lum b ia Su ic id e H isto ry Fo rm , b y type
o f behav io r
a
a
Total N included all those assessed with both the C-SSRS (past week
and since last assessment combined) and the Columbia Suicide His-
tory Form. kappa=0.66, 95% CI=0.23–1.00.

PO SneR , bROW n, StAnley, et A l .
Am J Psychiatry 168 :12 , Decem ber 2011 a jp.psychiatryonline.o rg 1 2 7 3
tA ble 3 . Conve rgen t and d ive rgen t Va lid ity o f the Co lum b ia–Su ic id e Se ve rity R a ting Sca le (C -SSR S ) Se ve rity and In ten sity
o f Id ea tion Sub sca le s Com pared W ith the be ck d ep re ssion Inven to ry (bd I) and the M on tgom ery -Å sbe rg d ep re ssion R a ting
Sca le (M AdR S ), based on d a ta From S tudy 1
C-SSRS Subscale

Severity of Ideation: Most Severe Ideation
Since Last Assessment
a
Intensity of Ideation: Most Severe Ideation
Since Last Assessment, Total Score
b
Measure r d
c
beta z r d
c
beta z
BDI
Loss of energy 0.403† 0.881 0.605† 4.62† 0.309† 0.650 1.433** 3.891†
Sleep disturbance 0.267† 0.554 0.278** 6.54† 0.306† 0.643 1.548*** 3.65***
Appetite disturbance 0.215† 0.440 0.207* 7.31† 0.263† 0.545 1.304** 4.31†
Fatigue 0.342† 0.728 0.451† 5.66† 0.308† 0.647 1.277** 3.83†
Suicidal ideation 0.627† 1.610 1.278† 0.510† 1.186 3.605†
MADRS
Decreased sleep 0.177† 0.360 0.059† 19.63† 0.199† 0.406 0.126* 14.78†
Decreased hunger 0.044 0.088 0.072* 20.85† 0.090** 0.181 0.365*** 16.01†
Increased sleep 0.021 0.042 –0.008 20.78† 0.041 0.082 0.057 16.70†
Increased hunger 0.042 0.084 0.006 20.38† 0.054 0.108 0.08 16.47†
Lassitude 0.234† 0.481 0.120† 20.86† 0.323† 0.683 0.318 13.28†
Suicide item 0.799† 2.657 1.278† 0.694† 1.928 1.408†
a
BDI data were available for 341 pairs, and MADRS data for 970 pairs.
b
BDI data were available for 346 pairs, and MADRS data for 971 pairs.
c
Cohen’s d; <0.3=small effect; 0.5=medium effect; >0.8=large effect.
*p<0.05. **p<0.01. ***p<0.001. †p<0.0001.
In te rna l Con sistency
In study 1, the C-SSRS intensity subscale was examined
at two assessment intervals: since last visit and past week.
The internal consistency of the intensity subscale was
high, with a Cronbach’s alpha of 0.937 for since last visit
and 0.946 for the past week. In studies 2 and 3, the internal
consistency of the intensity subscale across all visits was
moderate, with a Cronbach’s alpha of 0.73.
d iscu ssion
We examined the psychometric properties of the C-SSRS
and demonstrated convergent, divergent, and predictive
validity; sensitivity to change; sensitivity and specificity
of the instrument; and internal consistency of the inten-
sity subscale. The study design precluded examination of
other indices of reliability, although interrater reliability
has already been demonstrated (31, 32, 36). In all three
studies analyzed, the C-SSRS ideation and behavior sub-
scales showed strong convergent validity with established
ideation and behavior scales. The finding of only a moder-
ate convergent relationship between the C-SSRS severity
and intensity of ideation scores and the Scale for Suicide
Ideation total score, as well as the Suicidal Ideation Ques-
tionnaire–Junior score, was expected and was likely due to
nonoverlap in items and different construct operational-
ization. The C-SSRS demonstrated strong divergent valid-
ity with items on the BDI and the MADRS that were not ex-
pected to overlap with suicidal ideation and behavior (e.g.,
somatic depression symptoms such as fatigue). Because
suicide risk and protective factors are not orthogonal to
psychiatric diagnosis (40), establishing divergent validity
cide History Form (odds ratio=2.76, 95% CI=1.07–7.12,
p=0.036). In the parallel analyses, predicting from the
dichotomously scored lifetime severity of ideation to the
behavior classifications by the evaluation board, the odds
of actual attempts were almost four times higher for those
with a lifetime history (including past week) of the two
most severe levels of ideation at baseline (odds ratio=3.85,
95% CI=1.07–13.86, p=0.039).
We conducted similar analyses of predictive validity
with the total score (lifetime) and with the intent items
of the Scale for Suicide Ideation. No significant results
were observed for any of the outcomes. A one-standard-
deviation increase in the total score (lifetime) was not as-
sociated with an increase in odds of suicide attempts on
the Columbia Suicide History Form (odds ratio=1.02, 95%
CI=0.95–1.11, p=0.57) or in odds of actual, interrupted,
and aborted attempts combined on the Columbia Suicide
History Form at follow-up (odds ratio=1.01, 95% CI=0.95–
1.07, p=0.79).
In the categorical analysis based on the intent items
(a score ≥1 on item 4 or 5) from the Scale for Suicide Ide-
ation, the odds of attempts during the study were not
higher for actual attempts (odds ratio=1.44, p=0.76; all of
the attempters endorsed intent) or for the combined rat-
ings of actual, interrupted, and aborted attempts (odds
ratio=2.19, p=0.49; all of the attempters endorsed intent).
Because baseline Scale for Suicide Ideation scores (ei-
ther total score or score on the intent items) were not sig-
nificantly associated with attempts during the study, the
incremental predictive validity of the C-SSRS severity sub-
scale relative to the Scale for Suicide Ideation could not be
estimated.

tHe CO lUM b IA –SU IC Id e SeV eR Ity R At InG SCA le
1 2 7 4 ajp.psychiatryonline.o rg Am J Psychiatry 168 :12 , Decem ber 2011
tions on the Columbia Suicide History Form and by the
evaluation board.
A striking finding in this study was that the C-SSRS
demonstrated predictive validity but the Scale for Suicide
Ideation did not. The Scale for Suicide Ideation has shown
predictive validity for death by suicide with adults in other
long-term follow-up studies (41, 42), but it did not predict
near-term nonfatal suicidal behavior in this study. As with
any cross-study comparison, differences in predictive va-
lidity may result from differences in clinical populations,
assessment context, and time. Another plausible explana-
tion for this divergent finding is scoring differences be-
tween the two scales. The Scale for Suicide Ideation total
score aggregates many characteristics of suicidal ideation
along a continuum, whereas the C-SSRS identifies types
of ideation and classifies individuals as having intent, as
well as having intent and a plan. Factor structure analyses
of the Scale for Suicide Ideation have shown that certain
clusters of items assessing “plans” and “desire” show dif-
ferential prediction of past attempts and eventual suicide
(21, 43). The present study raises the question of whether
identifying specific types of suicidal ideation may be more
useful for prospective research and for risk stratification.
Further prospective studies of suicide risk using standard-
ized measures are warranted.
Of particular interest are the results from study 1 sug-
gesting that a history of severe ideation with at least some
intent to die may confer a greater risk for suicidal behavior
than a history of ideation with no intent to die. Establish-
ing clinically meaningful thresholds that indicate height-
ened suicide risk and predict which individuals will go on
to engage in suicidal behavior have been elusive in efforts
at suicide prevention (3). Because ideation severity can be
used to set criteria for clinical referral and inclusion or ex-
clusion criteria in research, operationalization of clinical
thresholds could facilitate enrollment of patients with sui-
with measures of other constructs is essential. In suicidal
adolescents, ideation was most closely related to suicide-
related items in other measures, in contrast to other types
of symptoms of psychiatric disorders or physical illnesses.
Several other findings have important implications. In
study 1, a decrease in the severity of ideation from “active
suicidal thoughts” to “wish to die” or “no ideation” was ac-
companied by corresponding decreases in Scale for Sui-
cide Ideation score, suggesting that the C-SSRS severity
subscale is sensitive to clinical change. Similarly, the C-
SSRS identified almost an identical number of cases with
specific types of suicidal behavior compared to the Co-
lumbia Suicide History Form and the suicide evaluation
board ratings, and this agreement held over the course
of the study. There was a high degree of agreement in the
classification of suicidal behavior between the Columbia
Suicide History Form, the evaluation board ratings, and
the C-SSRS. The behavior subscale demonstrated high
sensitivity and specificity relative to behavior classifica-
FIGURe 3 . M ean Va lue s in S tudy 1 fo r the Se ve rity and In -
ten sity o f Id ea tion Sub sca le s o f the Co lum b ia–Su ic id e Se -
ve rity R a ting Sca le (C -SSR S ) and the Sca le fo r Su ic id e Id e -
a tion (SS I) to ta l Sco re , b y trea tm en t W eek
FIGURe 4 . P ropo rtion o f Ca se s in S tudy 1 Id en tified on Co -
lum b ia–Su ic id e Se ve rity R a ting Sca le behav io r Item and by
the Su ic id e eva lua tion board

PO SneR , bROW n, StAnley, et A l .
Am J Psychiatry 168 :12 , Decem ber 2011 a jp.psychiatryonline.o rg 1 2 7 5
and divergent validity, predictive validity, sensitivity, spec-
ificity, sensitivity to change, and internal consistency of
the C-SSRS. Greater precision in the assessment of suicid-
al behavior and ideation is necessary for improving identi-
fication and clinical management, as well as for research-
derived risk-benefit analyses. The use of a standardized
measure such as the C-SSRS that comprehensively assess-
es suicidal behavior and ideation permits comparison of
findings across research and clinical populations, as well
as trends over time, providing data to guide treatment rec-
ommendations for suicidal patients and suicide preven-
tion efforts.
Rece ived Nov. 29 , 2010 ; rev isions rece ived M ay 18 and Ju ly 26 ,
2011 ; accepted Aug. 1 , 2011 (do i: 10 .1176 /app i.a jp.2011 .10111704 ).
From the Departm ent o f Psych iatry and the D iv ision o f Ch ild and
Ado lescent Psych iatry, Co lum bia University, Co lle ge o f Physicians
and Surgeons, and New York State Psych iatric Institu te , New York;
Departm ent o f Psych iatry, Un iversity o f Pennsylvan ia, Ph ilade lphia;
Un iversity o f P ittsburgh Schoo l o f M ed icine and Western Psych iatric
Institu te and C lin ic , P ittsburgh; Departm ent o f Psych iatry, Un iversity
o f Rochester M ed ical Center, Rochester, N .Y.; and the M onash Uni-
versity Centre fo r Deve lopm ental Psych iatry and Psycho logy, V icto ria ,
Australia . Address co rrespondence to D r. Posner (posnerk@nysp i.co -
lum bia.edu ).
D r. Po sner rece ives roya lty paym ents fo r the e lectron ic se lf-ra ted
ve rsions o f the Co lum bia–Su icide Severity Rating Sca le (eC -SSRS)
from ERT, Inc ., and is the d irecto r o f the Cen te r fo r Su ic ide R isk A s-
se ssm ent, w h ich , as part o f an e ffo rt to he lp execute the U.S . Food
and D rug Adm in istra tion ’s su ic ida lity c lassification m andates, has
rece ived support from Abbo tt, A lbany M o lecu lar Research , A lfre sa ,
A lkerm es, Am gen , A straZeneca , B iode live ry Sciences In te rnational,
B iom arin , B risto l-M yers Squ ibb, Canam , Cato Research , Cephalon ,
Ce te ro Research , Covance , CR I Worldw ide , D epom ed , Doug las Phar-
m aceutica ls, E isa i, Eu thym ics, Fo rest, G laxoSm ithK line , GW Pharm a,
Hum an Genom e Sciences, i3 Research , ICON, In te lGenx, In trace llu lar
Therap ie s, Johnson & Johnson , Kend le Early Stage , L illy USA , Lund -
beck A /S , Lundbeck USA , M ed Im mune , M edtron ic , M erck, Neuro -
search , Next W ave Pharm aceutica ls, Novartis , Noven , NovoNord isk,
O rexigen , O tsuka, Parexe l, Pfizer, PGx Health , Pharm aceutica l P rod -
uct D eve lopm ent, Inc ., P syadon , Q ED, Qu in tile s, Reckitt Benckise r,
Roche , Sanofi-Aventis, Schering-P lough , SCOPE In te rnational, Sep ra -
co r/Sunov ion , Sh ire , S iena B io tech , Supernus, Synosia Therapeutics,
Takeda, Theravance , Upsher-Sm ith , Va leant, V ivus, World W ide C lin i-
ca l Tria ls, and W yeth Research . D r. B row n rece ives roya lty paym ents
fo r eC -SSRS from ERT, Inc . D r. Stan ley rece ives roya lty paym ents fo r
eC -SSRS from ERT, Inc . D r. B ren t rece ives re search support from
N IMH , roya ltie s from Gu ilfo rd Press, and honoraria fo r se rv ing on the
ed ito ria l board o f UpToDate and fo r CM E p resen tations. D r. O quen -
do has rece ived unrestricted educational g ran ts o r lecture fees from
A straZeneca , B risto l-M yers Squ ibb, E li L illy, Janssen , O tsuko, Pfizer,
Sanofi-Aventis, and Sh ire , ow ns equ ity in Bristo l-M yers Squ ibb, and
rece ives roya lty paym ents fo r eC -SSRS from ERT, Inc . D r. G reenh ill has
rece ived re search support from Rhodes Pharm aceutica l, National In -
stitu te on D rug Abuse , and Johnson & Johnson and study m ed ication
and p lacebo from Sh ire Pharm aceutica ls fo r an investiga to r-in itia ted
im aging study. D r. M ann has rece ived re search support from G laxo -
Sm ithK line and Novartis and rece ives roya lty paym ents fo r eC -SSRS
from ERT, Inc . The o ther au tho rs repo rt no financia l re la tionsh ip s
w ith com m ercia l in te rests.
The Treatm ent o f Ado le scen t Su ic ide A ttem pters study (study 1 in
the artic le ) w as funded by N IMH through cooperative ag reem ent
g ran ts MH66750 (Duke Un iversity M ed ica l Cen te r), MH66769 ( Johns
Hopkins Un iversity ), MH66762 (New Yo rk Sta te Psych ia tric In stitu te ),
MH66775 (Un iversity o f P ittsburgh ), and MH66778 (Un iversity o f Tex -
as Southweste rn M ed ica l Cen te r). The adu lt em ergency departm ent
study w as funded in part by a g ran t from the Am erican Foundation
fo r Su ic ide P revention to D rs. B row n , Currie r, and Stan ley and by
a National In stitu te on A lcoho l Abuse and A lcoho lism “Deve lop ing
Cen te rs on In te rven tions fo r the P revention o f Su ic ide” g ran t (5 P20
cidal behavior in research studies, as well as clinical man-
agement more broadly.
As with any instrument, one must be mindful of the pop-
ulation one is working with. Depending on the population,
25% to 60% of attempts are considered “impulsive” (44–
46), but the role of impulsivity in suicide is far from clear
(41, 42), and “impulsive” attempts may include prior ide-
ation and planning (41). The results should be replicated
in studies designed to test psychometric properties of the
scale, and the application of the scale in different popu-
lations deserves further study, particularly in light of the
different potential routes to suicidal behavior (e.g., which
severity items predict which behaviors, and what other fac-
tors, such as substance abuse or family history, modify the
risk associated with the severity or intensity of ideation).
Lim ita tio n s
There are several significant limitations to this analysis.
The studies on which our analyses are based were not pro-
spectively designed to examine psychometric properties
of the instruments, although the replication of findings
across three different studies is reassuring. The significant
associations between the C-SSRS and the Scale for Suicide
Ideation and the Columbia Suicide History Form may be
attributed in part to the fact that the same interviewers
contemporaneously administered the scales; while this
may be an advantage in demonstrating convergent valid-
ity, it also increases the risk of interviewer or rater bias. To
address this issue, self-report measures (the BDI and the
Suicidal Ideation Questionnaire–Junior), ratings (on the
MADRS) by a study psychopharmacologist who was not
administering the C-SSRS, and ratings by the independent
suicide evaluation board were analyzed, and the results
were similar. Nevertheless, further examination of con-
current and incremental validity and interrater reliability
of this scale with other measures of suicidal ideation and
behavior is warranted.
The incidence of aborted, interrupted, and actual at-
tempts was very low in the two prospective studies (stud-
ies 1 and 2), which limits the precision of the sensitivity
and specificity estimates. The generalizability of the pre-
dictive validity findings is limited in study 1 because only
adolescent attempters were included in the sample (thus,
predictive validity for that study refers to prediction of re-
attempt). Although there are advantages to using diverse
populations in these analyses, there may be limitations to
the generalizability of results. While study 1 included only
adolescent attempters, study 2 excluded individuals with
current ideation or a history of suicide attempt, and study
3 was a clinical sample of adults presenting to an emer-
gency department for psychiatric treatment. These find-
ings must be replicated with community samples.
Conc lu sion s
These analyses of the C-SSRS using data from three
studies provide initial promising data on the convergent

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