The Columbia Suicide Severity Rating Scale— Clinical Implications 4/13/22

As a public health concerns, suicide is a serious issue. It is the 12^th leading cause of death accounting for the loss of nearly 46,000 Americans in 2020, occurring at a rate of 130 per day. There an estimated 1.2 million suicide attempts made in 2020. Overall male to female ratio for suicides is roughly 4:1. White middle age males account for 70% of suicides; firearms are involved in over 50% of cases.

For youth, the rate of suicide is 14 deaths per 100,000. Nearly 10% of high school youth report some form of suicidal act in the past year. For youth, females are twice as likely to make a suicide attempt. Alaskan Natives and American Indian youth have elevated rates of suicide attempts (55%) vs. Caucasian youth (8%). 2.5% of youth suicide attempts require medical attention overall but multiple race youth have a 4% rate.

Going beyond these statistics, the clinical challenges of managing suicidal and para-suicidal patients continues to be an area of great concern and confusion as well. Compounding the clinician’s challenges is the lack of uniformity in the use of the multiple terms that can be applied to what are essentially crisis situations.

When, for example, should someone who has made an attempt, or someone with suicidal ideation, or those who make gestures, threats, or are manipulative be referred for evaluation for a psychiatric hospital stay. What makes any of these situations more serious, which ones can be managed within the therapeutic encounter(s); which can’t safely be managed? What are we to make, both acutely and over the long term, of the ranges of lethality that different patients’ exhibit?

The good news: The understanding that has emerged and which can be incorporated into clinical practice from the development and study of the Columbia Suicide Severity Rating Scale is substantial. The key points of inquiry can easily be incorporated into a simple clinical approach in working with patients—formal use of the tool is actually optional, if the concepts underlying the tool are reviewed, understood and integrated into clinical assessment efforts.

Although research and public health strategies continue to use the tool and its findings, with the Centers for Disease Control (CDC), the Institute of Medicine, and many academic researchers all applying it to their activities, much of past research and interventions have been inadequately informed in their findings and outcomes. As recently as the 2004, the FDA’s widely publicized findings regarding the risks of using SSRIs in the treatment of adolescents, led and continue to lead to problems for clinicians. The FDA’s Black Box Warning that SSRIs were associated with increased suicidal ideation, arguably led to a reversal in the declining rate of suicides amongst adolescents, when pediatricians and psychiatrists and parents and patients decreased the use of the agents significantly. While suicidal ideation is an obvious concern, the current understanding about the reported increase in this symptom after initiating treatment did not result in an appreciable increase in actual suicides or other serious negative clinical outcomes. The lack of comfort in diagnosing and then treating teens with depression, psychotherapeutically and/or pharmacologically, that arose after the warning ay have been a key factor in the rise of youth suicide following its promulgation.

TWO QUESTIONS to start: Clinical management of a suicidal or para-suicidal patient comes down to understanding the answers to two screening questions.

Does the patient have a wish to die?
Do they have active thoughts of killing themselves?

If the answers to both questions are “NO”, no intensive interventions to prevent suicide are warranted, though ongoing treatment and care for the patient will be warranted. The critical consideration here is as to whether the patient intent (thoughts) are linked to behaviors (actions) that could (or have) led to injury up to and including death.

FOLLOW UP is required for an affirmative “YES” response to either of the questions, with 3 further areas of questioning needed to a “YES” to question #2.

What method killing themselves do (or did) they have in mind?
How intent are (or were) they planning to proceed?
What are the specifics of their plan?

Some further considerations:

Assessing Intent: When there is deemed to be significant risk, it is important to understand the intensity of a patient’s suicidal ideation as regards:
1. frequency, duration and intensity of the ideation
2. the patient’s capacity to control their behavior and
3. what are the deterrents and underlying causes (stressors, internal or external) for the ideation

as all of these factors have predictive value in assessing the potential for suicide and other self-harm.

Definitions:
1. Suicide Attempt: as “a non-fatal, self-inflicted potentially injurious behavior with any intent to die as a result”. (Centers for Disease Control)
2. Interrupted Attempt: an external factor (a person or circumstance) prevent the individual from proceeding with the planned suicide act.
3. Aborted Attempt: the patient changes their mind or behavior to not complete the suicide action
4. Preparatory Acts/Behaviors: Any behavior to prepare for a suicide action: e.g., collecting pills, buying a gun, writing a suicide note
Non-Suicidal Self Injury:
1. Behaviors such as cutting that are not driven by suicidal intent and have low lethality risk
2. Typically performed to achieve some internal psychological relief (reduce emotional pain)
3. May also be performed as a means of seeking attention, e.g., for sympathy or other impact on another individual
Lethality: 6 levels of medical impact
1. nil: a scratch or bruise
2. mild: injury not requiring medical attention
3. moderate: some need of medical attention
4. mod-severe: need for hospital attention
5. severe: need for intensive hospital level care
6. death: death