> ## Documentation Index
> Fetch the complete documentation index at: https://docs.getrivet.ca/llms.txt
> Use this file to discover all available pages before exploring further.
# C-SSRS — Columbia Suicide Severity Rating Scale
> The FDA's standard suicide severity rating — clinician-administered, never self-report, with explicit high-risk flagging.
The C-SSRS is the FDA's standard suicide severity rating in clinical
trials. It's used in emergency departments, primary care, schools, and
crisis hotlines. Rivet includes the **Screening (Recent)** variant: five
ideation severity items plus one behavior item covering the past three
months.
Columbia explicitly states the C-SSRS is **not** a self-report
instrument. It must be administered by a trained interviewer. Rivet
enforces this — the C-SSRS cannot be sent to a client as an async
link. You ask the questions in person, in the room or on a video
call.
## What it measures
Five ideation severity items, each scored Yes/No, structured so that the
highest YES captures the severity level:
| Item | Construct | Severity if YES |
| ---- | ------------------------------------------------------- | --------------- |
| 1 | Wish to be dead | 1 |
| 2 | Non-specific active suicidal thoughts | 2 |
| 3 | Active ideation with methods, without intent | 3 |
| 4 | Active ideation with some intent, without specific plan | 4 |
| 5 | Active ideation with specific plan and intent | 5 |
Plus one **behavior** item (item 6): Yes/No for actual, aborted, or
interrupted suicide attempts or preparatory acts in the past three months.
## When to use it
* Emergency department screening — every encounter, integrated with safety
plan triage
* Primary care annual screening — particularly in pediatric and
adolescent intake
* Clinical trial safety monitoring — FDA-required for many trial protocols
* SAMHSA Zero Suicide care model intake screening
* School gatekeeper training pairs with this scale
The Screening (Recent) variant Rivet includes is the right tool for
**screening contexts**. The Past 1-Month, Lifetime, Intensity of
Ideation, and Lethality of Behavior variants are separate Columbia
instruments — not in Rivet.
## How you administer it
Solo fill, in person or on a video call with the client. Open **C-SSRS**
from the templates picker and tap **New response**. The renderer presents
the six items in order; you ask each question of the client directly and
record the answer.
The form cannot be sent to a client — there is no "Send to client" option
for this measure. You are in the room (or on the call) for every
administration.
The Columbia Lighthouse Project provides free training videos at
[cssrs.columbia.edu](https://cssrs.columbia.edu). The Screening variant
does not require formal training to administer, but inter-rater
reliability improves meaningfully with the one-hour training module.
## How Rivet scores it
* **Ideation severity:** the highest YES level among items 1-5 (0 if all
No)
* **Behavior:** YES or NO on item 6
Both subscales are reported independently. The score is not a single
sum — it's the highest ideation level + the behavior flag.
## High-risk items — items 4, 5, and 6
**Items 4 (intent), 5 (plan), and 6 (behavior in the past 3 months)
trigger immediate clinical action.**
Any YES on item 4, item 5, or item 6 indicates high-risk presentation
and warrants:
* **Immediate safety planning** — Rivet's safety plan template
(Stanley-Brown format) is the standard pairing
* **Means restriction counseling** — firearms, medications,
high-lethality access
* **Level-of-care decision** — outpatient with frequent monitoring,
crisis stabilization, hospitalization, or emergency-department
referral
Rivet captures the data and surfaces the high-risk flags in the
response view. **Rivet does not auto-escalate, does not notify
anyone, does not contact crisis services, and does not substitute for
your clinical judgment in the room.** The decision is yours.
The standard pairing for a positive C-SSRS is a **Stanley-Brown Safety
Planning Intervention** (Stanley & Brown, 2012) — collaborative
identification of warning signs, internal coping strategies, social
contacts for distraction, social contacts for asking help, professional
contacts, and means restriction. The safety plan template lives in
Rivet's clinical template library and is designed to be filled
collaboratively with the client in the same session.
## Mandatory citation
Columbia requires the citation to appear in the clinical record whenever
the C-SSRS is administered. Rivet embeds the citation as a display item
in the template description so it appears inline as you administer the
scale and in the formatted note output.
## What we render vs. the source
Verbatim items from the Columbia Lighthouse Project Screening (Recent)
distribution PDF, with the mandatory citation embedded as a `display`
item. Items 1-5 each map to a single Yes/No with the YES value set to
the ideation severity score (1-5), so the scoring computes the highest
YES — matching Columbia's published scoring.
All six items are flagged sensitive in the response data model.
## What Rivet doesn't include
These Columbia variants are separate instruments and are not part of
the Screening (Recent) version:
* **Past 1-Month variant** — separate template
* **Lifetime variant** — rarely used in screening contexts
* **Intensity of Ideation subscale** — frequency, duration,
controllability, deterrents, reasons for ideation
* **Lethality of Behavior subscale** — 5-point ratings for actual
attempts
If you need any of these, the Columbia Lighthouse Project distributes
them at no cost from their training site.
## C-SSRS vs a suicidality item on a screening measure
Most depression measures carry one risk item — Item 9 on the
[PHQ-9](/clinical-templates/screening/phq-9), Item 12 on the
[QIDS-SR-16](/clinical-templates/screening/qids-sr-16), Items 14 and 15 on
the [CES-D-R](/clinical-templates/screening/ces-d-r). Those items are
tripwires. They tell you to ask, and nothing more.
The C-SSRS is the asking. It grades ideation across five levels, from a
wish to be dead through to a plan with intent, and separately asks about
behaviour in the past three months. A positive Item 9 and a C-SSRS of 5
are not the same finding and shouldn't be recorded as though they were.
The other difference is who administers it. The C-SSRS is explicitly not a
self-report instrument — it is meant to be asked by a trained interviewer,
and it is the reason Rivet won't let this one be sent ahead of a session.
What follows a positive C-SSRS is a
[safety plan](/clinical-templates/crisis/safety-plan), and the
[RFL-12](/clinical-templates/crisis/rfl-12) if you want to inventory what
protective beliefs the client still has to build that plan on.
## Is it free to use?
**Yes — with one condition.** The Columbia Lighthouse Project permits free clinical use, and **requires the citation to appear in the clinical record**. Rivet carries it inline where you administer the measure and includes it in what you copy out, so meeting that condition is not something you have to remember.
## Citations
* Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V.,
Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S.,
& Mann, J. J. (2011). "The Columbia-Suicide Severity Rating Scale:
initial validity and internal consistency findings from three
multisite studies with adolescents and adults." *American Journal of
Psychiatry,* 168(12): 1266-1277.
* Stanley, B., & Brown, G. K. (2012). "Safety planning intervention:
a brief intervention to mitigate suicide risk." *Cognitive and
Behavioral Practice,* 19(2): 256-264.
Free clinical use per The Columbia Lighthouse Project
([cssrs.columbia.edu](https://cssrs.columbia.edu)), with mandatory
citation in the clinical record.
## Related articles
Hamilton Depression Rating Scale. Item 3 (suicide) cutoff fires for
severity ≥3; pair with C-SSRS for dedicated suicide assessment.
Why these six measures don't ship to clients, and how solo fill works.