Recent studies show that increasingly more adults in the United States struggle with depression and suicidal ideation. Before the pandemic, over half of all adults with mental health conditions received treatment within primary care, in place of seeing a therapist or mental health-specialized prescriber. The COVID-19 era has further exacerbated the problem of under addressed behavioral health needs. Suicidal thinking and suicidal behaviors, which range in severity, most often occur in the context of a psychiatric diagnosis.   

In this brief blog post, we will highlight resources available to primary care providers as they provide care to patients with suicidal thoughts or behaviors. We will focus on the Columbia Suicide Severity Rating Scale (C-SSRS), which is a “gold standard” measure of suicide severity that is often used in primary care settings. 

Just like other medical conditions such as pain, we often talk about suicidal thinking in terms of frequency and intensity. The PHQ-9 measures the frequency of depressive symptoms, including thoughts of death or self-harm. It does not, however, measure the intensity or severity of these experiences; in other words, how far the patient has gotten in their thinking or planning around suicide. The C-SSRS, which measures severity, can be particularly useful in deciding on the most appropriate clinical interventions. 

Administering the C-SSRS 

The C-SSRS has up to 6 yes or no questions that are meant to be read verbatim. Just like other scales (including the PHQ-2 or PHQ-9), if you ask the questions any way other than how they are written, the scores are not valid. The patient’s responses to the first two questions guide which of the four other questions you ask.  

ALWAYS ask the first two questions. The first question asks about what is considered “passive suicidal ideation,” a wish to be dead or thoughts that it would be better to go to sleep and not wake up. The second question is about “active suicidal ideation,” or thoughts of dying by suicide.  Some research suggests that these experiences are equally predictive of a future suicide attempt. 

• If question 2 is NO, skip to question 6, which asks about lifetime and recent suicide attempts. Asking this provides important background information about current risk.  

• If question 2 is YES, ask questions 3 (thoughts about method), 4 (intention to act on thoughts), 5 (working out a specific plan), and 6 (past or recent attempts). 

We encourage you to watch a brief training video about the C-SSRS. Dr. Kelly Posner, one of the scale developers, has many additional videos on her YouTube channel freely available to you.  

Scoring and Interpreting the C-SSRS 

Each item is scored as either a 0 (NO) or 1 (YES). Higher scores indicate greater severity of suicidal thinking and behavior.   

Planning Appropriate Interventions 

This section includes general recommendations for responding to scores greater than 0 on the C-SSRS. Individual practices may vary with respect to mental health practices available to them and procedures in place to respond to mental health crises.  

We recommend that any score greater than 0 on the C-SSRS initiate mental health intervention, which could include a referral to specialized psychiatric services, or a discussion about potential medication management or other supports within the primary care practice.  

Patients who said “YES” to items 3, 4, 5, and/or 6 are at greatest risk of attempting suicide soon. Consider EMS activation or ED transfer for patients who said YES to any or all of these items. Certainly, we know that having a method, intent, and a specific plan in mind is a clear mental health emergency. Knowing if there has been a recent attempt (item 6a) will also help providers decide if additional medical interventions are needed (e.g., treatment of Tylenol ingestion).  

Collaboration is Key to Effective Suicide Prevention 

Collaborating with the patient in seeking emergency care is a key first step. While involuntary admission for suicidal ideation is sometimes necessary to keep the patient safe, it can be highly stressful. Trying to enlist the patient as a partner in their own safety is essential to immediate safety, as well as their long-term willingness to talk about suicide and cope with chronic distress.

A respectful discussion around the patient’s desire to die, live, seek help, or even ensuring they know that help is available can lead to a greater likelihood of the patient accepting emergency care and actively participating in their own safety. This ideally involves the patient indicating openness to either go to the emergency room or receive emergency care (by way of an ambulance). Note that police always accompany ambulance responses in New York City which can be a scary experience for some patients and may elevate concern in some instances. Trans Lifeline is a trans-led organization divested from police intervention and will not initiate nonconsensual active rescue. You may wish to make your trans and gender nonconforming patients aware of this resource.

If the patient elects to go to the emergency room, ensure that someone from the practice can escort them, or at least follow up by phone when they reach the emergency room. Remember that the patient may not have access to their phone or adequate phone service within the hospital. If the patient is unable or unwilling to go to the emergency room, calling 911 to the practice is a reasonable option. In some situations, it may also be helpful to call a local crisis hotline like NYC Well (1-888-NYC WELL) who can help additionally assess the patient and collaborate with the practice in initiating an emergency response.  

Other Interventions 

Coping plans, also called safety plans, can be a useful intervention, alongside psychotherapy and/or medications. They are not a replacement for emergency evaluation. Usually, these plans include contact information for the social support in the person’s life, warning signs a crisis is coming, and coping resources, in addition to emergency numbers.

Review this sample coping/safety plan from NYC Well in collaboration with Vibrant.

We do not recommend the use of “no harm” or “no suicide” contracts. Research shows that they have no clinical value.  

Suicidal thinking also exists in the context of many risk and protective factors that you should know about. Refer to our Provider’s Guide to Suicide Risk Assessment to learn more about risk and protective factors. This guide also features the SAMHSA SAFE-T protocol for evaluating and responding to risk.

As with all the other work we do, we cannot stress enough the importance of documenting your clinical thinking when taking care of a patient with suicidal thinking.  

Managing One’s Own Feelings 

Talking to patients about their thoughts of suicide can be an anxiety-provoking, and even uncomfortable, experience. This can be the case for experienced clinicians as well as newer practitioners. Anitha Iyer, PhD, shares some tips for talking with patients about suicidality and preparing a safety plan in two brief videos.

Concluding Thoughts

Mount Sinai Health Partners is here to support you as you respond to the growing mental health crisis in the New York area. We strongly recommend you use our resources, including our new Provider’s Guide to Suicide Risk Assessment, to help you triage and care for patients presenting with substantial distress. Remember that tools like the C-SSRS and SAFE-T are immensely helpful in informing your medical decision making.

Please reach out to Mount Sinai Health Partners for any in-office training on this or related topics.  

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