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Suicide Risk Assessment & Management (C-SSRS)

Suicide Risk Assessment & Management (C-SSRS): Suicide risk screening indicated → Intoxicated or confused, under 18 or wants to leave: adapt the assessm...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Suicide risk screening indicated

    Ask directly about suicide. Injury or overdose: start medical care at the same time. Do not delay the mental health assessment.

  2. 02Warning

    Intoxicated or confused, under 18 or wants to leave: adapt the assessment

    Check these before you rely on the screen.

    • Intoxicated, delirious, acutely psychotic or cognitively impaired: answers are not reliable. Keep the person safe and observed. Do not discharge on a negative screen. Treat the cause and assess again when they can engage.
    • Under 18: assessment by a clinician experienced with young people. Involve parents or carers. Check safeguarding.
    • Wants to leave before assessment: assess safety and mental state first. Use the state or territory Mental Health Act if needed.
  3. 03Action

    C-SSRS Q1 and Q2 (past month): always ask both

    Ask in these words.

    • Q1: Have you wished you were dead or wished you could go to sleep and not wake up?
    • Q2: Have you actually had any thoughts about killing yourself?
    • Q2 Yes: ask Q3, Q4 and Q5. Q2 No: skip to Q6.
  4. 04Action

    Only if Q2 Yes: ask Q3, Q4 and Q5

    Method, intent and plan.

    • Q3: Have you been thinking about how you might do this?
    • Q4: Have you had these thoughts and had some intention of acting on them?
    • Q5: Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
  5. 05Action

    C-SSRS Q6 (lifetime and past 3 months): always ask

    Suicidal behaviour.

    • Have you done anything, started to do anything, or prepared to do anything to end your life?
    • Includes actual, interrupted and aborted attempts and preparation (for example collected pills, wrote a note)
    • If yes, was this within the past 3 months?
  6. 06Decision

    Q4 Yes, Q5 Yes, or Q6 Yes in the past 3 months?

    Any one of these needs action now.

  7. If Yes
    1. 07Warning

      Yes (intent, plan or recent behaviour): act now

      Emergency mental health assessment now. Outside hospital: call 000 (ambulance or police) and stay with the person until help arrives.

      • Stay with the person. Do not leave them alone.
      • Remove access to means now (medicines, weapons, ligatures)
      • Arrange emergency mental health assessment. If they refuse and are at serious risk, use the Mental Health Act.
    2. 08Action

      Psychosocial assessment: needs, strengths and safety

      By a mental health clinician: for any Yes answer to Q2 to Q6, or self-harm in this presentation. Q1 Yes only: the treating clinician covers these points. Older people: suicide risk after self-harm is higher. Use an assessor experienced with older people. Check for depression, cognitive impairment, frailty and isolation.

      • Current: suicidal thoughts, plan, intent, access to means, intoxication, mental state, recent losses or crises
      • History: past self-harm or attempts, mental illness, substance use, trauma, chronic illness or pain
      • Protective: reasons for living, supports, connection to care, future plans
      • Collateral from family, carers, GP and records. Check capacity, consent and safeguarding.
    3. 09Decision

      Formulation: safety needs that need hospital care now?

      Decide care by needs, safety and supports. Do not use low, medium or high risk categories or scores to decide treatment or discharge.

    4. If Yes
      1. 10Action

        Yes: emergency or inpatient mental health care

        Admission for safety and treatment. Voluntary care first.

        • Keep the person safe and observed. The mental health team sets the level of observation.
        • Remove access to means (belongings, medicines, ligature points)
        • If admission is needed and refused: assess capacity and use the state or territory Mental Health Act
        • Needs physical care or cannot engage yet (for example intoxicated): admit to a general hospital bed and assess when able
        • Aboriginal and Torres Strait Islander people: offer culturally safe care, for example an Aboriginal liaison officer
      2. 11Action

        Safety plan with the person (any Yes answer or self-harm, before they leave)

        Written with the person. They keep a copy. Share it with carers and the care team as they agree.

        • 1. Warning signs of a crisis (thoughts, mood, situations, behaviour)
        • 2. Own coping strategies
        • 3. People and places for distraction
        • 4. People to ask for help
        • 5. Professionals and services, including after-hours crisis numbers
        • 6. Make the environment safe (reduce access to means)
      3. 12Warning

        Reduce access to lethal means (any Yes answer or self-harm)

        Ask directly about access to firearms, stored medicines and other methods.

        • Firearms: arrange removal from the home while at risk
        • Medicines: remove stockpiles; dispense small quantities; lock up. Review medicines: consider toxicity in overdose (for example opioids, tricyclic antidepressants) and choose safer options.
        • Other methods: make a plan with the person and family. Record who does each step.
      4. 13Outcome

        Disposition, crisis numbers and follow-up

        Aftercare within 48 hours of the assessment if safety concerns continue. Crisis in Australia: 000 or Lifeline 13 11 14.

        • Australia: 000. Lifeline 13 11 14. Suicide Call Back Service 1300 659 467.
        • 13YARN 13 92 76 (Aboriginal and Torres Strait Islander people). Kids Helpline 1800 55 1800 (children and young people).
        • Other countries: local emergency and crisis numbers (US: 911; 988 Suicide & Crisis Lifeline)
        • Give the person a copy of the care plan and aftercare contact details
        • Send a summary to the GP and treating team
      If No
      1. 14Action

        No: community care matched to needs

        A lower level of need does not mean no risk. Do not delay aftercare.

        • Choose the level of support by need: acute or crisis mental health team, GP, psychiatrist or psychologist
        • Involve family or carers, with consent where possible
        • Treat the underlying mental illness and substance use
        • Aboriginal and Torres Strait Islander people: offer culturally safe care, for example an Aboriginal Community Controlled Health Service
      2. Path rejoins step 11Shared downstream outcome
    If No
    1. 15Action

      No: act on the other answers

      Q4, Q5 and recent Q6 all No. A negative screen does not mean no risk.

      • Q2 or Q3 Yes (active thoughts or method): mental health evaluation before the person leaves
      • Q6 Yes more than 3 months ago: psychosocial assessment by a mental health clinician (next step)
      • Q1 Yes only (wish to be dead): the treating clinician explores it and refers for mental health follow-up (GP or mental health service)
      • All No: address the presenting concern. Self-harm in this presentation still needs a psychosocial assessment.
    2. 16Decision

      Any Yes answer (Q1 to Q6), or self-harm in this presentation?

      Yes: continue to the psychosocial assessment. No: screen negative.

    3. If Yes
      1. Path rejoins step 08Shared downstream outcome
      If No
      1. 17Outcome

        No: all answers No and no self-harm: screen negative

        A negative screen does not mean no risk. Not valid if intoxicated, delirious, psychotic or cognitively impaired: keep the person safe and assess again. Treat the presenting concern. Crisis in Australia: 000 or Lifeline 13 11 14.

Guideline Source

NICE NG225 Self-harm: assessment, management and preventing recurrence (2022), with the C-SSRS screener (Columbia Protocol) and RANZCP deliberate self-harm guideline (2016)

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Risk tools and risk categories do not predict suicide. Do not use them to decide treatment or discharge (NICE NG225 1.6; RANZCP 2016).
  • A negative screen does not mean no risk. People may not disclose; seek collateral information.
  • Written for adults. Young people need age-appropriate services and involvement of parents or carers.
  • Involuntary care follows the state or territory Mental Health Act.
  • Risk can change quickly. Reassess at each contact.
  • Culture affects disclosure. Offer culturally safe care.

Applicable Regions

AUUSEUGlobal

AU: Crisis: 000; Lifeline 13 11 14; Suicide Call Back Service 1300 659 467; 13YARN 13 92 76; Kids Helpline 1800 55 1800. Involuntary care: state or territory Mental Health Act.

US: Crisis: 911; 988 Suicide & Crisis Lifeline (call or text 988).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Suicide Risk Assessment & Management (C-SSRS)?

The Suicide Risk Assessment & Management (C-SSRS) is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on NICE NG225 Self-harm: assessment, management and preventing recurrence (2022), with the C-SSRS screener (Columbia Protocol) and RANZCP deliberate self-harm guideline (2016).

What guideline is the Suicide Risk Assessment & Management (C-SSRS) based on?

This algorithm is based on NICE NG225 Self-harm: assessment, management and preventing recurrence (2022), with the C-SSRS screener (Columbia Protocol) and RANZCP deliberate self-harm guideline (2016).

What are the limitations of the Suicide Risk Assessment & Management (C-SSRS)?

Known limitations include: Risk tools and risk categories do not predict suicide. Do not use them to decide treatment or discharge (NICE NG225 1.6; RANZCP 2016).; A negative screen does not mean no risk. People may not disclose; seek collateral information.; Written for adults. Young people need age-appropriate services and involvement of parents or carers.; Involuntary care follows the state or territory Mental Health Act.; Risk can change quickly. Reassess at each contact.; Culture affects disclosure. Offer culturally safe care.. Individual patient factors may require deviation from these recommendations.

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