Suicide Risk Assessment & Management (C-SSRS)

Algorithm Steps

1. ▶

   Start

   Suicide Risk Screening Indicated

   Patient presents with concern for suicide risk

   1. ◆

      Decision

      Wish to be Dead or Suicidal Thoughts?

      C-SSRS Questions 1-2: In the past month...

      • 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 of killing yourself?
      1. ●

         Action

         No Current Ideation

         Screen negative for current suicidal ideation

         • Document negative screen
         • Consider protective factors
         • Address presenting concerns
         • Provide crisis resources (988 Suicide & Crisis Lifeline)
         1. ◆

            Decision

            Recent Suicidal Behavior?

            C-SSRS Behavior Questions (Lifetime/Past 3 months)

            • Actual attempt: Did you do anything to hurt yourself?
            • Interrupted attempt: Started to do something but were stopped?
            • Aborted attempt: Took steps but stopped yourself?
            • Preparatory behavior: Took steps toward making an attempt?
            1. ●

               Action

               Assess Risk & Protective Factors

               Comprehensive risk assessment

               • RISK: Prior attempts, psychiatric diagnosis, substance use, hopelessness, isolation, access to means, recent loss, chronic pain
               • PROTECTIVE: Social support, reasons for living, children, religious beliefs, treatment engagement, future orientation
               1. ◆

                  Decision

                  Determine Risk Level

                  Integrate all assessment findings

                  1. ⚠

                     Warning

                     HIGH RISK

                     Psychiatric hospitalization indicated

                     • Active suicidal ideation with plan AND intent
                     • Recent attempt (especially high-lethality)
                     • Unable to commit to safety
                     • Severe psychiatric symptoms
                     • Intoxication with suicidal ideation
                     1. ●

                        Action

                        Psychiatric Hospitalization

                        Inpatient admission for safety

                        • Continuous observation (1:1 if needed)
                        • Remove access to means
                        • Voluntary vs. involuntary hold
                        • Consult psychiatry for admission
                        • Document capacity if refusing
                        1. ✓

                           Outcome

                           Disposition & Follow-up

                           Ensure continuity of care

                           • Schedule follow-up within 24-72 hours
                           • Provide 988 Lifeline number
                           • Confirm crisis resources understood
                           • Communicate with outpatient providers
                  2. ●

                     Action

                     MODERATE RISK

                     Intensive outpatient or partial hospitalization

                     • Suicidal ideation without imminent plan/intent
                     • Chronic ideation with current stressor
                     • Able to commit to safety plan
                     • Social support available
                     • Engaged with treatment
                     1. ●

                        Action

                        Create Safety Plan

                        Stanley-Brown Safety Planning Intervention

                        • 1. Warning signs (thoughts, images, mood, situation, behavior)
                        • 2. Internal coping strategies
                        • 3. People/social settings for distraction
                        • 4. People to ask for help
                        • 5. Professionals/agencies to contact
                        • 6. Making the environment safe (means restriction)
                        1. ⚠

                           Warning

                           ⚠️ Means Restriction Counseling

                           CRITICAL for all risk levels

                           • Firearms: Temporarily store outside home
                           • Medications: Lock up, limit quantities
                           • Other means: Individualized plan
                           • Involve family/support person
                           • Document counseling provided
                  3. ●

                     Action

                     LOW RISK

                     Outpatient management with safety plan

                     • Passive ideation only
                     • No prior attempts
                     • Strong protective factors
                     • Good social support
                     • Engaged in treatment
      2. ◆

         Decision

         Suicidal Thoughts with Method, Intent, or Plan?

         C-SSRS Questions 3-5

         • 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? Do you intend to carry out this plan?
         1. ●

            Action

            Passive Ideation Only

            Thoughts without method, intent, or plan

            • Lower acute risk but requires assessment
            • Assess chronicity and frequency
            • Evaluate protective factors
            • Consider outpatient management if safe
         2. ⚠

            Warning

            ⚠️ Active Ideation with Plan/Intent

            HIGH RISK - Immediate intervention required

            • Method identified
            • Intent to act
            • Specific plan formulated
            • Means access present