Protocol - Classification of Suicidal Ideation and Suicidal Behavior - Adolescent - Since Last Visit
This protocol includes two subscales from the pediatric Since Last Visit from the Pediatric version of the Columbia-Suicide Severity Rating Scale© (C-SSRS): Severity of Suicidal Ideation and Suicidal Behavior. Both subscales provide definitions of suicidal ideation and behavior and corresponding probes. The severity of ideation subscale is rated on a 5-point ordinal scale: 1 = wish to be dead, 2 = nonspecific active suicidal thoughts, 3 = suicidal thoughts with methods, 4 = suicidal intent and 5 = suicidal intent with plan. The suicidal behavior subscale is rated on a nominal scale that includes actual, aborted, and interrupted attempts; preparatory behavior; and nonsuicidal, self-injurious behavior.
The Since Last Visit version of the C-SSRS assesses suicidality since the subject has begun taking part in a clinical trial and over his or her lifetime. This version is suitable to assess suicidality in subjects who have already been enrolled in a clinical trial but have not yet been assessed using the C-SSRS as part of the trial. This is useful for determining any effects that a particular treatment method may have had on suicidality.
This protocol includes questions that can potentially identify respondents who are at risk of suicide. Investigators implementing this protocol should consider developing a risk management plan specific to their study to ensure the safety of participants. The following links provide additional information and guidelines for suicide-related research:
Ask questions 1 and 2. If both are negative, proceed to "Suicidal Behavior" section. If the answer to question 2 is "yes," ask questions 3, 4, and 5. If the answer to question 1 and/or 2 is "yes," complete "Intensity of Ideation" section below.
Since Last Visit
1. Wish to be Dead
Subject endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up.
Have you thought about being dead or what it would be like to be dead?
Have you wished you were dead or wished you could go to sleep and never wake up?
Do you ever wish you weren’t alive anymore?
If yes, describe:
2. Non-Specific Active Suicidal Thoughts
General, non-specific thoughts of wanting to end one’s life/commit suicide (e.g., "I’ve thought about killing myself") without thoughts of ways to kill oneself/associated methods, intent, or plan.
Have you thought about doing something to make yourself not alive anymore?
Have you had any thoughts about killing yourself?
If yes, describe:
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
Subject endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a specific plan with time, place, or method details worked out (e.g., thought of method to kill self but not a specific plan). Includes person who would say, "I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it…and I would never go through with it."
Have you thought about how you would do that or how you would make yourself not alive anymore (kill yourself)? What did you think about?
If yes, describe:
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
Active suicidal thoughts of killing oneself and subject reports having some intent to act on such thoughts, as opposed to "I have the thoughts but I definitely will not do anything about them."
When you thought about making yourself not alive anymore (or killing yourself), did you think that this was something you might actually do?
This is different from (as opposed to) having the thoughts but knowing you wouldn’t do anything about it.
If yes, describe:
5. Active Suicidal Ideation with Specific Plan and Intent
Thoughts of killing oneself with details of plan fully or partially worked out and subject has some intent to carry it out.
Have you ever decided how or when you would make yourself not alive anymore/kill yourself? Have you ever planned out (worked out the details of) how you would do it?
What was your plan?
When you made this plan (or worked out these details), was any part of you thinking about actually doing it?
If yes, describe:
(Check all that apply, so long as these are separate events; must ask about all types)
Since Last Visit
A potentially self-injurious act committed with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in mouth but gun is broken so no injury results, this is considered an attempt.
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred.
Did you ever do anything to try to kill yourself or make yourself not alive anymore? What did you do?
Did you ever hurt yourself on purpose? Why did you do that?
Did you______ as a way to end your life?
Did you want to die (even a little) when you_____?
Were you trying to make yourself not alive anymore when you _____?
Or did you think it was possible you could have died from_____?
Or did you do it purely for other reasons, not at all to end your life or kill yourself (like to make yourself feel better, or get something else to happen)? (Self-Injurious Behavior without suicidal intent)
If yes, describe:
Total # of Attempts
Has subject engaged in Non-Suicidal Self-Injurious Behavior?
Has subject engaged in Self-Injurious Behavior, intent unknown?
When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred).
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge. Hanging: Person has noose around neck but has not yet started to hang-is stopped from doing so.
Has there been a time when you started to do something to make yourself not alive anymore (end your life or kill yourself) but someone or something stopped you before you actually did anything? What did you do?
If yes, describe:
Total # of interrupted
When person begins to take steps toward making a suicide attempt, but stops themselves before they actually have engaged in any self-destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by something else.
Has there been a time when you started to do something to make yourself not alive anymore (end your life or kill yourself) but you changed your mind (stopped yourself) before you actually did anything? What did you do?
If yes, describe:
Total # of aborted
Preparatory Acts or Behavior:
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a suicide note).
Have you done anything to get ready to make yourself not alive anymore (to end your life or kill yourself)-like giving things away, writing a goodbye note, getting things you need to kill yourself?
If yes, describe:
Suicidal behavior was present during the assessment period?
© 2008 Research Foundation for Mental Hygiene, Inc.
Protocol Name from Source:
Personnel and Training Required
This scale is intended to be used by individuals who have received training in its administration. The questions contained in the Columbia-Suicide Severity Rating Scale are suggested probes. Ultimately, the determination of the presence of suicidal ideation or behavior depends on the judgment of the individual administering the scale.
For inquiries and training requirements, please contact firstname.lastname@example.org.
The PhenX Working Group acknowledges these questions can be administered in a computerized or noncomputerized format (i.e., paper-and-pencil instrument). Computer software is necessary to develop computer-assisted instruments. The interviewer will require a laptop computer/handheld computer to administer a computer-assisted questionnaire.
|Specialized requirements for biospecimen collection||No|
|Average time of greater than 15 minutes in an unaffected individual||No|
Mode of Administration
Adolescents, ages 12-18
The Columbia-Suicide Severity Rating Scale© (C-SSRS) is widely used in clinical trials, is low burden to participants and researchers, is not proprietary for non-industry-sponsored research, and has training materials available. Additionally, the C-SSRS corresponds to definitions for suicidal ideation and suicidal behavior endorsed by the Centers for Disease Control and Prevention (Crosby et al., 2011) and the U.S. Food and Drug Administration (FDA -Guidance for Industry Suicidal Ideation and Behavior: Prospective Assessment of Occurrence in Clinical Trials Office of Communications, Division of Drug Information Center for Drug Evaluation and Research Food and Drug Administration, 2012).
English, Available in other languages
|Common Data Elements (CDE)||Adolescent Since Last Visit Suicidal Ideation Behavior Classification Questionnaire Score||4588752||CDE Browser|
Process and Review
This section will be completed when reviewed by an Expert Review Panel.
The Columbia-Suicide Severity Rating Scale (C-SSRS) is copyrighted by the Research Foundation for Mental Hygiene, Inc.
For reprints of the C-SSRS contact:
Kelly Posner, PhD
New York State Psychiatric Institute
1051 Riverside Drive
New York City, NY 10032
Brent, D. A., Emslie, G. J., Clarke, G. N., Asarnow, J., Spirito, A., Ritz, L., Vitiello, B., Iyengar, S., Birmaher, B., Ryan, N. D., Zelazny, J., Onorato, M., Kennard, B., Mayes, T. L., Debar, L. L., McCracken, J. T., Strober, M., Suddath, R., Leonard, H., Porta, G., & Keller, M. B. (2009). Predictors of spontaneous and systematically assessed suicidal adverse events in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. American Journal of Psychiatry, 166(4), 418-426.
Brent, D. A., Greenhill, L. L., Compton, S., Emslie, G., Wells, K., Walkup, J. T., Vitiello, B., Bukstein, O., Stanley, B., Posner, K., Kennard, B. D., Cwik, M. F., Wagner, A., Coffey, B., March, J. S., Riddle, M., Goldstein, T., Curry, J., Barnett, S., Capasso, L., Zelazny, J., Hughes, J., Shen, S., Gugga, S. S., & Turner, J. B. (2009). The Treatment of Adolescent Suicide Attempters study (TASA): Predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48(10), 987-996.
Center for Drug Evaluation and Research (CDER). (2012). Guidance for industry suicidal ideation and behavior: Prospective assessment of occurrence in clinical trials. Rockville, MD: U.S. Department of Health and Human Services, U.S. Food and Drug Administration.
Crosby, A. E., Ortega, L., & Melanson, C. (2011). Self-directed violence surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G., 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.
Posner, K., Oquendo, M. A., Gould, M., Stanley, B., & Davies, M. (2007). Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry, 164(7), 1035-1043.
|Variable Name||Variable ID||Variable Description||Version||dbGaP Mapping|
|PX640103_NonSuicidal_SelfInjurious_Behavior_SinceLastVisit||PX640103140000||A potentially self-injurious act committed more||N/A|
|PX640103_SelfInjurious_Behavior_Unknown_Intent_SinceLastVisit||PX640103150000||A potentially self-injurious act committed more||N/A|
|PX640103_SuicidalIdeation_WithIntent_WithoutPlan_SinceLastVisit||PX640103070000||Active suicidal thoughts of killing oneself more||N/A|
|PX640103_SuicidalIdeation_WithIntent_WithoutPlan_SinceLastVisit_Describe||PX640103080000||Active suicidal thoughts of killing oneself more||N/A|
|PX640103_SuicidalIdeation_WithIntent_WithPlan_SinceLastVisit||PX640103090000||Thoughts of killing oneself with details of more||N/A|
|PX640103_SuicidalIdeation_WithIntent_WithPlan_SinceLastVisit_Describe||PX640103100000||Thoughts of killing oneself with details of more||N/A|
|PX640103_SuicidalIdeation_WithMethods_WithoutIntent_SinceLastVisit||PX640103050000||Subject endorses thoughts of suicide and has more||N/A|
|PX640103_SuicidalIdeation_WithMethods_WithoutIntent_SinceLastVisit_Describe||PX640103060000||Subject endorses thoughts of suicide and has more||N/A|
|PX640103_SuicidalThoughts_Nonspecific_Active_SinceLastVisit||PX640103030000||General, non-specific thoughts of wanting to more||N/A|
|PX640103_SuicidalThoughts_Nonspecific_Active_SinceLastVisit_Describe||PX640103040000||General, non-specific thoughts of wanting to more||N/A|
|PX640103_Suicidal_Behavior_Present_SinceLastVisit||PX640103240000||Suicidal behavior was present during the more||N/A|
|PX640103_Suicide_Aborted_Attempt_SinceLastVisit||PX640103190000||When person begins to take steps toward more||N/A|
|PX640103_Suicide_Aborted_Attempt_SinceLastVisit_Describe||PX640103200000||When person begins to take steps toward more||N/A|
|PX640103_Suicide_Aborted_Attempt_TotalNumber_SinceLastVisit||PX640103210000||When person begins to take steps toward more||N/A|
|PX640103_Suicide_Actual_Attempt_SinceLastVisit||PX640103110000||Actual Attempt: A potentially more||N/A|
|PX640103_Suicide_Actual_Attempt_SinceLastVisit_Description||PX640103120000||Actual Attempt: A potentially more||N/A|
|PX640103_Suicide_Actual_Attempt_TotalNumber_SinceLastVisit||PX640103130000||A potentially self-injurious act committed more||N/A|
|PX640103_Suicide_Interrupted_Attempt_SinceLastVisit||PX640103160000||When the person is interrupted (by an more||N/A|
|PX640103_Suicide_Interrupted_Attempt_SinceLastVisit_Describe||PX640103170000||When the person is interrupted (by an more||N/A|
|PX640103_Suicide_Interrupted_Attempt_TotalNumber_SinceLastVisit||PX640103180000||When the person is interrupted (by an more||N/A|
|PX640103_Suicide_Preparatory_Acts_Behavior_SinceLastVisit||PX640103220000||Acts or preparation towards imminently more||N/A|
|PX640103_Suicide_Preparatory_Acts_Behavior_SinceLastVisit_Describe||PX640103230000||Acts or preparation towards imminently more||N/A|
|PX640103_Wish_ToBe_Dead_SinceLastVisit||PX640103010000||Subject endorses thoughts about a wish to be more||N/A|
|PX640103_Wish_ToBe_Dead_SinceLastVisit_Describe||PX640103020000||Subject endorses thoughts about a wish to be more||N/A|
Classification of Suicidal Ideation and Suicidal Behavior
November 21, 2014
A questionnaire to assess suicidal ideation and suicidal behavior over a range of time frames.
Suicidal ideation and suicidal behavior can indicate an increased risk of suicide attempts and death by suicide. This measure can be used to determine levels of suicide risk and aid in making clinical decisions about care. In contrast to the PhenX measure Intensity of Suicidal Ideation (Continuum), which considers suicidal ideation existing as a continuous scale within a single construct, this measure distinguishes and classifies suicidal ideation and behavior, separately.
Suicide, Suicidal ideation, Suicide behavior, Columbia-Suicide Severity Rating Scale, C-SSRS, World Mental Health Composite International Diagnostic Interview, WMH CIDI