Figure 1. Suicidality Classification System
Color key : blue boxes = FDA “Primary Analysis” (Events Deemed Suicidal); blue and green boxes = FDA “Sensitivity Analysis” (Any Event That Could Possibly Be Suicidal) Note . From ‘Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDA's pediatric suicidal risk analysis of antidepressants,” by Posner, K. et al., 2007. American Journal of Psychiatry, 164(7): 1035-43. (https://doi.org/10.1176/ajp.2007). In the Creative Commons.
The criteria for a suicide attempt include both self-injurious behaviors and suicidal intent. Intent to die or an attempt to actively act on suicidal thoughts is considered a risk factor for future suicide and repeated attempts. The C-CASA’s clear definitions and classifications of intent allow social care personnel and psychiatric professionals to clearly distinguish between patents who self-injure for outcomes that are not suicide related and those who self-injure in an active attempt to die (Schatten et al., 2020). the C-CASA also includes operational guidelines defining the distinct stages from suicidal ideation to suicide attempt. Circumstances and behaviors tagged as “Clinically impressive” define suicidal intent when the cases feature the patient’s missing, denied, or unclear intent. Also, suicidal intent may be inferred based on two other pieces of data as outlined in the C-CASA: (1) Clinical circumstance such as suicide methods used and (2) the location of the injury on the body. Clinicians using this classification and its associated definitions consider a cut on the leg as a non-suicidal self-injurious behavior with or without a clear suicidal intent. Other data to be considered in the classification of suicidal severity according to the C-CASA include a family history of suicide/suicide attempts, history of self-injurious behavior bordering on suicide or intent to self-afflict a mortal injury, history of self-mutilation, history of drugs abuse, trauma, and history of past life crisis. In the youth and adult population, social factors that might act as a trigger for suicidal intent and attempts - including mid-life crises, financial difficulties, and medical conditions - are also considered before classifying severity. According to the C-CASA, clinical personnel must gather information on the triggers and factors related to suicidal The Columbia-Suicide Severity Rating Scale (C-SSRS) In 2012, the FDA adopted the C-SSRS as the “gold standard” to measure suicidal ideation and behavior (SIB; Salvi et al., 2019). the C-SSRS was developed to address inconsistencies in the previous classification systems and to provide a single standard measure to assess both suicidal ideations and behavior. A team of investigators from Columbia University, the University of Pennsylvania, and the University of Pittsburgh developed the C-SSRS not only to classify SIB but also to track the progression of changes in SIB. Since its introduction, C-SSRS has been used globally to monitor the safety of therapeutic interventions in clinical studies and also to identify the patterns of suicidal intent, attempts, and triggers in study populations. It has also been adopted by the Centers for Disease Control and Prevention (CDC) to define and stratify suicidal ideations and behavior (Salvi et al., 2019). In its design, the C-SSRS serves multiple purposes for policies centered on suicide assessment and prevention. Its primary design makes it useful as a standard measure of suicidality, for assessing the lethality and severity of suicidal behaviors, for monitoring treatment outcomes, and for establishing
ideation and behavior before a severity classification is made. the information can be obtained by relative screening, in- depth interviews, third-party entities with direct access to the patient, or observation. SIB data is used to encode the different behavioral patterns constituting suicidal ideation or attempt. For instance, passive suicidal ideation is coded as: ● The wish to not be alive. ● The desire to go to sleep and not wake up. Active suicidal ideation is coded as: ● Nonspecific thoughts (e.g., thoughts of killing oneself with no thought of how; no method, intent, or plan). ● Thoughts of a method of suicide, but no intent or plan. ● Thoughts of a method of suicide, with intent to perform a suicidal act, but no plan. ● Thoughts of a method of suicide, with the intent to perform a suicidal act. ● The presence of a specific suicide plan. Although C-CASA may appear laborious in its assessment data gathering and coding, it is relatively easy to gather the information required for coding in comparison to other classification guidelines. The advantages of this classification system have also created for it a large following in clinical care and drug evaluation processes. It requires some brief training and can be administered by different healthcare personnel. In many cases, the assessment process requires only a self- reported screening device or a brief interview that lasts for a few minutes. Screening and interviews help identify at-risk patients depending on their symptom presentation that can be coded in an abbreviated time. suicide risk in clinical and research settings. Until the C-SSRS, suicidal ideation and behavior were traditionally viewed as a unidimensional construct, with passive ideation, active intent, and behavior existing along a continuum with only a few clear boundaries in some cases. Unlike other suicide assessment and severity classification tools, the C-SSRS was designed to distinguish between the domains of suicidal ideations and suicidal behavior. There are five different constructs measured in the C-SSRS assessment including the severity of ideation, the intensity of the ideation subscale, the behavior subscale, and the lethality subscale. The first construct, severity of ideation, is rated on a 5-point scale: ● 1 codes for a wish to be dead. ● 2 codes for nonspecific active suicidal thoughts. ● 3 codes for suicidal thoughts with methods. ● 4 codes for suicidal intent. ● 5 codes for suicidal intent with a plan.
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