CLINICALTRIAGEGUIDELINESUSINGTHEC‐SSRS

Answerson theC‐SSRS provide theinformation neededin ordertoclassify someone’ssuicidal ideation and behavior,and when combined with clinical judgment, can help determinelevelsof riskand aid in making clinicaldecisionsabout care.

Severity ofIdeationSubscale -consists of5questions that reflectfivetypesof ideation of increasing severity:

  • ApositiveanswertoQuestion 4or5indicating presenceof ideation with atleast some intent todie in the past one month indicatesa severe risk and clearneedfor furtherevaluationandclinical management(e.g., triggersimmediatereferraltomentalhealth services and patient safety precautions).

4– ActiveSuicidalIdeationwithSomeIntenttoAct,WithoutSpecificPlan(e.g.,Iwould hang myself[method]andIcan’tguaranteethat Iwon’t doit [intent]).

5– ActiveSuicidalIdeationwithSpecificPlanandIntent (e.g.,tomorrowat1:00pmwhenI know no onewill behome [plan],Iamgoing to [intent]takea handful ofTylenol that Ihavein mymedicine cabinet).

SuicidalBehaviorSubscale -includes questionsabout 4suicidal behaviorsand non‐suicidal self-injurious behavior.

  • Presenceof ANYsuicidal behavior(suicideattempt,interruptedattempt,aborted attemptandpreparatorybehavior) inthepast3months indicatesa severerisk and clearneedfor furtherevaluationandclinical management(e.g., triggersimmediatereferraltomentalhealth services and patient safety precautions).

*Note:Endorsementof otherquestions on thescale could alsoindicate aneedfor further evaluation orclinical managementdependingonpopulation orcontext,howevera positive answerto Question4or5in thepast month oranybehaviorin thepast 3months indicatethe most severelyemergentclinical situation.

Additional sections on the Full C-SSRS and not on the Screener version that can augment clinical judgment.

IntensityofIdeationSubscale -includes 5questions abouttheFrequency,Duration, Controllability,Deterrents,and ReasonsforIdeation forthemostseverelevelofideation endorsed on theSeveritysubscale (i.e., highest endorsedfrom1to 5).

  • The total scorerangesfrom2to 25,with a higher number indicating moreintense ideation and greaterrisk.

SuicidalBehaviorLethalityinquires about thelevelof actual medical damageorpotential for it

  • Greaterlethality or potential lethalityof thebehavior(endorsed ontheBehaviorsubscale) indicates increased risk.

EXAMPLESOF TRIAGE/ALERTRULESINDIFFERENT CARE SYSTEMS

COMMUNITY CARE SETTINGS (CENTERSTONE,thelargestnon-profit provider of community‐basedbehavioralhealthservicesin the nation)

HOSPITAL SETTINGS FOR THE JOINT COMMISSION REQUIREMENT

This example is for an Emergency Department

ThisexamplefromtheReadingHospitalpolicyshowstypesofclinicaldispositioncorrespondingto thelevelofideationseverityinthelastmonth:

Thetriageplanshowsthatendorsingideationof1or2resultsina mentalhealthreferralat discharge, 3 results in a consult by a psychiatric nurse and 4 or 5 results in psychiatric consultation and patient safety monitoring.

Having anybehavior:withinthepastweekresultsinanMDconsult,withinthepastmonthresultsinaCare Teamconsult,withinthepastyearresultsina mentalhealthreferralatdischarge.

PRIMARY CARE

HARVARD PARTNERS HEALTHCARE/MASS GENERAL – C-SSRS WITH RISK AND PROTECTIVE FACTORS

STATE‐WIDEELECTRONIC MEDICAL RECORD SYSTEM

(used by the New York StateOfficeofMentalHealthfacilities with outpatient services)

Thesystemautomaticallyadds aREDSUICIDE WARNING ALERTtothepatient’srecordforendorsinga“4or5”inthepastmonthorabehaviorinthepast3months;andan ORANGE SUICIDE HISTORY ALERTifthereisanylifetimehistory ofideationseverityof”4or5”oranysuicidalbehavior.

MILITARYSETTINGS –MEDCOM

Policyspecifics:

Anideationseverityof:

  • 1or2resultsinaroutinebehavioralhealthreferral.
  • 3resultsina reviewbythecareteam
  • 4or5resultsinEMERGENTACTION – patient safety monitoring and psychiatric consult

Presenceofanysuicidalbehavior:

  • over3monthsagoresultsinaroutinebehavioralhealthreferral
  • withinthepast3monthsresultsinareviewbythecareteam
  • withinthepastweekresultsinEMERGENTACTION– patient safety monitoring and psychiatric consult

PRISON MENTAL STATUS EXAM

SAFE-T/C-SSRS TRIAGE TOOL FOR PSYCHIATRIC CARE/BEHAVIORAL HEALTH