SUICIDAL IDEATION – Resilient

COLUMBIA-SUICIDE SE COLUMBIA-SUICIDE SEVERITY
RATING SCALE
(C-SSRS)

1. Wish to be Dead

Do you endorse thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up?

Yes
No

Have you thought about being dead or what it would be like to be dead?

Yes
No

Have you wished you were dead or wished you could go to sleep and never wake up?

Yes
No

Do you wish you weren’t alive anymore?

Yes
No

If yes, describe:

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 during the assessment period. Have you thought about doing something to make yourself not alive anymore?

Yes
No

Have you had any thoughts about killing yourself?

Yes
No

If yes, describe:

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?

Yes
No

If yes, describe:

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.

Yes
No

If yes, describe:

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 decided how or when you would make yourself not alive anymore/kill yourself?

Yes
No

Have you planned out (worked out the details of) how you would do it?

Yes
No

What was your plan?

When you made this plan (or worked out these details), was any part of you thinking about actually doing it?

Yes
No

If yes, describe:

INTENSITY OF IDEATION

The following feature should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being the least severe and 5 being the most severe).

Most Severe Ideation

Type # (1-5) Description of Ideation Most Severe:

How many times have you had these thoughts? Circle your response.

Since Last Visit

Since Last Visit:

Have you had. AnActual Attempt?

Yes
No

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 do anything to try to kill yourself or make yourself not alive anymore? What did you do?

Yes
No

Did you hurt yourself on purpose? Why did you do that?

Yes
No

Did you______ as a way to end your life?

Yes
No

Did you want to die (even a little) when you_____

Yes
No

Were you trying to make yourself not alive anymore when you _____?

Yes
No

Or did you think it was possible you could have died from_____?

Yes
No

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)

Yes
No

If yes, describe:

Have you engaged in Non-Suicidal Self-Injurious Behavior? Please explain, if yes?

Yes
No

Please explain

Have you engaged in Self-Injurious Behavior, intent unknown? Please explain, if yes?

Yes
No

Total # of Attempts?

Interrupted Attempt

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?

Yes
No

If yes, describe:

Total # of interrupted:

Aborted Attempt or Self-Interrupted Attempt

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?

Yes
No

If yes, describe:

Total # of interrupted:

Aborted Attempt or Self-Interrupted Attempt

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?

Yes
No

If yes, describe:

Total # of preparatory acts: _____

Suicide:

Death by suicide occurred since last assessment.

Yes
No

Most Lethal Attempt Date: _______

Actual Lethality/Medical Damage: _______

Please Circle the best response since our last visit?

Death

Potential Lethality: Only Answer if Actual Lethality=0

Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying on train tracks with oncoming train but pulled away before run over).

Circle the best Response.

COLUMBIA-SUICIDE SE COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

Non-Specific Active Suicidal Thoughts

Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act

Active Suicidal Ideation with Some Intent to Act, without Specific Plan

INTENSITY OF IDEATION

Since Last Visit

Interrupted Attempt

Aborted Attempt or Self-Interrupted Attempt

Aborted Attempt or Self-Interrupted Attempt

Suicide:

COLUMBIA-SUICIDE SE COLUMBIA-SUICIDE SEVERITY
RATING SCALE
(C-SSRS)