The Columbia-Suicide Severity Rating Scale (C-SSRS): Has the "Gold Standard" Become a Liability?

OBJECTIVE: The Columbia- Suicide Severity Rating Scale has become the gold standard for the assessment of suicidal ideation and behavior in clinical trials. Criticism of the instrument has been mounting. We examine whether the instrument meets widely accepted psychometric standards and maps to the United States Food and Drug Administration's most recent 2012 algorithm for assessment of suicidal phenomena. Our goal is to determine if the Columbia-Suicide Severity Rating Scale should be retained as the preferred instrument for assessment of suicidal ideation and behavior.
METHOD: Standard psychometric criteria dictate that categorizations to avoid type I and type II errors should be comprehensive and address the full spectrum (i.e., all dimensions) of a phenomenon. The criteria should also be well defined and consistent, and the wording throughout should be unambiguous. We examine the Columbia-Suicide Severity Rating Scale in terms of these criteria.
RESULTS: The Columbia-Suicide Severity Rating Scale does not address the full spectrum of suicidal ideation or behavior. As a result, it has the potential to miss many combinations of suicidal ideation and behavior that present to clinicians in practice (type II error). Potential misclassifications (type I and II errors) are compounded by flawed navigation instructions; mismatches in category titles, definitions, and probes; and wording that is susceptible to multiple interpretations. Further, the Columbia-Suicide Severity Rating Scale in its current form does not map to the 2012 Food and Drug Administration's draft classification algorithm for suicidal ideation and behavior.
CONCLUSION: The evidence suggests that the Columbia-Suicide Severity Rating Scale is conceptually and psychometrically flawed and does not map to the Food and Drug Administration's new standards. A new gold standard for assessment of suicidality may be warranted.