Prediction of fatal and non-fatal suicide attempts by the Columbia Suicide Severity Rating Scale (C-SSRS): systematic review and meta-analysis

Abstract

Background:The Columbia Suicide Severity Rating Scale (C-SSRS) is apredominant tool for screening and scoring suicidal ideation andbehaviour to identify individuals at risk. No meta-analysis hasexamined its predictive significance.Aims: To evaluate the C-SSRS assessment of suicidal ideation andsuicidal behaviour as predictors of future fatal and non-fatalsuicide attempts.Method: A systematic search of Medline, PsycInfo, Embase, and Healthand Psychosocial Instruments databases was conducted fromJanuary 2008 to February 2024. The Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) guidelineswere followed, and the study was registered in PROSPERO(CRD42022361944). Two independent reviewers screened andextracted data, and assessed the risk of bias. Pooled odds ratioswere calculated using random-effects models, and heterogeneitywas assessed with the I2 statistic. Publication bias wasevaluated with Egger’s test and funnel plots.Results: The search identified 1071 unique records, of which 28 studiesmet inclusion criteria. The meta-analysis included 27 studieswith independent samples. Suicidal behaviour (pooled oddsratio 3.14, 95% CI 1.86–5.31) and suicide attempts (pooled oddsratio 2.78, 95% CI 1.82–4.24) were predictors of future non-fatalsuicide attempts. Suicidal ideation severity (odds ratio1.46/point, 95% CI 1.28–1.77) was a stronger predictor of futurenon-fatal suicide attempts than suicideal ideation intensity(odds ratio 1.11/point, 95% CI 1.04–1.18). Two studies linkedhigher suicidal ideation severity and a history of suicidalbehaviour with an increased risk of fatal suicide attempts,though meta-analysis was not feasible for only two studies.Conclusions: Suicidal behaviour, suicide attempts and to a lesser extentsuicidal ideation, identified using the C-SSRS, predicted futurenon-fatal suicide attempts. These findings support the use of theC-SSRS to detect individuals at higher-risk requiring enhancedpreventive interventions.