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Am J Psychiatry. 2011 December ; 168(12): 1266–1277. doi:10.1176/appi.ajp.2011.10111704.

The Columbia–Suicide Severity Rating Scale: Initial Validity and

Internal Consistency Findings From Three Multisite Studies With
Adolescents and Adults
Kelly Posner, Ph.D., Gregory K. Brown, Ph.D., Barbara Stanley, Ph.D., David A. Brent, M.D.,
Kseniya V. Yershova, Ph.D., Maria A. Oquendo, M.D., Glenn W. Currier, M.D., M.P.H., Glenn
A. Melvin, Ph.D., Laurence Greenhill, M.D., Sa Shen, Ph.D., and J. John Mann, M.D.
Department of Psychiatry and the Division of Child and Adolescent Psychiatry, Columbia
University, College of Physicians and Surgeons, and New York State Psychiatric Institute, New
York; Department of Psychiatry, University of Pennsylvania, Philadelphia; University of Pittsburgh
School of Medicine and Western Psychiatric Institute and Clinic, Pittsburgh; Department of
Psychiatry, University of Rochester Medical Center, Rochester, N.Y.; and the Monash University
Centre for Developmental Psychiatry and Psychology, Victoria, Australia
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Abstract
Objective—Research on suicide prevention and interventions requires a standard method for
assessing both suicidal ideation and behavior to identify those at risk and to track treatment
response. The Columbia–Suicide Severity Rating Scale (C-SSRS) was designed to quantify the
severity of suicidal ideation and behavior. The authors examined the psychometric properties of
the scale.
Method—The C-SSRS’s validity relative to other measures of suicidal ideation and behavior and
the internal consistency of its intensity of ideation subscale were analyzed in three multisite
studies: a treatment study of adolescent suicide attempters (N=124); a medication efficacy trial
with depressed adolescents (N=312); and a study of adults presenting to an emergency department
for psychiatric reasons (N=237).
Results—The C-SSRS demonstrated good convergent and divergent validity with other multi-
informant suicidal ideation and behavior scales and had high sensitivity and specificity for suicidal
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Address correspondence to Dr. Posner (posnerk@nyspi.columbia.edu).

Dr. Posner receives royalty payments for the electronic self-rated versions of the Columbia–Suicide Severity Rating Scale (eC-SSRS)
from ERT, Inc., and is the director of the Center for Suicide Risk Assessment, which, as part of an effort to help execute the U.S. Food
and Drug Administration’s suicidality classification mandates, has received support from Abbott, Albany Molecular Research,
Alfresa, Alkermes, Amgen, AstraZeneca, Biodelivery Sciences International, Biomarin, Bristol-Myers Squibb, Canam, Cato
Research, Cephalon, Cetero Research, Covance, CRI Worldwide, Depomed, Douglas Pharmaceuticals, Eisai, Euthymics, Forest,
GlaxoSmithKline, GW Pharma, Human Genome Sciences, i3 Research, ICON, IntelGenx, Intracellular Therapies, Johnson &
Johnson, Kendle Early Stage, Lilly USA, Lundbeck A/S, Lundbeck USA, MedImmune, Medtronic, Merck, Neurosearch, Next Wave
Pharmaceuticals, Novartis, Noven, NovoNordisk, Orexigen, Otsuka, Parexel, Pfizer, PGx Health, Pharmaceutical Product
Development, Inc., Psyadon, QED, Quintiles, Reckitt Benckiser, Roche, Sanofi-Aventis, Schering-Plough, SCOPE International,
Sepracor/Sunovion, Shire, Siena Biotech, Supernus, Synosia Therapeutics, Takeda, Theravance, Upsher-Smith, Valeant, Vivus, World
Wide Clinical Trials, and Wyeth Research. Dr. Brown receives royalty payments for eC-SSRS from ERT, Inc. Dr. Stanley receives
royalty payments for eC-SSRS from ERT, Inc. Dr. Brent receives research support from NIMH, royalties from Guilford Press, and
honoraria for serving on the editorial board of UpToDate and for CME presentations. Dr. Oquendo has received unrestricted
educational grants or lecture fees from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen, Otsuko, Pfizer, Sanofi-Aventis, and
Shire, owns equity in Bristol-Myers Squibb, and receives royalty payments for eC-SSRS from ERT, Inc. Dr. Greenhill has received
research support from Rhodes Pharmaceutical, National Institute on Drug Abuse, and Johnson & Johnson and study medication and
placebo from Shire Pharmaceuticals for an investigator-initiated imaging study. Dr. Mann has received research support from Glaxo-
SmithKline and Novartis and receives royalty payments for eC-SSRS from ERT, Inc. The other authors report no financial
relationships with commercial interests.
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behavior classifications compared with another behavior scale and an independent suicide
evaluation board. Both the ideation and behavior subscales were sensitive to change over time.
The intensity of ideation subscale demonstrated moderate to strong internal consistency. In the
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adolescent suicide attempters study, worst-point lifetime suicidal ideation on the C-SSRS
predicted suicide attempts during the study, whereas the Scale for Suicide Ideation did not.
Participants with the two highest levels of ideation severity (intent or intent with plan) at baseline
had higher odds for attempting suicide during the study.
Conclusions—These findings suggest that the C-SSRS is suitable for assessment of suicidal
ideation and behavior in clinical and research settings.

Suicide prevention strategies outlined by the Centers for Disease Control and Prevention
(CDC), the U.S. Department of Health and Human Services, and the National Institutes of
Health depend on establishing the frequency and severity of suicidal behavior and
identifying risk and protective factors (1, 2). Data collection to support these aims must
employ valid and reliable assessment tools that allow comparison at local, national, and
international levels.

A lack of uniformity in assessment stems in part from the variability of terms referring to
similar or even identical behavior. Without a common language for reporting and
communicating occurrences of suicidal behavior and ideation, prevention research is
undermined in several key areas, including the establishment of reliable incidence and
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prevalence rates; comparison of data across studies, time periods, and locations;
development of adequate tools for identifying and screening patients in primary and other
care settings; measurement of risk and benefit in drug trials and postmarketing surveys; and
training of health care workers, gatekeepers, and first responders in suicide risk detection
(3). Furthermore, the exclusion of individuals with suicidal ideation and behavior from
clinical trials has resulted in a dearth of evidence for interventions for these populations, and
the methods for determining which patients will be excluded have been variable, making it
even more difficult to conduct analyses of these populations on suicide-related questions (4,
5).

Studies of risk factors predicting suicide consistently suggest that suicidal ideation and a
history of suicide attempts are among the most salient risk factors for suicide (6–9).
Moreover, a structured assessment of suicidal ideation and behavior significantly improves
identification of high-risk patients relative to a routine clinical interview (10). However, to
date, the field has lacked a single standard measure that assesses both suicidal ideation and
behavior (10).

To address inconsistencies in nomenclature, the impact of such inconsistencies on accurate

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identification, and the need for a single measure to assess the severity of and track changes
in suicidal ideation and behavior, a team of investigators from Columbia University, the
University of Pennsylvania, and the University of Pittsburgh developed the Columbia–
Suicide Severity Rating Scale (C-SSRS).

Suicidal ideation and behavior have traditionally been conceived as a unidimensional

construct, with passive ideation, active intent, and behavior existing along a continuum (11,
12). The C-SSRS, however, was designed to distinguish the domains of suicidal ideation and
suicidal behavior. Four constructs are measured. The first is the severity of ideation
(hereafter referred to as the “severity subscale”), which is rated on a 5-point ordinal scale in
which 1=wish to be dead, 2=nonspecific active suicidal thoughts, 3=suicidal thoughts with
methods, 4=suicidal intent, and 5=suicidal intent with plan. The second is the intensity of
ideation subscale (hereafter referred to as the “intensity subscale”), which comprises 5
items, each rated on a 5-point ordinal scale: frequency, duration, controllability, deterrents,

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and reason for ideation. The third is the behavior subscale, which is rated on a nominal scale
that includes actual, aborted, and interrupted attempts; preparatory behavior; and nonsuicidal
self-injurious behavior. And the fourth is the lethality subscale, which assesses actual
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attempts; actual lethality is rated on a 6-point ordinal scale, and if actual lethality is zero,
potential lethality of attempts is rated on a 3-point ordinal scale.

The items for assessing severity of ideation (e.g., a specific plan or method) and intensity
(e.g., frequency, duration) of ideation were based on factors predicting attempts and suicide
identified in previous studies (13–20). The C-SSRS uses different assessment periods,
depending on research or clinical need; the lifetime period assesses the worst-point ideation,
which research has suggested may be a stronger predictor of subsequent suicide than current
ideation (7, 21).

Item selection for the scale was influenced by research on what aspects of past suicidal
ideation and behavior predict the risk of future suicidal behavior, including severity of
worst-point ideation and intent and medical damage or lethality of past suicide attempts (7).
Items assessing suicidal behavior were expanded to encompass not only actual attempts but
also interrupted attempts, because these are predictive of suicide (22), and aborted attempts,
because they are associated with actual attempt behavior (23). Preparatory activity was
included in the assessments because analyses suggest that individuals who engage in
preparatory behavior are more likely to commit suicide than those who do not report such
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behavior (7, 23, 24). Neurobiological research suggests that the degree of suicide intent and
the degree of medical lethality are related to serotonin indices in the brain (25), which
prompted the inclusion of items on the scale related to preparation for suicide attempt and to
scoring the severity of medical damage. The more medically damaging or potentially lethal
but nonfatal suicide attempts show serotonin abnormalities analogous to those found in
postmortem examination of brain tissue from people who died by suicide (26).

The C-SSRS was designed to 1) provide definitions of suicidal ideation and behavior and
nonsuicidal self-injurious behavior and corresponding probes; 2) quantify the full spectrum
of suicidal ideation and suicidal behavior and gauge their severity over specified periods; 3)
distinguish suicidal behavior and nonsuicidal self-injurious behavior; and 4) employ a user-
friendly format that allows integration of information from multiple sources (e.g., direct
patient interview, family and other interviews, and medical records). As reviewed by Meyer
et al. (27), these criteria are considered essential for judging the utility of scales assessing
suicide-related phenomena, and the scale is unique among rating instruments in meeting all
of these criteria.

The C-SSRS (available at www.cssrs.columbia.edu) includes definitions of suicidal

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behavior adapted from the Columbia Suicide History Form (28). The definitions of ideation
and behavior were also used in the Columbia Classification Algorithm for Suicide
Assessment, commissioned by the U.S. Food and Drug Administration to classify
retrospective reports of potentially suicidal adverse events and to provide interpretable data
to inform pivotal drug safety questions (29). These definitions were subsequently adopted by
the CDC (2).

In this study, we evaluated the C-SSRS’s convergent, divergent, and predictive validity, its
sensitivity and specificity, and its sensitivity to change, as well as the internal consistency of
the intensity subscale, based on use of the scale in three multisite studies. Other indices of
reliability could not be examined because of the study design, although interrater reliability
has been demonstrated elsewhere (30–32).

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Method
The studies used in the analyses are described below. More detailed descriptions of the
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studies and the relevant scales are included in a data supplement that accompanies the online
edition of this article. Convergent validity, divergent validity, sensitivity, specificity,
sensitivity to change, predictive and incremental validity, and internal consistency, as
defined in Table 1, were analyzed as shown in Table 2. Rates of suicidal ideation at study
entry and lifetime actual suicide attempts for the three studies are presented in Figure 1.

Studies Used in the Analyses

Study 1—The Treatment of Adolescent Suicide Attempters study was a National Institute
of Mental Health multisite feasibility study designed to develop and evaluate treatments to
prevent suicide reattempts in adolescents. Participants were 124 male and female patients
12–18 years of age with a suicide attempt or interrupted attempt during the 90 days before
enrollment (34–36). Participants were evaluated at baseline and at treatment weeks 6, 12, 18,
and 24, as well as during intervening unscheduled visits. Evaluations included the C-SSRS,
the Columbia Suicide History Form, the Scale for Suicide Ideation, and Beck’s Lethality
Scale. All instruments were administered by independent evaluators, who were Ph.D.-,
R.N.-, or master’s-level clinicians. Assessment of participants also included the self-report
Beck Depression Inventory (BDI) at the same visits, as well as ratings by the treating
psychopharmacologist (who was not the independent evaluator) on the Montgomery-Åsberg
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Depression Rating Scale (MADRS). Any potential suicidal events in the study were rated by
the suicide evaluation board, which was an independent panel of suicidology experts
uninvolved in the day-to-day management of the trial. The board, which was blind to
original event classifications, treatment status, and other potentially biasing information,
rated narratives according to predetermined criteria and definitions of potential suicidal
events. Unanimous consensus was reached in cases where there was any initial
disagreement.

Most participants (N=96, 77.4%) were assessed at week 12; 87 (70.2%) were evaluated at
week 18, and 83 (66.9%) at week 24. Attrition between the study visits was due to
participants refusing to continue study treatment or assessments. Participants who refused
treatment but continued with assessments were included in the analyses. There was one
death by suicide in the study during the follow-up period. As previously reported (36),
participants who remained in the study for longer than the median duration were similar to
those who were followed for less than the median duration on all baseline predictors of
suicidal events except income.

Study 2—Study 2 was an industry-sponsored multisite, double-blind, placebo-controlled,

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parallel-group, fixed-dose clinical trial to evaluate the efficacy of the selective serotonin
reuptake inhibitor escitalopram relative to placebo in the treatment of major depressive
disorder (37). Participants were 312 adolescents 11–17 years of age with a diagnosis of
major depressive disorder. The study excluded patients who were considered a “suicide risk”
by the investigators, including those who had suicidal ideation or had made a suicide
attempt, although approximately 5.5% reported some level of ideation at study entry (Figure
1).

The self-report Suicidal Ideation Questionnaire–Junior (the version for grades 7–9) (38) and
the C-SSRS were administered by the study clinicians at initial screening, at baseline, and at
weeks 4, 8, 16, and 24 (or on early termination). Patients who completed at least one
postbaseline assessment were included in the present analysis (N=259). The characteristics
of the validation sample were similar to the baseline characteristics of the total sample (37).

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Study 3—Study 3, funded by the American Foundation for Suicide Prevention, evaluated
the identification and classification of recent suicide attempts and nonsuicidal self-injurious
behavior by emergency department providers at three sites. Participants (N=237) were at
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least 18 years of age and presented to an emergency department for psychiatric reasons.
They were categorized as having made a suicide attempt prior to the emergency evaluation,
having engaged in nonsuicidal self-injurious behavior in the week prior to the evaluation, or
reporting psychiatric symptoms without a suicide attempt or nonsuicidal self-injurious
behavior prior to the evaluation. Study clinicians administered measures in the emergency
department, including the C-SSRS, the Scale for Suicide Ideation, Beck’s Lethality Scale,
and the Columbia Suicide History Form.

Data Analyses
Analyses of data from studies 1 and 2 were conducted with SAS, version 9.1 (SAS Institute,
Cary, N.C.). Analyses of data from study 3 were conducted with SPSS, version 19 (SPSS,
Chicago).

Convergent and divergent validity—In study 1, to examine the convergent and

divergent validity of the ideation and behavior components of the C-SSRS, associations
between the scale and other instruments measuring corresponding constructs were initially
tested using Pearson’s r. Effect sizes were computed (Cohen’s d=2r/sqrt[1−r2]) in order to
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compare the magnitude of the correlations. A mixed-effects regression model was used to
adjust for the effect of repeated assessments over the course of the study. The C-SSRS
ideation scores were entered as dependent variables and the scores from corresponding
scales as independent variables. Unstructured covariance structure was specified.

The choice of random effects was based on the following assumption: each participant has
his or her own systematic baseline on the measures, and each starting point is treated as the
result of a random deviation from some mean intercept. This model captures both the
repeated-measures effect and random-intercept effect in individuals when the correlation
between measures is assessed. Intercept and time (days in treatment) were included as
random-effect variables. A Steiger’s z test for comparison of correlated correlations
evaluated whether the severity and intensity subscales were more related to the suicidal
ideation item than items measuring somatic features of depression on the MADRS and the
BDI.

In study 2, the analysis was parallel to that in study 1 except that the self-report Suicidal
Ideation Questionnaire–Junior total score was used as the criterion measure for the
convergent validity of the intensity subscale. The convergent and divergent validity of the
C-SSRS behavior subscale and the lethality subscales were not examined in study 2 because
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no other behavior measure was available for comparison.

In study 3, the convergent validity of the severity subscale, intensity subscale, and behavior
subscale was evaluated with the phi coefficient.

Sensitivity/specificity and sensitivity to change—Analysis of specificity in studies

1 and 3 examined the rate of true negatives on the C-SSRS behavior subscale relative to
behavior ratings on the Columbia Suicide History Form and, in study 1, also to the suicide
evaluation board ratings. The rate of true positives relative to the ratings on the Columbia
Suicide History Form and the suicide evaluation board ratings was used to show the
sensitivity of the behavior subscale.

In studies 1 and 2, mixed-effects linear regression was used to test sensitivity to change of
the severity and behavior subscales over the study period as measured by criterion scales.

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The C-SSRS scores were entered as dependent variables, and the scores from the Scale for
Suicide Ideation (study 1) or the Suicidal Ideation Questionnaire–Junior (study 2) were
entered as independent variables. Unstructured covariance structure was specified, and
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intercept and time (days in treatment) were included as random-effect variables.

Predictive and incremental validity—In study 1, the predictive validity of the worst-
point lifetime ideation on the severity sub-scale for 1) actual attempts and 2) actual,
interrupted, and aborted attempts combined as reported on the Columbia Suicide History
Form between weeks 1 and 24 was examined using logistic regression. Similarly, the
predictive validity of the severity subscale was tested for the actual attempts classified by
the evaluation board. The C-SSRS severity scores were entered as a continuous variable, and
suicidal behavior, including multiple attempts, as a dichotomous variable. The average
length of time between the baseline administration of the C-SSRS and the week 24
Columbia Suicide History Form ratings was 134.63 days (SD=65.48), as some subjects had
their week 24 visit beyond 168 days. This variability was addressed in the model by
including time as a covariate.

Incremental validity was evaluated by comparing the predictive validity of the lifetime
worst-point ideation (including past week) on the C-SSRS severity subscale to the predictive
validity of 1) the total score and 2) the suicidal intent items on the Scale for Suicide Ideation
for the same time period. Because intent to die appears to confer heightened risk for suicide
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(14, 15, 39), it was hypothesized a priori that presence of ideation with at least some intent
(the two most severe levels of ideation on the C-SSRS) would confer greater risk than
presence of ideation without intent. Logistic regression was used to test whether a history of
ideation with at least some intent in contrast to levels of ideation on the C-SSRS without
intent resulted in a greater risk of suicide attempts or combined ratings of aborted,
interrupted, and actual attempts classified on the Columbia Suicide History Form and actual
attempts classified by the evaluation board.

Internal consistency—The internal consistency of the C-SSRS ideation subscale in all

three studies was tested with Cronbach’s alpha. The severity and behavior subscales use an
ordinal scale and are therefore not subject to internal consistency analysis. Other types of
reliability (e.g., interrater) could not be examined because of the design of the studies.

Results
Convergent Validity
At baseline, the C-SSRS severity subscale and the Scale for Suicide Ideation assessment of
worst-point ideation both capture the most suicidal period during the patient’s lifetime; at all
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subsequent assessments, the since-last-visit and worst-point assessments both measure the
most severe suicidal ideation since the last assessment.

The C-SSRS severity subscale was moderately correlated with the worst-point score on the
Scale for Suicide Ideation (r=0.52, p<0.001; effect size=1.22, N=472). The C-SSRS
intensity subscale containing the frequency, duration, controllability, certainty, and
deterrents items for the most severe ideation was moderately correlated with the worst-point
ideation total score on the Scale for Suicide Ideation (r=0.56, p<0.001; effect size=1.36,
N=487). For the since-last-visit assessments, there was a strong relationship between the C-
SSRS severity subscale and the MADRS suicidal ideation item (r=0.63, p<0.001; effect
size=1.61) as well as the BDI suicide item, which asks subjects to rate on a 4-point scale
their thoughts of killing themselves (r=0.80, p<0.001; effect size=2.66) (Table 3). For the
since-last-visit assessments, there was also a strong relationship between the C-SSRS

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intensity subscale and the MADRS suicidal ideation item (r=0.69, p<0.001; effect
size=1.93) as well as the BDI suicide item (r=0.51, p<0.001; effect size=1.19).
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In study 2, the convergent validity of the C-SSRS with the self-report Suicidal Ideation
Questionnaire–Junior total score over the course of the study was moderate for the C-SSRS
severity subscale (r=0.36, p<0.01; effect size=0.77) and low for the C-SSRS intensity
subscale (r=0.23, p<0.001, effect size=0.47) based on pair correlations at multiple time
points across the study (total number of pairs=234).

In study 3, the correlation between the C-SSRS severity subscale and the Scale for Suicide
Ideation total score was moderate (r=0.69, p<0.001, N=211). The C-SSRS intensity subscale
total score correlated modestly with the Scale for Suicide Ideation total score (r=0.34,
p<0.001; N=193).

In study 1, the C-SSRS’s sensitivity and specificity of behavior classifications relative to the
behavior classifications on the Columbia Suicide History Form and those by the evaluation
board were examined. A total of 15 study subjects had at least one actual, interrupted, or
aborted attempt. The total number of these three behaviors in the study based on all visits
was 24, including unscheduled (emergency) visits. Relative to the Columbia Suicide History
Form, the C-SSRS had 99.4% specificity and 100% sensitivity in correctly identifying
aborted attempts and 100% sensitivity and specificity for both interrupted and actual
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attempts (Figure 2). Two aborted attempts were identified by the behavior subscale that
were not identified using the Columbia Suicide History Form. The C-SSRS demonstrated
100% sensitivity and 96% specificity relative to the evaluation board ratings using the
combined classifications of actual and interrupted attempts. Five cases of behavior were
identified on the behavior subscale but not by the evaluation board. Because the board did
not classify aborted attempts (of which two were identified by the C-SSRS), the total
number of attempts analyzed here is 22, not 24.

In study 2, the convergent validity of behavior classifications was not examined because no
parallel measure of suicidal behavior was available.

In study 3, the degree of association regarding the identification of lifetime (including past
week) actual, interrupted, and aborted attempts using the C-SSRS and the Columbia Suicide
History Form was high (phi values, 0.99, 0.92, and 0.94, respectively; all p values <0.001;
N=237). The C-SSRS had 100% specificity and 100% sensitivity in correctly identifying
lifetime actual attempts and 99% specificity and 94% sensitivity in correctly identifying
lifetime interrupted attempts that were recorded on the Columbia Suicide History Form.
Two lifetime interrupted attempts were identified on the Columbia Suicide History Form
that were not identified using the C-SSRS. The scale had 99% specificity and 93%
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sensitivity in correctly identifying lifetime aborted attempts that were recorded on the
Columbia Suicide History Form. Four lifetime aborted attempts were identified on the
Columbia Suicide History Form that were not identified using the C-SSRS.

The actual lethality subscale was robustly correlated with the Beck’s Lethality Scale score
from the Columbia Suicide History Form (r=0.79, p<0.001; N=237). The lethality subscale
is rated on a 6-point scale (running from 0 to 5) using general anchors for lethality, whereas
the Columbia Suicide History Form lethality subscale is rated on a 10-point scale (running
from 0 to 9) using anchors that correspond to the method of injury.

Divergent Validity
In study 1, the divergent validity of the C-SSRS severity subscale was examined by
correlating raw scores on the fatigue, sleep, appetite, and loss of energy items on the self-

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report BDI and similar items on the MADRS, administered by the psychopharmacologist,
with the C-SSRS’s most severe ideation since last visit, administered by a different clinician.
Effect sizes using Cohen’s d were computed to evaluate the strength of the significant
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correlations. As in the analyses of convergent validity, mixed-effects regression was used to

adjust for the effect of multiple assessments over time (Table 3).

For the since-last-visit assessments, weak or moderate correlations were observed between
the C-SSRS severity and intensity subscales and the BDI and MADRS somatic depression
items. A much stronger association with the BDI and MADRS suicidal ideation items, in
contrast to the weak relationship with nonsuicidal items demonstrated by the Steiger’s z test
for comparison of correlated correlations, further supports the divergent validity of the C-
SSRS (Table 3). When adjusted for the effect of multiple assessments, the findings were
similar—for example, a one-unit increase in the severity subscale score for the since-last-
visit assessments correlated (on average) with 0.278 units on the BDI sleep disturbance item
(Table 3).

The relationship of the C-SSRS intensity subscale total score to somatic symptoms of
depression on the BDI and MADRS was also examined. As seen in Table 3, correlations
between the intensity subscale and the BDI and MADRS items were generally small to
moderate, in contrast to larger correlations with the C-SSRS severity sub-scale. Effect sizes
for these associations varied from small to large. When adjusted for the effect of repeated
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assessments, a one-unit change on the BDI and MADRS scores expressed in standard
deviation units corresponded to measurable changes in the intensity subscale, indicated by
the beta coefficients.

The divergent validity of the C-SSRS severity and intensity subscales in studies 2 and 3 was
not examined.

Sensitivity to Change
In study 1, results from the random-effects mixed linear regression that tested sensitivity to
change of the C-SSRS on the criterion scales over the study period showed that the scale’s
ideation and behavior ratings were related to other measures over time. In the linear
regression, a one-unit decrease in the “total current” ideation score on the Scale for Suicide
Ideation corresponded to a decrease of 0.106 units in the C-SSRS severity subscale score
(p<0.001). Similarly, change in the Scale for Suicide Ideation worst-point ideation
corresponded to a significant change on the C-SSRS intensity subscale for since-last-visit
assessments (beta=0.071, p<0.001). Figure 3 demonstrates that the mean severity subscale
scores and the mean intensity subscale scores responded similarly to the change on the Scale
for Suicide Ideation. All unscheduled/emergency visits (N=39) occurring between baseline
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and week 24 were excluded from these analyses.

To assess the behavior subscale’s sensitivity to change, three types of suicidal behaviors
(aborted, interrupted, and actual attempts) identified by the independent evaluators were
plotted against those identified by the Columbia Suicide History Form at weeks 6, 12, 18,
and 24 (Figure 2) and against interrupted, actual, and one completed attempt combined, as
classified by the evaluation board. There was full agreement for interrupted and actual
attempts and moderate agreement for aborted attempts relative to the Columbia Suicide
History Form classifications (kappa=0.66, 95% confidence interval [CI]=0.23–1.00) and
high agreement (kappa=0.88, 95% CI=0.77–0.98) with the attempt and interrupted attempt
classifications made by the evaluation board (Figure 4). Only cases in which both the C-
SSRS and Columbia Suicide History Form ratings (N=364) from the same assessments were
available were included in the analysis. All unscheduled/emergency visits occurring between
baseline and week 24 were excluded from the analysis. All potential events on the C-SSRS

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were later classified by the evaluation board and included in the analyses. One suicide rated
by the board after the study was completed was not rated on the scale.
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In study 2, linear regression showed that a one-unit decrease in total score on the Suicidal
Ideation Questionnaire–Junior corresponded to an average decrease of 0.31 units in the C-
SSRS severity subscale score (p=0.01) and to a decrease of 0.17 units in the intensity of
ideation scores (p<0.001).

Predictive and Incremental Validity

The predictive validity of the C-SSRS was evaluated using the Columbia Suicide History
Form and the suicide evaluation board classifications; the severity subscale was examined
continuously and categorically (with or without intent). The results were comparable with
either approach.

In study 1, baseline C-SSRS ratings (based on worst-point lifetime suicidal ideation and
conducted before patients received any treatment) significantly predicted suicide attempts
during treatment (odds ratio=1.45, 95% CI=1.07–1.98, p=0.02) as well as actual,
interrupted, and aborted attempts combined on the Columbia Suicide History Form between
week 1 and week 24 (odds ratio=1.34, 95% CI=1.05–1.70, p=0.02) and classifications made
by the suicide evaluation board. In the parallel analyses predicting the behavior
classifications made by the suicide evaluation board from the baseline severity of ideation
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ratings, for a one-standard-deviation increase in the lifetime (including past week) severity
of ideation on the C-SSRS, the odds of actual attempts increased by 43% (odds ratio=1.43,
95% CI=0.99–2.05, p=0.05). Analyses included all 124 participants who were assessed at
baseline, using intent-to-treat model.

For every one-standard-deviation increase in the level of lifetime suicidal ideation reported
at study entry, the odds of attempting suicide during the study increased by 45%. The odds
of actual, interrupted, or aborted suicide attempts combined as assessed by the Columbia
Suicide History Form increased by 34% for every one-standard-deviation increase in
lifetime severity of ideation score. Predictive validity was also evaluated using a lifetime
history of the most severe ideation with and without intent on the C-SSRS severity subscale.
The odds of suicide attempts scored on the Columbia Suicide History Form during follow-
up were compared in participants who endorsed a lifetime history of the two most severe
levels of ideation (where at least some intent to die was present) reported at baseline and
those who endorsed a history of less severe ideation (types 0–3) (odds ratio=3.26, 95%
CI=1.02–10.45, p=0.047). The lifetime history of the two highest severity levels of ideation
reported on the C-SSRS at baseline were also associated with higher odds of actual,
interrupted, and aborted attempts combined on the Columbia Suicide History Form (odds
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ratio=2.76, 95% CI=1.07–7.12, p=0.036). In the parallel analyses, predicting from the
dichotomously scored lifetime severity of ideation to the behavior classifications by the
evaluation board, the odds of actual attempts were almost four times higher for those with a
lifetime history (including past week) of the two most severe levels of ideation at baseline
(odds ratio=3.85, 95% CI=1.07–13.86, p=0.039).

We conducted similar analyses of predictive validity with the total score (lifetime) and with
the intent items of the Scale for Suicide Ideation. No significant results were observed for
any of the outcomes. A one-standard-deviation increase in the total score (lifetime) was not
associated with an increase in odds of suicide attempts on the Columbia Suicide History
Form (odds ratio=1.02, 95% CI=0.95–1.11, p=0.57) or in odds of actual, interrupted, and
aborted attempts combined on the Columbia Suicide History Form at follow-up (odds
ratio=1.01, 95% CI=0.95–1.07, p=0.79).

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In the categorical analysis based on the intent items (a score ≥1 on item 4 or 5) from the
Scale for Suicide Ideation, the odds of attempts during the study were not higher for actual
attempts (odds ratio=1.44, p=0.76; all of the attempters endorsed intent) or for the combined
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ratings of actual, interrupted, and aborted attempts (odds ratio=2.19, p=0.49; all of the
attempters endorsed intent).

Because baseline Scale for Suicide Ideation scores (either total score or score on the intent
items) were not significantly associated with attempts during the study, the incremental
predictive validity of the C-SSRS severity sub-scale relative to the Scale for Suicide Ideation
could not be estimated.

Internal Consistency
In study 1, the C-SSRS intensity subscale was examined at two assessment intervals: since
last visit and past week. The internal consistency of the intensity subscale was high, with a
Cronbach’s alpha of 0.937 for since last visit and 0.946 for the past week. In studies 2 and 3,
the internal consistency of the intensity subscale across all visits was moderate, with a
Cronbach’s alpha of 0.73.

Discussion
We examined the psychometric properties of the C-SSRS and demonstrated convergent,
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divergent, and predictive validity; sensitivity to change; sensitivity and specificity of the
instrument; and internal consistency of the intensity subscale. The study design precluded
examination of other indices of reliability, although interrater reliability has already been
demonstrated (31, 32, 36). In all three studies analyzed, the C-SSRS ideation and behavior
sub-scales showed strong convergent validity with established ideation and behavior scales.
The finding of only a moderate convergent relationship between the C-SSRS severity and
intensity of ideation scores and the Scale for Suicide Ideation total score, as well as the
Suicidal Ideation Questionnaire–Junior score, was expected and was likely due to
nonoverlap in items and different construct operationalization. The C-SSRS demonstrated
strong divergent validity with items on the BDI and the MADRS that were not expected to
overlap with suicidal ideation and behavior (e.g., somatic depression symptoms such as
fatigue). Because suicide risk and protective factors are not orthogonal to psychiatric
diagnosis (40), establishing divergent validity with measures of other constructs is essential.
In suicidal adolescents, ideation was most closely related to suicide-related items in other
measures, in contrast to other types of symptoms of psychiatric disorders or physical
illnesses.

Several other findings have important implications. In study 1, a decrease in the severity of
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ideation from “active suicidal thoughts” to “wish to die” or “no ideation” was accompanied
by corresponding decreases in Scale for Suicide Ideation score, suggesting that the C-SSRS
severity subscale is sensitive to clinical change. Similarly, the C-SSRS identified almost an
identical number of cases with specific types of suicidal behavior compared to the Columbia
Suicide History Form and the suicide evaluation board ratings, and this agreement held over
the course of the study. There was a high degree of agreement in the classification of
suicidal behavior between the Columbia Suicide History Form, the evaluation board ratings,
and the C-SSRS. The behavior subscale demonstrated high sensitivity and specificity
relative to behavior classifications on the Columbia Suicide History Form and by the
evaluation board.

A striking finding in this study was that the C-SSRS demonstrated predictive validity but the
Scale for Suicide Ideation did not. The Scale for Suicide Ideation has shown predictive
validity for death by suicide with adults in other long-term follow-up studies (41, 42), but it

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did not predict near-term nonfatal suicidal behavior in this study. As with any cross-study
comparison, differences in predictive validity may result from differences in clinical
populations, assessment context, and time. Another plausible explanation for this divergent
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finding is scoring differences between the two scales. The Scale for Suicide Ideation total
score aggregates many characteristics of suicidal ideation along a continuum, whereas the C-
SSRS identifies types of ideation and classifies individuals as having intent, as well as
having intent and a plan. Factor structure analyses of the Scale for Suicide Ideation have
shown that certain clusters of items assessing “plans” and “desire” show differential
prediction of past attempts and eventual suicide (21, 43). The present study raises the
question of whether identifying specific types of suicidal ideation may be more useful for
prospective research and for risk stratification. Further prospective studies of suicide risk
using standardized measures are warranted.

Of particular interest are the results from study 1 suggesting that a history of severe ideation
with at least some intent to die may confer a greater risk for suicidal behavior than a history
of ideation with no intent to die. Establishing clinically meaningful thresholds that indicate
heightened suicide risk and predict which individuals will go on to engage in suicidal
behavior have been elusive in efforts at suicide prevention (3). Because ideation severity can
be used to set criteria for clinical referral and inclusion or exclusion criteria in research,
operationalization of clinical thresholds could facilitate enrollment of patients with suicidal
behavior in research studies, as well as clinical management more broadly.
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As with any instrument, one must be mindful of the population one is working with.
Depending on the population, 25% to 60% of attempts are considered “impulsive” (44–46),
but the role of impulsivity in suicide is far from clear (41, 42), and “impulsive” attempts
may include prior ideation and planning (41). The results should be replicated in studies
designed to test psychometric properties of the scale, and the application of the scale in
different populations deserves further study, particularly in light of the different potential
routes to suicidal behavior (e.g., which severity items predict which behaviors, and what
other factors, such as substance abuse or family history, modify the risk associated with the
severity or intensity of ideation).

Limitations
There are several significant limitations to this analysis. The studies on which our analyses
are based were not prospectively designed to examine psychometric properties of the
instruments, although the replication of findings across three different studies is reassuring.
The significant associations between the C-SSRS and the Scale for Suicide Ideation and the
Columbia Suicide History Form may be attributed in part to the fact that the same
interviewers contemporaneously administered the scales; while this may be an advantage in
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demonstrating convergent validity, it also increases the risk of interviewer or rater bias. To
address this issue, self-report measures (the BDI and the Suicidal Ideation Questionnaire–
Junior), ratings (on the MADRS) by a study psychopharmacologist who was not
administering the C-SSRS, and ratings by the independent suicide evaluation board were
analyzed, and the results were similar. Nevertheless, further examination of concurrent and
incremental validity and interrater reliability of this scale with other measures of suicidal
ideation and behavior is warranted.

The incidence of aborted, interrupted, and actual attempts was very low in the two
prospective studies (studies 1 and 2), which limits the precision of the sensitivity and
specificity estimates. The generalizability of the predictive validity findings is limited in
study 1 because only adolescent attempters were included in the sample (thus, predictive
validity for that study refers to prediction of re-attempt). Although there are advantages to
using diverse populations in these analyses, there may be limitations to the generalizability

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of results. While study 1 included only adolescent attempters, study 2 excluded individuals
with current ideation or a history of suicide attempt, and study 3 was a clinical sample of
adults presenting to an emergency department for psychiatric treatment. These findings must
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be replicated with community samples.

Conclusions
These analyses of the C-SSRS using data from three studies provide initial promising data
on the convergent and divergent validity, predictive validity, sensitivity, specificity,
sensitivity to change, and internal consistency of the C-SSRS. Greater precision in the
assessment of suicidal behavior and ideation is necessary for improving identification and
clinical management, as well as for research-derived risk-benefit analyses. The use of a
standardized measure such as the C-SSRS that comprehensively assesses suicidal behavior
and ideation permits comparison of findings across research and clinical populations, as well
as trends over time, providing data to guide treatment recommendations for suicidal patients
and suicide prevention efforts.

Acknowledgments
The Treatment of Adolescent Suicide Attempters study (study 1 in the article) was funded by NIMH through
cooperative agreement grants MH66750 (Duke University Medical Center), MH66769 (Johns Hopkins University),
MH66762 (New York State Psychiatric Institute), MH66775 (University of Pittsburgh), and MH66778 (University
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of Texas Southwestern Medical Center). The adult emergency department study was funded in part by a grant from
the American Foundation for Suicide Prevention to Drs. Brown, Currier, and Stanley and by a National Institute on
Alcohol Abuse and Alcoholism “Developing Centers on Interventions for the Prevention of Suicide” grant (5 P20
AA015630) to Dr. Stanley. The data for the analysis of the escitalopram trial (study 2) were provided by Forest
Laboratories, which did not participate in the data analysis, interpretation of results, or review or contribute to this
article.

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FIGURE 1. Baseline Rates of Suicidal Ideation and Lifetime Actual Attempts in Three Studiesa
a Study 1 was a treatment study of adolescent suicide attempters (N=124); study 2 was a
medication efficacy trial in depressed adolescents (N=312); study 3 was a study of adults
presenting to an emergency department for psychiatric reasons (N=237). In study 1, ideation
data for “last week” were missing for 17 (13%) subjects. In study 2, ideation data at baseline
were missing for 97 (31%) subjects. b In study 1, among patients with lifetime actual
attempts, 46.8% had multiple actual attempts.
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FIGURE 2. Number of Cases in Study 1 Identified on the Columbia–Suicide Severity Rating

Scale (C-SSRS) Behavior Subscale and the Columbia Suicide History Form, by Type of
Behaviora
aTotal N included all those assessed with both the C-SSRS (past week and since last
assessment combined) and the Columbia Suicide History Form. kappa=0.66, 95% CI=0.23–
1.00.
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FIGURE 3.
Mean Values in Study 1 for the Severity and Intensity of Ideation Subscales of the
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Columbia–Suicide Severity Rating Scale (C-SSRS) and the Scale for Suicide Ideation (SSI)
Total Score, by Treatment Week

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FIGURE 4.
Proportion of Cases in Study 1 Identified on Columbia–Suicide Severity Rating Scale
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Behavior Item and by the Suicide Evaluation Board

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TABLE 1

Definitions of Measures Used in Psychometric Analyses of the Columbia–Suicide Severity Rating Scalea
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Measure Definition
Convergent validity The covariance between scores from assessment instruments that measure the same or similar constructs
Divergent validity The degree to which scores from an instrument are not related to scores on unrelated constructs
Predictive validity The extent to which a score on the instrument predicts an outcome
Incremental validity The degree to which data from a new instrument increase power, sensitivity, specificity, and predictive efficacy of
judgments beyond those from comparable instruments
Sensitivity The probability that a subject with an event will be so identified by the assessment instrument
Specificity The probability that a subject without an event will be so identified by the assessment instrument
Sensitivity to change The degree to which data from an instrument reflect small changes in the targeted construct
Internal consistency The magnitude of covariance between items of multi-item measures, reflecting their conceptual integrity

a
Definitions are based on Haynes et al. (33).
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TABLE 2
Validity Measures Used in Analyses of Items in the Columbia–Suicide Severity Rating Scale (C-SSRS) Using Data From Three Studies

Subscale and Studya Measure Rater Convergent Validity Divergent Validity Predictive Validity Incremental Validity Sensitivity to Change Internal Consistency Sensitivity and Specificity
Posner et al.

Severity of ideation subscale

Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation; items 4 and 5 for Independent evaluator ✓ ✓ ✓
predictive validity)

Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for convergent validity; items Study psychopharmacologist ✓ ✓
4, 5, 7, 11, and 12 for divergent validity)

Study 1 Beck Depression Inventory (item 9 for convergent validity; items 15, 16, 18, and 20 Self-report ✓ ✓
for divergent validity)

Study 2 Suicidal Ideation Questionnaire–Junior (total score) Self-report ✓ ✓

Study 1 Columbia Suicide History Form Independent evaluator ✓ ✓ ✓ ✓

Study 1 Suicide evaluation board Suicide evaluation board (consensus of ✓ ✓ ✓ ✓

three suicidology experts)

Intensity of ideation subscale

Studies 1, 3 Scale for Suicide Ideation (current total and worst-point ideation) Independent evaluator ✓ ✓

Study 1 Montgomery-Åsberg Depression Rating Scale (item 10 for convergent validity; items Study psychopharmacologist ✓ ✓
4, 5, 7, 11, and 12 for divergent validity)

Study 1 Beck Depression Inventory (item 9 for convergent validity; items 15, 16, 18, and 20 Self-report ✓ ✓
for divergent validity)

Study 2 Suicidal Ideation Questionnaire–Junior Self-report ✓ ✓

Studies 1, 2, 3 C-SSRS (intensity of ideation subscale, for most severe ideation) Clinician and independent evaluators ✓

Suicidal behavior subscale

Studies 1, 3 Columbia Suicide History Form Independent evaluator ✓ ✓ ✓

Suicidal behavior lethality

Study 3 Columbia Suicide History Form Independent evaluator ✓

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a
Study 1 was a treatment study of adolescent suicide attempters (N=124); study 2 was a medication efficacy trial in depressed adolescents (N=312); study 3 was a study of adults presenting to an emergency department for psychiatric reasons (N=237).
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TABLE 3
Convergent and Divergent Validity of the Columbia–Suicide Severity Rating Scale (C-SSRS) Severity and Intensity of Ideation Subscales Compared
With the Beck Depression Inventory (BDI) and the Montgomery-Åsberg Depression Rating Scale (MADRS), Based on Data From Study 1
Posner et al.

C-SSRS Subscale

Severity of Ideation: Most Severe Ideation Since Last Assessmenta Intensity of Ideation: Most Severe Ideation Since Last Assessment, Total Scoreb

Measure r dc beta z r dc beta z

BDI

Loss of energy 0.403† 0.881 0.605† 4.62† 0.309† 0.650 1.433** 3.891†
Sleep disturbance 0.267† 0.554 0.278** 6.54† 0.306† 0.643 1.548*** 3.65***
Appetite disturbance 0.215† 0.440 0.207* 7.31† 0.263† 0.545 1.304** 4.31†
Fatigue 0.342† 0.728 0.451† 5.66† 0.308† 0.647 1.277** 3.83†
Suicidal ideation 0.627† 1.610 1.278† 0.510† 1.186 3.605†

MADRS

Decreased sleep 0.177† 0.360 0.059† 19.63† 0.199† 0.406 0.126* 14.78†
Decreased hunger 0.044 0.088 0.072* 20.85† 0.090** 0.181 0.365*** 16.01†
Increased sleep 0.021 0.042 −0.008 20.78† 0.041 0.082 0.057 16.70†
Increased hunger 0.042 0.084 0.006 20.38† 0.054 0.108 0.08 16.47†
Lassitude 0.234† 0.481 0.120† 20.86† 0.323† 0.683 0.318 13.28†
Suicide item 0.799† 2.657 1.278† 0.694† 1.928 1.408†

a
BDI data were available for 341 pairs, and MADRS data for 970 pairs.

Am J Psychiatry. Author manuscript; available in PMC 2014 January 16.

b
BDI data were available for 346 pairs, and MADRS data for 971 pairs.
c
Cohen’s d; <0.3=small effect; 0.5=medium effect; >0.8=large effect.
*
p<0.05.
**
p<0.01.
***
p<0.001.
†
p<0.0001.
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