A Simple Questionnaire Is a Gold-Standard Tool for Suicide Prevention. It’s Not Working.
Reading Time: 6 minutesA Key Tool for Suicide Prevention Isn’t Working. What Would It Take to Get Something Better?, The Columbia scale isn’t useless, but death by suicide is at an all-time high., Suicide Prevention: Experts say a gold-standard questionnaire isn’t working.
Eight years ago, the American Foundation for Suicide Prevention announced a goal to reduce suicide deaths by 20 percent by 2025. They will, it seems, not be successful: In the years since, suicide rates have increased by 13 percent. Initial counts suggest that some 50,000 people died by suicide in 2023 alone. Counting deaths in proportion to the population, this is a high not seen since the grim midpoint of World War II.
The reasons are multifold, complex, and not easy to pin down. Suicide has been on the rise since 1999, and substance abuse, loneliness, and financial instability have all also crept ever higher in those years. In the midst of an anguishing public health failure, some researchers are questioning the very way we determine who is at risk of suicide.
The Columbia-Suicide Severity Rating Scale is the gold standard. Since its introduction in 2008, it has been promoted by the Centers for Disease Control, National Institute of Mental Health, and Veterans Administration and widely adopted by doctors, therapists, schools, police, the military, and prisons.
The standard version consists of six questions: Have you wished you were dead? Have you thought about killing yourself? Have you considered how? Do you intend to act on these thoughts? Have you started to work out how? Have you done anything to prepare?
How a person answers these questions often determines the level of care they receive next. The Columbia scale can decide who is quickly released from an emergency room hold, who a therapist schedules for an urgent follow-up appointment, and who a primary care physician refers to a psychiatrist. In other words, the Columbia scale determines who is at imminent risk—and who is probably safe without urgent treatment.
This is hardly foolproof. One only need look at the trend in suicides to understand the need for a better system. But two studies became the first to test the Columbia scale using hospital and death records. Researchers at a Colorado hospital system tracked 92,643 people who were evaluated at its emergency rooms and screened with the Columbia scale. Of the 11 who later died by suicide, only two had been flagged as high-risk. For most patients, slipping through the Columbia scale seemed to halt mental health interventions.
A study from Sweden used the records of 18,684 psychiatric emergency patients. Patients who were flagged by the Columbia scale were almost four times more likely die by suicide within a month of the ER visit, and twice as likely within a year. But the researchers thought something more was needed. They concluded that the Columbia scale ‘may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide.’
Yes, the Columbia scale may have prevented some suicides in those populations from occurring at all. But the totality of evaluations of the Columbia scale show evidence that is ‘mixed,’ according to a meta-analysis, a study that systematically combines research from other studies.
The problem, argue some researchers, is that thinking about and preparing for a suicide—the only areas covered by the Columbia scale—are not the only signs someone will end their own life. The questions fail to touch on some other pretty clear predictors, like social isolation, stressful life events, and access to guns.
‘I think a lot of the research and science going on right now is trying to take a holistic approach to patients who come in reporting thoughts of self-injury or harm,’ said Bernard Chang, an emergency room doctor and researcher at, incidentally, Columbia University. The Columbia scale doesn’t zoom out much. It doesn’t even ask patients about their access to lethal means—for example, whether they have a gun in the house.
A couple of recent journal articles have put the failures of the Columbia scale and other tools to predict suicidal behavior bluntly. One said: ‘their accuracy of predicting a future event is near 0.’ ‘Suicide risk assessments: Why are we still relying on these a decade after the evidence showed they perform poorly?’ asked another, which suggested that the energy used to try to predict suicide ‘is better directed at … providing treatment for those who seek it.’
Some researchers have groaned that the mass adaptation of the Columbia scale, specifically, unfolded faster than research evaluating it. Some say it overstates the relationship between ideation and action. A portion of people who are thinking about ending their life will. ‘But it is very small percentage,’ said Russell Copelan, a retired emergency room psychiatrist and one of the loudest campaigners for an overhaul. ‘And there are attempters who do not have ideation.’
In countless studies, ideation raises the risk of suicide exponentially. But it is difficult to estimate how many people experience—or will admit to—intensely dark ruminations before they try to end their life.
One study of patients who attempted suicide after taking a different assessment of suicide risk found that a whopping one-fourth responded ‘not at all’ to a question asking if they were experiencing suicidal thoughts. Researchers at Kaiser Permanente talked to some of them and they ‘were either not experiencing suicidal ideation at the time of screening or feared the outcome of disclosure, including stigma, overreaction, and loss of autonomy.’
The Columbia scale may persist in part because of how it’s marketed. ‘It is glossy,’ said Copelan. It gives people who are desperately looking for a tool something simple that can help.
The biggest advocate for the Columbia scale is the lead scientist of the team that created it almost 20 years ago. Kelly Posner Gerstenhaber, a Columbia psychiatry professor, oversees the Columbia Lighthouse Project, which promotes its usage. She stars in a YouTube tutorial on applying the test, posting 11 subtitled foreign-language versions. In an interview I did with her, in response to a single question, she launched a 26-minute rundown of its benefits, peppered with anecdotes about better-functioning hospital systems and foreign governments that have approached with interest.
The Columbia scale stemmed from a request from the National Institute of Mental Health for a screening tool to be used for a single study. But independent of the NIMH, the researchers took the opportunity to create a uniform standard by which to evaluate suicide risk, said Gerstenhaber. There were a handful that were out there, which she didn’t think was ideal. She compared it to blood pressure tests: ‘If we had more than one blood pressure cuff, you wouldn’t know what your blood pressure means as well as you should.’
As for the focus on ideation and planning, Gerstenhaber said that research showed they were the most important factor, and the test’s success is its simplicity. The Columbia scale takes minutes. Overworked doctors without a psychiatric specialty can apply it in a hurried ER. Non–medical professionals can use it. It can be adapted across countries and cultures.
‘We knew that [thoughts and behaviors] were the first most important things you had to get centrally across every population,’ she said.
Gerstenhaber credits the Columbia scale with a lot: limiting legal liability, involving non–medical professionals in intervention, and ensuring that resources—both monetary and the staff’s attention—go to the patients who need them most.
For example, Oklahoma, which adopted the Columbia scale in a 2014 overhaul of suicide prevention, ‘saved millions of dollars reducing unnecessary hospital bed nights,’ which also allowed clinicians to focus on patients who were the most at risk, she said.
Gerstenhaber keeps an extensive list of 600-plus studies showing evidence to support the Columbia scale or showing its ubiquity or ease of use. Some test it in tandem with other methods, some are preliminary arguments for its introduction into hospital systems, and some used attempts and returns to the ER as stand-ins for suicide or suicidal ideation. She said that all that outweighs the recent drubbing in some academic journals. ‘When you look at the whole, that’s what you see,’ she said.
Gerstenhaber said that the Colorado study, which has been often cited by critics, is fundamentally flawed. The study simplified the status of the patients as either at risk or not at risk, when in reality there is a range, she said. Also, 11 patients who died is too few to draw clear conclusions from. (This is one of the challenges of studying suicide risk factors: Though the number of suicides is, overall, concerning, it is still a rare outcome.)
Some of the Columbia scale’s fiercest critics, including Copelan, have gone so far as to create wholesale alternatives. A group that includes a longtime University of South Florida professor—who authored a paper asking ‘Has the ‘Gold Standard’ Become a Liability?’—created an eight-question test that also queries about recent incidents of self-harm and, instead of the yes/no structure of the Columbia scale, asks patients to rate the severity of their suicidal thoughts.
Copelan does not try to emulate the simplicity of the Columbia scale on his assessments. The one for adolescents has 27 questions and the one for adults 29. Patients are asked about living conditions, isolation, and feelings of burdensomeness to others. Adults are asked about substance abuse, recent humiliations, and any history of violence. The assessment also asks clinicians look for nervous habits, like pacing or rocking back and forth. ‘It attempted to cover as much of this landscape as parsimoniously as possible,’ said Copelan.
He says when he has presented it to medical professionals, most are skeptical. As he sees it, there’s a simple reason the Columbia scale remains ubiquitous: ‘The problem is that the inertia is too great to do something differently.’
If you need to talk, or if you or someone you know is experiencing suicidal thoughts, call the suicide lifeline at 988 or text the Crisis Text Line at 741-741.
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