A 38-year-old man with a 10-year history of bipolar disorder presents to the emergency department after a suicide attempt by pesticide ingestion. He reports persistent suicidal ideation despite being on lithium monotherapy. Which investigation is most appropriate to assess his current suicide risk and guide immediate management?

## Investigation of Choice for Suicide Risk Assessment **Key Point:** The Columbia-Suicide Severity Rating Scale (C-SSRS) is the gold-standard structured instrument for assessing suicide risk in clinical and research settings. It evaluates both ideation and behavior dimensions, making it the most appropriate investigation for immediate suicide risk stratification. ### Why C-SSRS is Optimal The C-SSRS comprehensively measures: - Frequency, intensity, and duration of suicidal ideation - Deterrents to suicide - Reasons for living vs. dying - Suicidal behavior (attempts, preparatory acts, interrupted attempts) - Lethality and intent of past attempts **High-Yield:** The C-SSRS has superior psychometric properties (sensitivity ~90%, specificity ~80% for predicting future attempts) compared to unstructured clinical judgment alone, which misses risk in 30–40% of cases. ### Clinical Context in This Case This patient has multiple high-risk features: - Recent suicide attempt (highest predictor of future attempt) - Persistent suicidal ideation despite pharmacotherapy - Bipolar disorder (lifetime suicide risk ~15–20%) - Possible medication non-adherence or inadequate dosing A structured assessment (C-SSRS) will: 1. Quantify current ideation severity 2. Identify modifiable risk factors (e.g., intoxication, access to means) 3. Guide disposition (inpatient vs. intensive outpatient) 4. Establish baseline for monitoring response to intervention **Clinical Pearl:** C-SSRS is recommended by the FDA, WHO, and Indian Psychiatric Society guidelines as the first-line structured tool in acute suicide risk assessment. ### Why Other Investigations Are Secondary | Investigation | Role in This Case | |---|---| | Serum lithium level | Necessary but *adjunctive* — checks therapeutic level/toxicity; does not assess suicide risk directly | | Brain MRI | Not indicated for acute suicide risk assessment; may be useful if organic pathology suspected (not in this case) | | EEG | No role in suicide risk assessment; may be considered if seizure suspected post-ingestion | **Tip:** In exam questions, distinguish between investigations that *assess risk* (C-SSRS, structured interviews) and those that *manage complications* (lithium level, toxicology screen). The question asks for risk assessment, not management of poisoning.