Crisis & Treatment

Right Services at the Right Time



In North Dakota the rate of suicide increased by 57.6% from 1999 to 2016, the largest increase of any state during that time period, and in Minnesota the rate also jumped 40.6%.

The Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS), supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs.

Targeting Adoption by Tier 1: First Responders.

  • FM Ambulance, FirstLink, Fargo police, Moorhead police, West Fargo police, Solutions/SE Human Services, Lakeland Mental Health mobile crisis, Clay County Sheriff’s office, Cass County Sheriff’s office, RRV Dispatch, Sanford and Essentia emergency departments.
  • Finalize work with EMS group to develop triage plan for services
  • Implement plan
  • Monitor progress and challenges


Adoption by Tier 2: Community Organizations Working Regularly With Vulnerable Persons.

  • Meet with and recruit community clinicians and school personnel
  • Work with group to develop triage plan for services
  • Bring together interested person’s from targeted sectors for training
  • Develop Implementation plan and monitoring progress and challenges tracking
  • Write policy or practice protocol and update as needed

Mobile crisis unit utilization and effectiveness.

    • Work with project team and mobile crisis providers to decrease barriers to meeting the under 20 minute’s response to crisis.
    • Work with mobile crisis providers to realign hours to operate during peak crisis volume times (data-driven).
    • Project team to develop strategies to decrease incidence of “streeted” patients at emergency departments.
    • Expand use of mobile crisis units to emergency departments or other key organizations.

Columbia Suicide Severity Rating Scale in the FM Community

As part of the ReThink Mental Health initiative, local organizations have come together to take a community-wide approach to more effectively respond to mental health crisis including suicidal thoughts and behaviors by training organizations to use a common tool, the Columbia-Suicide Severity Rating Scale (C-SSRS).


The C-SSRS is an evidence-supported screening tool which consists of questions to determine whether and when a person has thoughts about suicide and what actions they have taken or are likely to take. It is designed to be used by anyone anywhere to effectively identify who is most at risk.


Several community organizations have begun utilizing the C-SSRS as their screening tool. Those organizations include:

  • Fargo, Moorhead, WF PDs and high schools
  • Cass and Clay County Crisis Intervention Teams
  • FM Ambulance
  • Essentia Health System
  • Sanford Health System
  • Sanford Parish Nurses
  • Solutions Behavioral Health
  • Lakeland Mental Health
  • FirstLink
  • MSUM Hendrix Health
  • PATH of ND
  • Clay County Social Services, Family Home Visitor, and Maternal and Child Health nurses
  • Fargo Cass Public Health Maternal and Child Health nurses
  • Rape and Abuse Crisis Center
  • Shelters: New Life Center, YWCA, Gladys Ray, Dorothy Day, Churches United for the Homeless
  • Eastern ND and west central MN Catholic priests
  • West central MN Lutheran pastors
  • Cass and Clay County School Resource Officers

“The C-SSRS is a simple tool that will allow our officers another way to better serve our residents. It should result in a positive impact for those in need by having a standardized set of questions and a community unified using the same system,” 

Deric Swenson

Lietenant, Moorhead Police

Example from the Field

Nurse Family Partnership

The Columbia Suicide Severity Rating Scale (CSSRS) has proved to be a useful tool for Clay County Public Health home visiting nurses.  It provides a thoughtful plan of care for the client and gives the nurse confidence she has adequately assessed the client’s risk and taken the steps necessary to provide client safety.


I work in one of our two evidenced-based home visiting programs, the Nurse-Family Partnership (NFP).  NFP requires we assess clients for depression in the beginning of their pregnancy, at 36 weeks of pregnancy and again when their baby turns 1 year old.  Assessments are also repeated more frequently if the scores indicate depression or if the nurse feels there may have been a change in the client’s mood or thoughts.  We use the Patient Health Questionnaire-9 (PHQ-9) depression screening.  The last question on the form asks, “Over the last 2 weeks, how often have you been bothered by any of the following problems?  Thoughts that you would be better off dead or of hurting yourself in some way” and gives a variety of answers options.


One of my clients is a 23-year-old mother of an 18-month old toddler.  She often gives vague, rambling answers to questions making her status very difficult to discern.  On several occasions though, her depression scores were high and she answered ‘yes’ to the last question on the PHQ-9.  She told me she wouldn’t actually follow through with harming herself because of how it would negatively affect the baby but had thoughts of this almost every day.  We talked about where to seek immediate care if thoughts seemed to worsen, involved the father of her baby to enlist his help in watching for signs of increased suicidal ideation and I sent her mental health provider the PHQ-9 and what I assessed.  I frequently reminded the mother about the importance of taking her medications as directed and follow up appointments with her mental health provider.


I brought the CSSRS to her home once it became available.  She answered ‘yes’ to question number 1, that she wished she could just fall asleep and not wake up and ‘no’ to question number 2.  The CSSRS then directed her to answer question number 6, “has she ever done anything to prepare to end her life” to which she answered ‘yes’, she used cutting in middle school to relieve stress and pain.  Because she answered ‘no’ to the last part of the question, ‘if this was within the past 3 months?’, I felt comfortable faxing the PHQ-9 and CSSRS forms to her mental health provider and reviewed coping skills and mental health plans if thoughts became more severe.


Our home visiting nurses have not yet experienced a client who needed immediate notification of the physician and/or behavioral health but with the CSSRS, we’ll be able to identify that risk with more confidence.

Process Map



Expansion of Mobile Crisis Unit utilization and effectiveness. Implement Columbia Suicide Severity Rating Scale use community-wide with triage and referral plan that effectively addresses and mitigates suicide attempts.


Since FM Ambulance staff were trained on C-SSRS in late 2016, there has been about a 10% decline in transports for “Dispatch Code 25 – Psychiatric / Abnormal Behavior / Suicide Attempts” and cancellations are trending up.

Mental Health Intervention Spectrum

Image source: Substance Abuse and Mental Health Services Administration


Questions or want to get involved?

Mental Well-Being

“The People Project” is bringing simple tools to individuals and organizations so communities can flourish by promoting health through happiness                         


“Building Compassionate Schools” to recognize the impacts of trauma and create an environment where all children can flourish.

Crisis & Treatment

Boosting the community-wide use of a common suicide screening tool to identify those at risk and to connect them with timely and appropriate care.

Recovery Support

Host quarterly “Recovery Roundups” to share knowledge of resources and to promote partnerships and networks that support a life in recovery