As a 15-year veteran of emergency psychiatry, Amy Barnhorst, MD, vice chair for community mental health at the University of California (UC) Davis Department of Psychiatry, said she feels that most of the existing tools to help identify suicidality are inadequate. Her patients are often people with serious mental illness who end up in the emergency department or the county jail. Commonly used screening devices and checklists don’t capture the breadth and depth of their problems.

By way of example, she points to the omnipresent Columbia-Suicide Severity Rating Scale, saying that it “seems like it was designed with the assumption that all suicidal patients being evaluated are rational, and able to answer those questions clearly and honestly.” She added that the Columbia Protocol was probably created “by someone with high-functioning outpatient clientele. And it’s probably great for those patients, but those are not my patients.”

Recently Barnhorst heard about another new framework for identifying suicidality — this one developed by a team based out of Mount Sinai’s Suicide Prevention Research Lab in New York City. Her initial response was skepticism. She assumed it would be one more attempt to make suicide screening more effective and efficient that would miss the mark. But the more she read about Suicide Crisis Syndrome (SCS), a diagnosis identified by the Mount Sinai team, the more she became convinced that it was a breakthrough.

“SCS really gets at that final state that people are so often in,” said Barnhorst, who is also the associate director of the UC Davis Centers for Violence Prevention. “This is the framework we should really be using.”

The approach was developed over the course of 15 years of study — research that has included clinical investigation and data collection by questionnaires — led by Igor Galynker, MD, director of Mount Sinai’s Suicide Prevention Research Lab. Galynker was driven to the work because, during four decades of working as a psychiatrist, he felt like too many of the patients he’d encountered suffered from a “terminal illness without a description,” as he said. “I treated hundreds of people who attempted suicide after telling their clinicians and loved ones that they would never.” He added, “As a clinician, I recognized a pattern in their behavior which urgently needed to be described so lives could be saved.”

 In 2024, Galynker and his team published a paper about their work and the related narrative model they have developed, aimed at helping clinicians identify and treat those with SCS. Their study provides stage-specific treatments along with “an empirically grounded conceptual framework for intervention at each stage of the psychological progression towards suicidal action.” Unlike the Columbia Protocol, Galynker’s approach doesn’t rely on patients to report suicidal ideation or planning. That’s because, as he explained, people at high risk for suicide often can’t accurately foresee or grasp their own intentions, and therefore also can’t accurately answer questions about if or how they intend to kill themselves.

The suicidal mental state can come on so fast and violently that it can “swallow a person like a wave,” Galynker said. Barnhorst has a similar remark: “If someone is losing it and spiraling, then they are just going to be like, ‘Uh no, no, I don’t know,’” in response to questions about suicidal intent or planning, she said. “But they could still be at a really high risk.”

Someone experiencing a suicidal crisis “is in an unbearably painful autonomic state, which interferes with rational thinking,” according to Galynker. He added that in many cases, suicidality is more akin to an uncontrollable urge than a carefully executed plan. (Certainly, the abbreviated length of many suicidal crises reflected in a number of studies suggests that plenty of people who try to take their lives don’t spend much time thinking it through. A 2005 Centers for Disease Control and Prevention report, based on interviews with more than 150 survivors of near-lethal suicide attempts, found that a quarter of survivors attempted suicide a mere five minutes after deciding they should do it.

To diagnose SCS, Galynker advises emergency physicians to look for the presence of four symptoms. The first red light is a state of “frantic hopelessness,” as Galynker calls it, characterized by a sense of being trapped in suffering or difficulty, without any solution or way forward. Second is a state of real or perceived social isolation. Cognitive dysfunction and physical or emotional arousal round out the list. A patient with all four markers is often in a near-psychotic state, especially if they have underlying vulnerabilities and trouble managing stress. Such a person is likely undergoing an acute suicidal crisis, according to Galynker, so even if they deny suicidal intent or plans, they should be admitted to the hospital for psychiatric care.

Galynker tries to help emergency physicians better understand which patients should be discharged and which should not. He described two examples: one in which a seemingly suicidal person does not need to be admitted to the hospital for care and one in which a person who denies suicidal intent should be admitted to delineate the complexity for emergency physicians.

The first example relates to a teenager with divorced parents. She leaves a note saying she hates living with her mother so much that she wants to die. Her mother takes her to the emergency department, where she tells the doctor that she wants to live with her father and would prefer to die if she can’t. Since she sees a clear possible solution to her problem, she doesn’t appear to feel hopelessly trapped. She also doesn’t seem aroused or disturbed, nor does she seem socially isolated. She appears to be in fine cognitive control. Therefore, despite her statements about wanting to die, she does not have SCS and can be safely discharged.

The second example, a 55-year-old man who has just lost his job. His wife arrives home to find him shaking, saying over and over again, “My head is going to explode. I don’t know what to do.” His wife sees him making phone calls, in a frantic manner, though no one picks up. Frightened by her husband’s agonized state, she takes him to the hospital, where he refuses to explain why he lost his job, something he’s also refused to discuss with his wife. In the emergency room, he asks to be discharged, arguing that he is not suicidal, never has been, and that he wants to go home and start looking for a new job.

Despite his vehement denials about suicidality, this patient should not be sent home, according to Galynker. He is visibly agitated, showing affective disturbance and arousal. All the phone calls he made suggest he is desperately trying to solve the problem of being fired. His repeated muttering about his head exploding suggests a loss of cognitive control, specifically ruminative flooding. His refusal to tell his wife or the doctor why he lost his job are evasions that indicate feelings of social isolation.

The team that Galynker leads has applied to have SCS included as a diagnosis in the preeminent mental health manual, DSM-5. That application should be greenlighted, said Barnhorst. Others have expressed skepticism, such as Dr. Paul S. Appelbaum, a professor of psychiatry at Columbia University. He recently told The New York Times that an SCS diagnosis could have a “stigmatizing effect,”  affecting a patient’s “insurability.” But Barnhorst said, “I am not a big proponent of not doing things because they might be stigmatizing.”

Corey N. Goldstein, an assistant professor at Rush University Medical Center in Chicago who is board certified in both emergency medicine and psychiatry, acknowledged that insurability is a complex question. “Now [by law] you can’t discriminate against people based on their medical history,” he pointed out. “But that could change at any moment.” An SCS diagnosis could also affect a person’s ability to get life insurance or disability insurance. Dr. Goldstein he acknowledged that stigmatization is not insignificant, adding, “If that is the case, does [an SCS diagnosis] increase safety and save lives? Because if it does that on a significant level, then it might be worth the potential downsides.”

Goldstein said he thinks there’s value in using an SCS tool. “Most emergency physicians have [an] obvious background in evaluating mental health symptoms and risk, but we all would like to improve care and our ability to really figure out who needs help, who needs to stay, and who can be discharged, because psychiatrists are not always available in hospital settings. On top of that, there are a limited number of psychiatric beds available.” SCS can help doctors make effective, efficient choices, he said.

The American Foundation for Suicide Prevention (AFSP) has a slightly different take. “Many years ago, people thought that saying the word ‘suicide’ could make someone suicidal,” Jill Harkavy-Friedman, PhD, senior vice president of research at AFSP, pointed out. “​​That was simplistic, disrespectful, and incorrect. We have learned that the opposite is true. Opening the conversation can bring relief and access to help.”

The available data suggest that SCS might be beneficial. One 2024 study at a large urban hospital system that incorporated an SCS-based risk assessment tool into its emergency department found that emergency department patients diagnosed with SCS and admitted to the hospital with moderate to severe suicidal ideation were about 75 percent less likely to be readmitted to the hospital than patients with the same level of suicidal ideation who did not have SCS.

Unfortunately, Galynker and his team have not yet received funding to support a randomized controlled trial. AFSP’s Harkavy-Friedman suggests that may not be necessary. “Galynker and his team have been studying SCS for many years across many samples, situations, and settings,” she said, noting that data are being collected in a number of different countries such as Israel, Hungary, and Norway. “I am not sure that one large grant is more important than many studies in diverse settings. Validity is accrued.”

Nonetheless, Galynker remains hopeful. He teaches a course at the American Psychiatric Association’s annual meeting on how to identify imminent risk in patients who deny suicidal ideation and for psychiatry departments hoping to spread the concept of SCS and save lives.

Maura Kelly is a journalist who focuses on health, wellness, and healthcare. She is working on a memoir. She has been a Contributing Writer for Harvard Public Health and an op-ed consultant for Peterson Center on Healthcare.