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.