Clinicians often ask patients in crisis a direct question: Are you thinking of killing yourself?

Clinicians often ask patients in crisis a direct question: Are you thinking of killing yourself?

Dr Igor Galynker, director of the Suicide Prevention Research Lab at Mount Sinai Health System in New York, has treated patients for nearly four decades and lost three under his care who never disclosed suicidal intent. One sent a gift and a note before taking his life, a stark reminder of how ordinary outward signs can mask inner crisis. According to Galynker, some patients may not report suicidal thoughts because they lack awareness or are determined not to reveal them. His conclusion: relying solely on self-report is “absurd” when it comes to predicting imminent risk,

Introducing the suicide crisis syndrome

According to an article in the New York Times, Galynker and his colleagues have spent more than fifteen years researching a proposed mental-health condition called suicide crisis syndrome (SCS). It seeks to identify the physiological, emotional and cognitive shifts that precede suicidal behaviour, even when ideation is denied. Typical features include intense feelings of entrapment and hopelessness, marked anxiety or agitation, insomnia, cognitive narrowing and withdrawal from social supports. These symptoms, the researchers argue, often appear in the days or hours before a suicide attempt, yet escape standard screening tools because they do not require admission of suicidal intent.

Why the change matters

Traditional risk-assessment protocols such as the Columbia-Suicide Severity Rating Scale ask whether an individual has been thinking about, planning or attempting self-harm. That framework places enormous reliance on disclosure. But literature reviews estimate that nearly half of individuals who die by suicide had denied intent shortly before their deaths. SCS, by contrast, proposes a model where the mental state of crisis becomes the warning sign, not simply the verbal admission.

Challenges and clinical implications

Introducing SCS into diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) remains a long-term endeavour. One concern raised by critics is whether SCS would become a label that risks stigmatizing patients or increasing insurance and licensing scrutiny. Others ask whether it is a true disorder or simply a cluster of symptoms indicative of acute risk. Still, emerging studies show that when high-intensity treatment is applied on the basis of SCS criteria, the likelihood of readmission or repeat crisis drops substantially.

A call for more nuanced care

For clinicians, the rising conversation around SCS offers a critical reminder: when a patient denies suicidal intent, it does not necessarily mean the danger has passed. Rather than treating denial as reassurance, doctors, families and support networks may need to pay greater attention to signs of emotional overload, increasingly narrow thinking and a sense of “there is no way out.” For those in distress, reaching out, even absent suicidal words, can still be life-saving.