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OXFORD

THE SUICIDAL CRISIS

Clinical Guide to the Assessment
of Imminent Suicide Risk

Second Edition

IGOR GALVNKER
 T H E SU IC I DA L C R I SI S

“In this important book, informed by both academic rigor and common
sense, Igor Galynker proposes that suicidality is not only a symptom of other
illnesses, but also a critical condition of its own. He proposes a new diagnostic
category that may be more likely than existing ones to catch affected individuals
ahead of their suicide attempts. The writing is clear and accessible, the lucid
arguments profound for changing the way we assess and treat patients at risk of
self-annihilation.”
—Andrew Solomon, Professor of Clinical Psychology, Columbia University
“Igor Galynker has crafted a masterful 2nd edition of his seminal book The
Suicidal Crisis. This book is an elegant tapestry that weaves clinical wisdom,
empirical data, theoretical sophistication, and support from over 50 cases.
Galynker’s ‘Suicide Crisis Syndrome’ is a much-needed candidate diagnosis
that deserves to be included in the DSM. Penned by one of the most thoughtful
psychiatrists, Galynker’s guide should be sitting on the desk of every clinician
who aspires to understand, assess, and treat suicidal patients. This extraordinary
book has the potential to save the lives of patients suffering in suicidal despair.”
—David A. Jobes, Professor of Psychology and Director of the Suicide
Prevention Laboratory, The Catholic University of America, Washington DC
“Study this book to grasp the core of Suicide Crisis Syndrome. The author guides
readers through inner perspectives of patients’ suicidal crises, and the book
advances clinicians’ abilities to assess and prevent suicide. This second edition
is a must-read, especially in light of the major public health issue of suicide
worldwide.”
—Maurizio Pompili, Professor and Chair of Psychiatry, Sant’Andrea Hospital,
Sapienza University of Rome, Italy
“Galynker’s second edition of The Suicidal Crisis is unique in its presentation of
deep-dive, scientifically derived constructs about suicide, alongside its pragmatic
utility for clinicians. Galynker’s passion to find answers through science and
to truly help suicidal people, has led to promising data that can inform how
clinicians assess risk for suicide, and how they can engage in person-centered,
compassionate, effective care.”
—Christine Yu Moutier, Chief Medical Officer, American Foundation for
Suicide Prevention
 The Suicidal Crisis
Clinical Guide to the Assessment of Imminent
Suicide Risk
Second Edition

IG O R G A LY N K E R
 Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2023

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Galynker, Igor I., 1954– author.
Title: The suicidal crisis : clinical guide to the assessment of
imminent suicide risk / Igor Galynker.
Description: 2. | New York : Oxford University Press, [2023] |
Includes bibliographical references and index.
Identifiers: LCCN 2022044627 (print) | LCCN 2022044628 (ebook) |
ISBN 9780197582718 (paperback) | ISBN 9780197582732 (epub) |
ISBN 9780197582749 (online)
Subjects: MESH: Suicide—psychology | Suicide—prevention & control |
Risk Factors | Risk Assessment—methods | Models, Psychological
Classification: LCC RC569 (print) | LCC RC569 (ebook) | NLM WM 165 |
DDC 362.28—dc23/eng/20230120
LC record available at https://lccn.loc.gov/2022044627
LC ebook record available at https://lccn.loc.gov/2022044628

DOI: 10.1093/​med/​9780197582718.001.0001

This material is not intended to be, and should not be considered, a substitute for medical or other professional
advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances.
And, while this material is designed to offer accurate information with respect to the subject matter covered and
to be current as of the time it was written, research and knowledge about medical and health issues is constantly
evolving and dose schedules for medications are being revised continually, with new side effects recognized and
accounted for regularly. Readers must therefore always check the product information and clinical procedures with
the most up-to-date published product information and data sheets provided by the manufacturers and the most
recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties
to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing,
the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the
drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim,
any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use
and/or application of any of the contents of this material.

Printed by Marquis Book Printing, Canada

To the American Foundation for Suicide Prevention
 Contents

Acknowledgments  xv

1. Introduction and Overview  1

The Ticking Time Bomb of the American Suicide Health Crisis  1
What Is Imminent Suicide?  4
Long-​Term versus Imminent Suicide Risk: Who versus When  5
Lack of Tests for Suicide Prediction  8
The Problem of “Non-​Disclosure”  9
Suicide Crisis Syndrome  11
The Narrative-​Crisis Model of Suicide  13
One-​Informant versus Multi-​Informant Suicide Risk Assessments  15
Using Clinicians’ Emotions in Suicide Prevention  17
Risk Stratification versus Clinical Judgment  18
How To Use The Suicidal Crisis  20
A Roadmap for Comprehensive Assessment  21
References  23
2. Psychological Models of Suicide  32
With Shira Barzilay, Olivia C. Lawrence, and Abigail Cohen
Introduction  32
Historical Perspective  33
Shneidman’s Theory of Psychache  34
Suicide as Escape from Self  36
The Cry of Pain/​Arrested Flight Model  37
Cognitive Vulnerability Model  39
Fluid Vulnerability Model  41
Beck’s Diathesis-​Stress Model  42
Mann’s Stress-​Diathesis Model  46
Joiner’s Interpersonal Model  47
Thwarted Belongingness  48
Perceived Burdensomeness  48
Acquired Capability  49
Opponent Processing  49
O’Connor’s Integrated Motivational-​Volitional Model of Suicide  50
Klonsky’s Three-​Step Theory of Suicide  52
Summary  54
References  55
viii Contents

3. The Narrative-​Crisis Model of Suicide 62

Introduction 62
Trait versus State Risk Factors 63
Static versus Dynamic Risk Factors 64
The Narrative-​Crisis Model: Overview 65
Long-​Term Risk Factors  65
The Suicidal Narrative  66
The Suicide Crisis Syndrome  66
The Long-​Term Risk Component  67
Stressful Life Events  69
The Suicidal Narrative: The Subacute Component  69
The Suicide Crisis Syndrome: The Acute Component  73
Model Flexibility: Narrative-​Driven versus Crisis-​Driven Suicidal
Behaviors  74
Conclusion  75
References  76
4. Long-​Term or Chronic Risk Factors 81
Demographics 81
Gender and Age  81
Sexual Orientation and Identity  82
Race, Ethnicity, and Geographic Region  83
Psychological Factors  84
Impulsivity  84
Hopelessness and Pessimism  85
Perfectionism  85
Fearlessness and Pain Insensitivity  86
Attachment Style  87
Historical Factors  88
History of Mental Illness  88
History of Suicide Attempts  90
Suicide in the Family  92
Suicide Exposure and Practicing  92
Childhood Trauma  93
Parenting Style  94
Social Factors  95
Cultural Attitudes and Immigration Status  95
Moral, Philosophical, and Religious Objections  96
Suicide Clusters  98
COVID-​19 Pandemic  98
Case Examples  99
Interview Algorithm  99
Case 1: High Risk for Imminent Suicide  102
Case 2: Moderate Risk for Imminent Suicide  104
 Contents ix

Case 3: Low Risk for Imminent Suicide  107

Test Case 1  110
References  113
5. Stressful Life Events  120
With Olivia C. Lawrence, Inna Goncearenco, and Kimia Ziafat
Introduction  120
Work and Financial Hardship  121
Economic Hardship  121
Business or Work Failure  122
Case 4  122
Loss of Home  123
Case 5  124
Case 6  124
Relationship Conflict  125
Romantic Rejection  125
Case 7  126
Intimate Relationship Conflict  126
Case 8  127
Parents in Conflict with Children  128
Case 9  129
Serious Medical Illness  129
Recent Diagnosis  129
Case 10  130
Prolonged and Debilitating Illness  131
Case 11  132
Acute and Chronic Pain  133
Case 12  134
Serious Mental Illness  134
Recent Diagnosis  134
Case 13  135
Recent Hospitalization  136
Case 14  139
Illness Exacerbation and Acute Episodes  140
Case 15  142
Medication Changes: Initiation, Discontinuation, or Nonadherence  142
Case 16  146
Recent Suicide Attempt  147
Case 17  148
Attempt Lethality  148
Case 18  150
Recent Substance Misuse  151
Drug and Alcohol Use Disorder  151
Acute Alcohol Intoxication and Recent Drug Use  152
x Contents

Case 19  154
Alcohol and Drug Withdrawal  154
Case 20  156
Adolescents  157
Children in Conflict with Parents  157
Case 21  159
Ongoing Childhood and Adolescent Abuse and Neglect  160
Bullying  162
Case 22  163
Case 23  164
Internet and Social Media  165
Screen Time  166
Internet Addiction  166
Cyberbullying  167
COVID-​19 Pandemic  168
References  169
6. Suicidal Narrative 187
The Seven Stages of the Suicidal Narrative 187
Stage 1: Unrealistic Life Goals 192
Case 24  193
Case 25  195
Stage 2: Entitlement to Happiness  197
Case 26  202
Case 27  203
Stage 3: Failure to Redirect to More Realistic Goals  205
Case 28  207
Case 29  208
Stage 4: Humiliating Personal or Social Defeat  209
Case 30  212
Case 31  212
Stage 5: Perceived Burdensomeness  214
Case 32  215
Case 33  216
Stage 6: Thwarted Belongingness  217
Case 34  220
Case 35  221
Stage 7: Perception of No Future  222
Case 36  224
Case 37  226
Constructing the Suicidal Narrative  227
Probing the Suicidal Narrative: An Interview Algorithm  230
Case Examples  232
Case 38: High Risk for Imminent Suicide  232
 Contents xi

Case 39: Moderate Risk for Imminent Suicide  236

Case 40: Low Risk for Imminent Suicide  240
Test Case 2  245
References  249
7. Suicide Crisis Syndrome  256
Distinction between Chronic Long-​Term and Acute
Short-​Term Suicide Risk  256
Suicide Warning Signs  257
Suicidal Ideation and Suicide Intent  259
Suicidal Ideation  259
Suicide Intent and Plan  261
Case 41  262
Case 42  264
Suicide Crisis Syndrome  266
SCS Diagnostic Structure  266
Clinical Utility of the SCS  269
Suicide-​Specific Modifiers for SCS  272
Suicide Crisis Syndrome Criteria and Symptoms  278
Criterion A: Frantic Hopelessness/​Entrapment  278
Case 41—​Continued  282
Case 42—​Continued  283
Criterion B1: Affective Disturbance  284
Case 41—​Continued  289
Case 42—​Continued  292
Criterion B2: Loss of Cognitive Control  294
Case 41—​Continued  299
Case 42—​Continued  301
Criterion B3: Hyperarousal  302
Case 41—​Continued  304
Case 42—​Continued  305
Criterion B4: Acute Social Withdrawal  306
SCS Assessment Algorithm  306
The Full SCS Assessment  307
The One-​Minute Assessment  312
Case Examples—​Continued from Chapter 6  312
Case 38: High Risk for Imminent Suicide—​Continued  312
Case 39: Moderate Risk for Imminent Suicide—​Continued  320
Case 40: Low Risk for Imminent Suicide—​Continued  327
Test Case 3  332
References  340
xii Contents

8. Emotional Response to Suicidal Patients in the Assessment of

Imminent Suicide Risk 352
With Benedetta Imbastaro, Olivia C. Lawrence,
Inna Goncearenco, and Kimia Ziafat
Introduction 352
The Need for New Approaches in Risk Assessment 352
Clinician’s Emotional Responses to Suicidal Patients and Their
Underlying Mechanisms  353
Experimental Evidence for Clinician’s Emotional Responses  353
Clinicians’ Defense Mechanisms in Psychotherapy with
Suicidal Patients  356
Reaction Formation  357
Case 43  357
Repression  358
Case 44  358
Turning against the Self  358
Case 45  359
Projection  359
Case 46  360
Denial  360
Case 47  360
Rationalization  361
Case 58  361
Clinicians’ Pattern of Emotional Response  362
From Rescue Fantasy to Helplessness and Anger  364
Case 49  364
Countertransference Love  367
Case 50  368
Countertransference Hate  369
Clinicians’ Conflicting Emotional Responses in the Prediction of
Imminent Suicide  370
Relevance of Clinician Emotional Response in Clinical Practice  372
A Predictive Factor in Suicide Risk Assessment  372
How to Appraise the Emotional Response  373
Incorporating Clinicians’ Emotional Responses in Patient Suicide
Risk Assessment—​A Quantitative Measure  375
A Practical Method for Assessing One’s Emotional Response  376
Case 51  378
Case Examples  379
Case 52: High Risk for Imminent Suicide—​Reaction Formation  379
Case 53: High Risk for Imminent Suicide—​Repression and Denial  380
Case 54: Low Risk for Imminent Suicide  382
Conclusion  384
References  386
 Contents xiii

9. Conducting Short-​Term Risk Assessment Interviews  391

Comprehensive Short-​Term Risk Assessment Outline  392
Long-​Term Risk Factors  392
Stressful Life Events  394
Suicidal Narrative  397
Suicide Crisis Syndrome  399
Suicidal Ideation, Intent, and Plan  402
Preliminary Risk Assessment  403
Clinician’s Emotional Response  403
Final Risk Assessment  404
Suicidal Ideation and Intent: Self-​Report and Its Limitations  404
Development and Use of Suicide Risk Assessment Instruments  406
Short-​Term Risk Assessment Instruments  406
Risk Assessment Interview Strategies  415
Comprehensive Interview  417
Case 55: Comprehensive Short-​term Risk Assessment
Interview Example  419
The Brief MARIS Interview  430
The MARIS Interview Strategy  431
Case 56: Brief MARIS Interview Example  432
Expanded MARIS Interview  437
Case 57: Expanded MARIS Interview Example  438
The Case of Eerie Calm  444
Case 58  447
Appendix A: The Suicide Crisis Inventory-​2 (SCI-​2)  448
Subscales (Dimensions)  457
Appendix B: The Modular Assessment of Risk for Imminent
Suicide (MARIS-​2)  457
Part 1: Self-​Report SCI-​SF  457
Part 2: Clinician Assessment TRQ-​SF  458
Appendix C: Suicide Crisis Syndrome Checklist (SCS-​C)  459
References  460
10. The Narrative-​Crisis Model of Suicide as a Framework for
Suicide Prevention  465
With Inna Goncearenco, Lakshmi Chennapragada,
and Megan L. Rogers
Introduction  465
Overview of the Narrative-​Crisis Model  465
Empirical Support for the Narrative-​Crisis Model  468
Utilizing the Narrative-​Crisis Model as a Framework for Clinical
Intervention  470
Lethal Means Counseling  470
Treatment of the Suicide Crisis Syndrome  472
xiv Contents

Treatment of the Suicidal Narrative  476

Stress Management  479
Digital Interventions  482
Long-​Term Risk Factors/​Trait Vulnerabilities  484
Cultural Considerations  484
African Americans  485
Hispanics  486
American Indians/​Alaskan Natives  487
Asian Americans  487
Cultural Competence  488
Implications for Future Research and Clinical Practice  489
Conclusions  491
References  491

Index  507
 Acknowledgments

I am thankful to Oxford University Press for believing that The Suicidal

Crisis is an important book worthy of a second edition. I am equally thankful
to my editors, Andrea Knobloch and Katie Lakina, for their expertise and
support throughout the writing process.
I thank the American Foundation for Suicide Prevention for its support of
research in acute suicidal states and in predicting short-​term suicide risk. In
particular, I thank Dr. Jill Harkavy-​Friedman for her dedication to the cause
of suicide prevention; for her generosity with her time and her ideas; for her
brilliant knowledge of suicidology; for her unparalleled scientific rigor; for
her belief in the importance of developing clinical approaches to suicide pre-
vention; and for her grace, wit, and good humor. I am deeply grateful to Rob
and Kathy Masinter for their visionary and inspirational trust in our work
and gratefully acknowledge the Eric Masinter Memorial Fund for its gen-
erous support of the Mount Sinai Beth Israel Suicide Prevention Research
Laboratory.
This book would not have been possible without the work of my long-​time
collaborator, Dr. Lisa Cohen. During our many years of trying to solve the
puzzle of the psychological processes that make suicide possible, I benefited
greatly from Lisa’s intellectual voracity, unparalleled commitment to both
clinical work and science, and unwavering moral compass. She has been in-
valuable in providing scientific evidence for the Narrative Crisis Model of
Suicide, which is the backbone of this book.
I also thank my other collaborators from the Mount Sinai Suicide
Prevention Research Laboratory. Their contribution to The Suicidal Crisis
lies in many stimulating and lively discussions we have had during our re-
search meetings and clinical work rounds. For this I am particularly grateful
to Drs. Megan Rogers, Shira Barzilay, Sarah Bloch-​Elkouby, and Benedetta
Imbastaro. I am indebted to Inna Goncearenco and Olivia Lawrence for their
editing work on the book as a whole and for their co-​authorship of several
book chapters, and to Inna Goncearenco alone for her development of the
second edition’s wonderful cover design. I am most grateful to my other
chapter co-​authors—​Lakshmi Chennapragada and Kimia Ziafat.
xvi Acknowledgments

I consider working in the field of suicide prevention a great privilege, and

the decision to change my research focus to suicidology was the best career
decision I have ever made. Writing the second edition of this book gave me
an opportunity to add experimental evidence to 30 years of clinical expe-
rience as an inpatient and outpatient psychiatrist. With increasing special-
ization in both research and clinical work, this essential blend of research
and clinical expertise is becoming increasingly rare, and yet it is critically
important for keeping psychiatric research clinically relevant. In this book,
the names and identifiers of individual patients and their family members
have been changed to protect their privacy. I remember all of them, and I am
deeply grateful for their trust in my skill and judgment.
Finally, I thank my wife Asya for her love, kindness, and patience. The
second edition of The Suicidal Crisis was written after hours (as was the first
edition) and the Guide would not be possible without her support.
 1
Introduction and Overview

The Ticking Time Bomb of the American

Suicide Health Crisis

In June of 2019, the summer before the COVID-​19 pandemic, three Navy
sailors assigned to the USS George H.W. Bush aircraft carrier died by suicide
in three separate incidents. These deaths marked the third, fourth, and fifth
crew members of the carrier to take their own lives in two years. The mil-
itary suicide problem is echoed by a similar problem in the medical field.
Every day, one U.S. doctor ends his or her own life—​one of the highest sui-
cide rates in any profession (Peterson et al., 2020). In another demographic
subgroup, American Indians have the highest rate of suicide of any racial or
ethnic group in the United States (Curtin et al., 2021). The suicide epidemic
has reached all of us.
The U.S. suicide statistics are sobering, and the scope of the suicide epidemic
represents a major public health crisis. In 2020, 45,979 people in the United
States died by suicide (Centers for Disease Control and Prevention [CDC],
2020) and it is estimated that 1,200,000 attempted suicide. To put this in per-
spective, among individuals under the age of 45, suicide accounts for more an-
nual deaths than homicide, AIDS, car accidents, and war (Heron, 2021). More
teenagers and young adults will die from suicide than from cancer, heart di-
sease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung di-
sease combined. While the first year of the COVID-​19 pandemic coincided
with a drop in overall suicide rates in the United States, there was an increase
in suicide rates in children and adolescents and young adults 10 to 34 years old.
Remarkably, in 2020, deaths among Black girls and women between ages 10
and 24 increased more than 30%, from 1.6 to 2.1 per 100,000 people. Black boys
and men of the same age had a 23% increase, from 3 to 3.7 per 100,000 (Curtin
et al., 2021). According to the CDC, in the summer of 2020, 11% of surveyed
adults over 18 years old reported having seriously considered suicide since
the beginning of the pandemic. This translates into an astounding 22,000,000
Americans who should be evaluated for suicide risk (Czeisler et al., 2020).
2 The Suicidal Crisis

While the suicide rates in the United States have been steadily
increasing over the past two decades, in other industrialized countries,
such as Great Britain, pre-​COVID suicide rates have been steadier, while
the rates have decreased worldwide, from their peak at 1,000,000 in 1995
to the estimated 703,000 in 2019 (World Health Organization, 2021). In
the United States, however, in 2017 alone, suicide rates increased by 10%
in adolescents and young adults age 15 to 24 and rose by a staggering 50%
in children age 10 to 14. Despite a 3% decrease in U.S. suicide rates in 2019,
suicide is currently the tenth leading cause of death overall and the second
leading cause of death in adolescents and young adults 10 to 34 years old
(Heron, 2021).
Although somewhat obscured by the COVID-​19 pandemic, the U.S. sui-
cide epidemic continues unabated, and it is time to confront it with the same
determination that we confronted the epidemic of HIV/​AIDS. We can start
the battle by understanding that the mental state leading to suicide is an in-
dependent medical condition, one that can be diagnosed and treated with
medications and psychotherapy.
As doctors and therapists have learned from decades of experience, a su-
icidal person cannot be expected to volunteer the truth about suicide plans.
This is partly because the suicidal crisis may be very short-​lived, and partly
because the mind of a suicidal person is critically afflicted and therefore
cannot be relied upon to adequately assess its own dangerous state. Recent re-
search shows that the pre-​suicidal state of mind is an illness in itself, a mental
state characterized by five recognizable criteria, including entrapment, affec-
tive dysregulation, loss of cognitive control, hyperarousal, and acute social
withdrawal (Bloch-​Elkouby et al., 2020; Calati et al., 2020; Rogers et al., 2019;
Schuck et al., 2019). This condition is called the Suicide Crisis Syndrome
(SCS), and SCS can and should be treated.
Because our understanding of the pre-​suicidal mental state is relatively
new and has yet to be incorporated into the Diagnostic and Statistical Manual
of Mental Disorders (DSM), contemporary clinical practice largely sees su-
icide as a manifestation of other mental disorders, such as depression or
schizophrenia. Clinicians try to prevent suicide by treating the underlying
condition, while relying on individuals to develop insight into, and to report,
their mental processes that may lead to suicide. Specifically, mental health
professionals rely on patients to honestly and accurately disclose their su-
icidal ideation (SI) by answering questions like “Have you ever thought of
harming yourself?” or “Are you planning to harm yourself?”
 Introduction and Overview 3

The success rate of this method is low, performing slightly above chance.
That is not surprising, given that about 75% of people who die by suicide
never reveal their suicidal thoughts to anyone, according to the CDC (Stone
et al., 2018). Indeed, some of them may not have a conscious suicidal plan
until the very last moment of their life, or even not at all.
Such was the case of Kathy (name changed), the mother of a 12-​year-​old
boy, who was in the throes of a hostile divorce and who, at the last second, did
not move away from an oncoming van. Somehow, Kathy survived. When her
many fractures healed, she said, pensively, “I never thought I was suicidal,
but I guess I was, because otherwise I would have moved away.” Kathy would
not have reported being suicidal, but she met all the SCS criteria.
In the inpatient and outpatient facilities at Mount Sinai Beth Israel, in
New York, the attending staff and psychiatry residents were trained to recog-
nize SCS and to use it as the centerpiece of suicide risk assessment. Through
training and practice, they were able to confidently identify high-​risk indi-
viduals and help them recover, without relying on the patients’ self-​diagnosis
via admission of their suicidal intent. Furthermore, after SCS assessment was
implemented in the NorthShore University Health System in Chicago, the
emergency department clinicians started using SCS diagnosis as a tool to in-
form their admission and discharge decision-​making related to SI. Over the
first two years, there were no completed suicides, and the readmission rate
for suicide risk went down by 40% (Figure 1.1).
While doctors would never dream of basing a diagnosis solely on a
patient’s declaring “I am schizophrenic” or “I am bipolar,” the pre-​suicidal
mind is more distorted and acutely life-​threatening than either schizo-
phrenia or bipolar disorder. Still, for decades, risk assessment has been based

8%

44%

92% 56%

SCS + SCS – SI + SI –

Figure 1.1 Clinical utility of abbreviated SCS assessment versus suicidal

ideation (admission).
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