That is were details matter.

Before making up your mind you need to have a good understanding of what the patient’s intent was.

Consider these two scenarios:

Young man in distress after breaking up with his first love tells you he took 3 Tylenol pills as he “wanted to die”. Heard Tylenol could be lethal and though that was a good way to take himself out. He comes in after mom finds good bye note and is cleary disappointed when told that 3 Tylemols are unlikely to result in any significant damage.  The patient is medically clear, however he should be hospitalized for close observation for danger to self.


Young women self referred to the ED with complaints of nausea and vomiting. You are called to consult as it turns out patient took almost 50 Tylenol Extra Strength for a “terrible headache that would not go away no matter what”.  She took way over the the recommended total daily dose of acetaminophen (4 grams per day) and is in acute liver failure. The patient is not depressed, anxious, psychotic, etc.  or in other words is, from a psychiatric perspective, “clear”.  She might need to be admitted to ICU, but if that is the whole history the psych consult can sign off.

And the point is? that…

Intent matters much more than any other component of the suicidality assessment.

Of course one needs to pay attention to the whole, which includes other data: important demographics (with divorced, older, Caucasian male having a higher risk), past history of mental illness (with major Axis I disorders and substance abuse increasing the risk), past history of suicide, or specific psychiatric symptoms (with hopelessness, command auditory hallucinations increasing risk); however, when all the above are considered and added, the intent still comes at the top.

The intent is in fact so important that it can trump a clinical picture of  otherwise minimal risk. If a young married African American woman with a non-contributory past psychiatric and medical history (in other words with a minimal risk profile) presents with clear intent, the intent should trump the otherwise minimal risk, and close monitoring should be initiated.