An Emergency Department's Response to a Patient's Threat to Kill the President

To the Editor: I was troubled by the Open Forum by Zitek and colleagues (1) in the August issue. The authors rightfully observed that "a comprehensive evaluation is impractical" in the psychiatric emergency service, yet they recommended a low threshold for contacting the Secret Service from the psychiatric emergency service when someone threatens the president—a knee-jerk reaction that does not allow exploration of all the options available to the physician. The usual practice for psychiatric patients with homicidal ideation is to admit them to the hospital, involuntarily if necessary, to fully explore the seriousness of the threat, and only then to warn the intended victims (through the Secret Service, in this case) as necessary.

The authors asserted that the Secret Service "has developed a level of expertise in systematic violence risk assessment that is unmatched by the average clinician working in a psychiatric emergency service setting," but they cited no references to back up their claim. Mere knowledge of an individual's history of violence and possession of weapons does not equate to superior skills for assessing future dangerousness.

In the history as presented by the authors, Mr. K "agreed" to sign the Authorization to Review Medical/Psychiatric Files presented to him by the Secret Service agents. I wonder how much of his agreement was coercion or intimidation and how much was voluntary. Was a determination made that Mr. K had the capacity to sign the form? Did anyone warn him of the implications of signing the form and of talking to agents of the secret service? Did anyone advise him of his rights to consult with an attorney before proceeding? The casualness of the authors about these matters is amazing. A patient came voluntarily to the emergency department for treatment and left with a criminal conviction and a sentence of five years' probation without adequate warning or representation ab initio.

The authors presented three scenarios "that may warrant immediate notification of the Secret Service from the emergency service." These are a patient with a risk of elopement, an intoxicated patient, and a patient with personality disorder. To conclude that a patient is suffering from only a personality disorder on the basis of a quick interview in the emergency department is both naïve and dangerous. Further evaluation, including obtaining collateral information, is warranted. The standard procedure for eloped dangerous patients is to inform the police so that they can be apprehended and returned to the hospital, and as for the intoxicated patient, how credible is a history obtained when a patient is intoxicated?

In conclusion, threats to kill the president (or anyone else for that matter) should be taken seriously by psychiatrists in any setting and should trigger a comprehensive evaluation. Informing the Secret Service after a cursory evaluation in the emergency department and without adequate measures to protect the patient's rights is unethical. Although most of the issues raised in my letter are similar to those in Dr. Zonana's commentary, the authors' emphatic recommendation for a low threshold to call the Secret Service, without due consideration of our ethical obligations, compelled me to write.

Dr. Dike is principal psychiatrist at Whiting Forensic Services at the Connecticut Valley Hospital in Middletown, Connecticut, and assistant clinical professor in the division of law and psychiatry of the department of psychiatry at Yale University School of Medicine.