It looks as if British psychiatrists may have been infected with President Clinton’s "Don’t ask, don’t tell" policy—not regarding the subject of homosexuality, but of violence. At least a study reported in the April 22 British Medical Journal suggests that this is the case.

Steven Milne, M.D., a forensic psychiatrist with St. Luke’s Hospital in Middlesbrough, England, wondered why British psychiatrists are trained to question patients routinely about suicidal thoughts, but are not trained to do so regarding thoughts of violence toward other people. And he wondered what impact this training—or lack thereof—actually has on psychiatric practice. So he and some colleagues decided to conduct a study to find out.

Their study focused on 114 patients admitted to the psychiatric wards of St. Luke’s Hospital over a three-month period and what types of questions psychiatrists admitting the patients asked regarding suicide or homicide. What they found was not surprising in view of psychiatrists’ training: Whereas 94 percent inquired whether the patients had any thoughts of suicide, only 13 percent asked whether any had thoughts about hurting others.

One might argue, of course, that such a disparity does not matter. However, other data from the study suggest that it might: Whereas 94 percent of psychiatrists inquired about suicide, only 47 percent of patients said that they were harboring such thoughts, yet while only 13 percent inquired about violence, 30 percent said that they were contemplating such action. Certainly, most mentally ill persons do not commit violence toward others, but some do. In fact, of the 114 patients in the study, 17 percent admitted that they had already been convicted of a violent act. Thus, psychiatrists should routinely inquire about violent as well as suicidal ideation, the researchers concluded.

When asked whether these results apply to other hospitals in Britain as well as to hospitals in the United States, Milne told Psychiatric News. "We don’t have any reason to suppose that St. Luke’s Hospital in Middlesbrough is particularly different from any other hospital in the country. . . . I can speak with less confidence about the United States because I have never worked or lived there. But it would be interesting to know."

Yes, it would.

In the opinion of Carl C. Bell, M.D., vice chair of the APA Task Force on Psychiatric Aspects of Violence, the situation in the United States is similar to that in Britain—psychiatrists do not inquire enough about patients’ violent thoughts. Even as far back as 1986, he said in an interview, "we were advising that physicians get a violence-and-assault history both as perpetrator and victim from all patients. . . . The APA Task Force on Violence is coming out with a report, and we are suggesting it again."

Richard Kluft, M.D., also a member of the APA Task Force on Violence, generally agreed with Bell that psychiatrists are often not likely to ask patients about violent thoughts or actions.

"I think marital therapists hear it a lot more than do family therapists because domestic violence is often an aspect of why they are doing work with a couple. But when the average person comes in for psychotherapy treatment or for psychopharmacology, I do not think that most [psychiatrists] are asking about violence."

Yet John Lion, M.D., another member of the APA Task Force on Violence, expressed a different opinion: Whereas American psychiatrists inquire enough about violent thoughts, they are remiss in the opposite direction—not asking homicidal patients whether they are harboring suicidal thoughts.