Psychiatry on Trial: Are Psychiatrists Responsible for Their Patients’ Criminal Behavior?

Lindsay Clancy is currently being tried for the murder of her 3 children. The question for the jury is about whether or not Clancy is criminally responsible. The prosecution argues that she is guilty despite her history of postpartum depression and anxiety, while the defense counters that she had postpartum psychosis. The defense further argues that the diagnosis was missed, and that she was overmedicated anyway.

A good portion of the public and the media appear to support the defense theory as they struggle to understand how a mother could commit such a crime. The defendant and her then-husband have filed malpractice lawsuits against her psychiatric providers. They argue that the psychiatrists’ negligence led to the events. None of the psychiatrists who evaluated Clancy as a patient before the murders documented evidence of psychosis. Yet public opinion appears to favor a simple narrative: she is not to be blamed because she asked for help, and therefore the mental health system should be blamed.

But what are the implications of these trials? Can psychiatry, or the mental health system, be responsible for a patient’s criminal behavior? The litigation places psychiatrists and other mental health providers under scrutiny, looking for possible errors or inconsistencies to demonstrate that they did not provide adequate care.

The Role of Psychiatry & Psychopharmacology

In regular psychiatric care, where caseloads are large and time is limited, physicians rely on the medical record and on information provided by the patient, family members, and other treating providers. Psychiatrists must work with the information available. They cannot approach every patient as detectives whose primary task is to uncover or disprove every piece of information they are given. Clinical care requires judgment, and that judgment is necessarily based on incomplete information.

Similarly, in clinical psychiatry, the quality of care cannot be defined solely by the outcome. Patients can receive excellent psychiatric care and still have devastating outcomes. Imagine an oncologist providing the best possible treatment to a patient with stage IV cancer. If the patient ultimately dies, would that alone demonstrate that the oncologist provided poor care? Of course not. The outcome is heavily influenced by the severity and biology of the disease, not simply by the quality of medical care. Psychiatry is no different in this regard. Despite the best care, occasionally there are bad outcomes and deaths—suicides and homicides both.

In clinical psychiatry, the treatment of depression, including postpartum depression, may include psychotherapy and medication when indicated. In severe depression with suicidal ideation, antidepressant treatment combined with psychotherapy is a standard approach. Characterizing the prescription of an antidepressant together with a medication for sleep as evidence of inappropriate or excessive treatment, without considering the clinical circumstances, oversimplifies psychiatric practice.

Misdiagnosis vs Different Diagnoses

Another argument commonly raised in malpractice litigation is that a patient may have been misdiagnosed. But psychiatric diagnosis is different from the diagnosis of many medical conditions for which objective laboratory findings or biomarkers can confirm a disease. Psychiatric diagnoses are based primarily on clinical observation, history, reported symptoms, collateral information, and interpretation of the patient’s presentation. Presentations can change from one encounter to another, and reasonable clinicians can sometimes arrive at different diagnostic formulations.

This does not mean that psychiatric diagnosis is arbitrary. It means that psychiatry operates within a degree of uncertainty that is inherent to clinical medicine. There is often no laboratory test that can definitively confirm depression, psychosis, or a personality disorder at the time of an outpatient encounter. Treatment decisions are therefore based on the information available at that moment, and psychiatric treatment often involves adjusting medications and therapeutic approaches according to the patient’s response over time. Trial and error is not necessarily evidence of poor care; it can be an unavoidable component of treating many psychiatric disorders.

Responsibility of Clinicians

But ultimately, the most important question is one of responsibility. If a person is found not criminally responsible for a crime because of mental illness, can the psychiatrist then become responsible for the crime? And if so, should that responsibility depend primarily on the outcome? Can psychiatrists be held responsible for their patients’ behavior?

Tarasoff-like cases consider psychiatrists’ duties to third parties who are potential victims. But this is different—the perpetrator suing their psychiatrists. Decades ago, Wendell Williamson was found insane after killing 2 people in Chapel Hill, North Carolina. He then sued his former psychiatrist. Initially the jury returned a $500k verdict against the retired psychiatrist, but this was overturned by an appeals court—due to the specific facts of the case and the lack of foreseeability.

Can malpractice litigation become an additional legal strategy for defendants and their families following catastrophic acts? If the legal system shifts responsibility for patients’ behavior toward their physicians, will psychiatrists respond by practicing more defensively? The consequences could extend far beyond individual lawsuits. More defensive psychiatry could mean more documentation, more testing, more hospitalizations when there is any concern of risk, more consultations, more time spent obtaining records, and more effort devoted to protecting clinicians from future litigation. That would come at a cost. Time spent protecting oneself from a possible future lawsuit is time that cannot be spent treating the patient in front of you. And, if this becomes increasingly common, will anyone want to practice psychiatry in the future?

The question should not be, “Given what happened, what should the psychiatrist have known?” The question should be, “Given what was reasonably knowable at the time, what would a reasonable psychiatrist have done?” That distinction is essential. Otherwise, psychiatry risks being judged not by the quality of the care provided, but by whether the patient ultimately had a good outcome. And if we begin to judge psychiatric care by the crimes our patients commit rather than by the care we provide, psychiatry itself may end up on trial.

Dr Forcen is a psychiatrist at McLean Hospital in the division of depression and anxiety disorders.

Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; professor of psychiatry, reproductive biology, and pediatrics; and adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the Group for the Advancement of Psychiatry volume Family Murder: Pathologies of Love and Hate, which won the Manfred S. Guttmacher Award. an editor of the textbook Malpractice and Liability in Psychiatry.