Behavioral Health: Court Expands Outpatient Mental Health Providers’ Duty to Third Parties

​The Washington state supreme court, in a ruling that expands the scope of liability for providers of outpatient mental healthcare in the state, held that a psychiatrist may be held civilly liable for homicides committed by an outpatient, even though the patient had never communicated a threat of violence against any reasonably identifiable victim or victims. The case involved a murder-suicide committed by a man who received outpatient care from the defendant psychiatrist over a period of nine years for bipolar and associated disorders. Almost 10 years before receiving outpatient treatment by the defendant, the patient had been admitted to a facility for suicidal ideation. During his nine years of outpatient treatment with the defendant, the patient and his wife divorced. Before the divorce, the patient's wife had reported to the psychiatrist certain behaviors her husband exhibited. For instance, he played "Russian roulette"; lay on a train track hoping to be decapitated; exhibited "severe road rage" even when merely a passenger; and "acted out fantasies of sex with anyone available," among other things. She also reported that he had dreams of "going on killing and shooting sprees." After their divorce, the patient told the psychiatrist about his "negative fantasies" about his ex-wife and her lover, at times expressing suicidal and generalized homicidal ideations.

Five years before the murder-suicide, the patient threatened to retaliate against whoever had vandalized his truck; at that time his family removed loaded firearms from his home. Another time, the patient experienced a mental health "crisis" resulting from failure to adhere to his antipsychotic medication schedule, and the psychiatrist referred him to a community-based mental health clinic. On the patient's final visit with the psychiatrist before the murder-suicide, the psychiatrist noted he was in a "hypomanic mood" but with "judgment and insight intact." The psychiatrist's note described the patient as "logical" and indicated that his life was "stable" and that the patient reported that when he was depressed he had bothersome suicidal ideation that he would not act upon. He and his fiancée were "taking marriage classes," the psychiatrist's note continued, repairing their relationship after his fiancée had terminated a pregnancy. The psychiatrist continued the patient's prescription of three different medications. Three months later, the patient's fiancée ended her relationship with the patient. One week later, the patient entered her house and shot and killed her and...