In light of Georgia’s lack of a duty-to-warn statute and strict confidentiality protection law, William Nelson, M.D., president of the Georgia Psychiatric Physicians Association, said the case of psychologist Anthony Stone promises to "give Georgia psychiatrists gray hairs," especially because psychiatrists face cases such as this one "with some frequency."

He advises his colleagues to assess three factors that can help them decide whether to break the confidentiality expectations and warn a third party about patient threats. The first element is to evaluate thoroughly the patient’s mental status so that the threats are placed in the context of the illness. Next, assess the specificity of what the patient is describing—the more specific the targets, time frame, and contemplated method, the more likely the patient is to act on the threats, Nelson suggested. He said he also considers the length and quality of the relationship he has with the patient. It is extremely difficult, he noted, to base a decision about the seriousness with which a threat should be taken if you have had, for example, just one emergency room contact with the individual making the threat.

Washington, D.C., attorney Nancy Wheeler, consultant to APA’s Legal Consultation Plan, emphasized the need for psychiatrists to act quickly to warn third parties if they determine that a threat is in fact real and imminent. She noted that a two-week delay in warning police officials of a patient’s threat against them likely contributed to a jury’s finding that found Stone at fault in a confidentiality-violation case.

Wheeler warned that some of the most difficult cases in which a psychiatrist’s duty to warn is pitted against confidentiality guarantees occur in the workplace setting. "Usually, the potential damages for breaching confidentiality would be slight when compared with potential damages that could be assessed in a wrongful death suit," she pointed out. "However, in the employment context, loss of job can spell big jury awards" if jurors find in favor of a patient whose confidentiality privilege was violated by a therapist.

Wheeler also advises psychiatrists to determine if a patient has a history of violent behavior, because "cases in which a history of violence is coupled with a current threat argue in favor of making a warning, notifying the police, or taking other appropriate action like civil commitment." In addition, they should "seek consultation from a colleague" if they are unsure about the appropriate clinical decision where a patient has threatened violence and get legal advice.

"It is a Catch-22 situation" for psychiatrists, Nelson acknowledged, since as psychologist Stone learned in the Georgia case, a therapist certainly opens himself or herself to liability if confidentiality laws are violated. However, serious consequences may also await a psychiatrist who has knowledge of a patient’s serious intent to commit violence and declines to warn potential victims.