Hallucinations, delusions, and depression can all potentially distort reality for a person with a psychiatric condition, leading them to tell the “truth” according to their narrative – but one which doesn’t necessarily line up with real-world events. So, if the accounts of these people can’t necessarily be believed, what are doctors to do if a psychiatric patient admits to a murder?

The Hippocratic Oath dictates that doctor-patient confidentiality is respected between clinicians and psychiatric patients to an extent, but when it comes to confessions of violent crimes they may have to break this.

“The question you have to ask yourself is can you be sure what they are telling you is really the truth or is it due to their mental state affecting their capacity to judge what is going on around them,” a source, who is a general practitioner (GP) from the UK with experience in psychiatric care, told IFLScience.

“You have to establish if the person has capacity, and if there could be any other reason that they might be admitting to some crime such as delusions resulting from the guilt associated with a serious depressive illness for example.”

False confessions among the wider population aren’t uncommon, Saul Kassin, a psychologist at the John Jay College of Criminal Justice in New York and leading expert on interrogation, told Science – and trauma and stress have been identified as potential drivers. 

Among people with psychiatric illness, however, there can be further contributing factors towards’ a person’s likelihood of making a false confession to a crime they didn’t commit.

“Certain conditions such as psychotic illnesses associated with fixed false beliefs or delusions, and as I say severe depression might rarely lead to a person falsely trying to take responsibility for a crime,” our source continued.

“Also, some personality disordered patients may try to confess to criminal acts to get attention from others which may be a secondary gain for them.”

An article from Medscape details a real case study of a person who confessed to murder while being treated for an overdose. Unsure of the validity of the patient’s claims, those involved were left at a sticking point.

"This was much more of a gray zone case than we typically see," said Dr Meghan Musselman of the department of psychiatry at Temple University in Philadelphia, who was involved in the case.

"If someone is threatening to harm someone, most states have statutes about what to do in that situation. The same doesn't really exist for when the crime has already happened."

That “gray zone” ultimately falls to the clinician to make a call as to whether or not a person’s condition could be influencing them to make the confession, false or otherwise.

“If someone has capacity and admits to committing a murder then you do have to involve the police and that would be considered your duty as a medical practitioner to protect the public from possible harm and to uncover a serious crime,” the source told IFLScience.

“If you have genuine reason to believe that in your professional judgement, they were not able to discern the true reality, then if it turned out that their confession was in fact true you would have a reasonable defence for not reporting any concern at the time, although I feel that this scenario is unlikely.”

In Musselman’s case, patient confidentiality was waived as clinicians feared that the alleged victims could possibly still be alive and in need of help – but in the end, the patient agreed to speak to police officers of their own accord. Making this call is undoubtedly a tough one, but one which Musselman recommends clinicians make with the support of legal guidance.

"There's a saying in forensic psychiatry by Thomas Gutheil,” she said. “‘Never worry alone.’”

[H/T: Medscape]