Right, and it would be instructive to compare the level of psychiatric care between the US and similar countries.
I know nothing about the details of American healthcare. In Britain what tends to happen is
1) Consultation with GP
2) Referral to a specialist
3) Patient decides between drugs and therapies or both.
4) If prescribed medication, it costs about $10/month regardless of actual price. Various therapies, such as group talk therapy or CBT, if chosen, are entirely free.
In the case of something serious like some psychosis related illnesses such as schizophrenia one might lose one's driver's licence - and probably face losing their job, depending on your job and your employer. I suppose in the States there might be complications related to insurance.
But the health services are pretty good - if one can be motivated to take advantage of them. Early intervention centres in the case of illnesses like schizophrenia (and I know there are some such centres in the States, based on a quick google search on the topic). There is a certain trend of recalcitrance in schizophrenics et al, so there's always a struggle to keep them following treatment.
Here in Britain we make medication cheap, and easy to access and we try to give the 'service user' the choices in their treatment, offering CBT and other related treatments as needed/wanted.
I'm guessing America has some pretty good treatment plans for people displaying disturbing divergences from reality. Though I'm thinking that anti-psychotics are prescribed like candy, and those that refuse are pressured to do otherwise. That 'schizophrenia' (a term which is becoming questionable) counts as a 'pre-existing condition', making insurance options/premiums rise to potentially unaffordable levels. But that's just a Brit's eye view - perhaps you could fill me in?
I'm actually quite curious because my other half is currently building a training package for our workplace to raise awareness of mental health issues and tackle the associated stigma. I think Britain isn't perfect, but I think it's a passing grade.
That being said - the belief that the mentally ill are more likely to be criminally violent isn't quite so clear when the evidence is examined (it may still be true, but the effect is much smaller than public perception). It might be based on the fact that a hugely disproportionate amount of mentally ill people, especially psychotics, are either homicidal or suicidal in American film and TV. This can lead to a sort of
Availability Heuristic effect going on. Especially combined with the fact that the mental health of a person is almost always mentioned in the news only when a person is mentally ill and they have committed a violent crime.
I don't think there is any healthcare system in the world which will completely prevent all mentally ill persons committing terrible crimes, and which is also a good mental healthcare system (of course, it should seek to reduce the number of such crimes as much as ethically possible). It would be a terrible system to make treatments mandatory. It would be terrible to deprive people of their liberty because they are ill (obviously for particularly bad cases these options may be necessary).
As for what a doctor should do if a patient confesses to intrusive violent thoughts and fantasies? It's difficult because these symptoms commonly appear in mentally ill people with no subsequent violent behaviour. If you force medication on them, put them in a hospital against their will etc., you just deter ill people from talking about their problems out of (justified) fear.
Intrusive thoughts occur with OCD, posttraumatic stress disorder, other anxiety disorders, eating disorders, or psychosis.
I think most people have experience intrusive violent and sexual thoughts before - even had violent or inappropriate sexual fantasies. It is not always obvious when these fantasies become 'a clear threat', until after the fact of course, see
Hindsight bias.
All that said, I think there is an overwhelming public interest in those documents should the exist. That way we can analyse it, along with other similar documents by other patients to see if there is anything there that truly is indicative of a threat to harm others. One of the signs a problem is brewing, I believe, is the development of a plan. So if this guy did have a specific plan, that should have raised an alarm - but then, that's why we say hindsight is 20/20.
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