How the mental health system fai

WINNIPEG — Vince Li jumped from the bus window likely thinking he would be greeted as a hero.

In his mind, he and his trusty buck knife had just slain a demon. With blood smeared across his face and three of the demon's body parts stuffed in his pocket, he couldn't understand why police surrounded him as soon as he landed, or why they “put cuffs on my hand and then they took me to the police station and treated me like a murderer,” he later told a psychiatrist.

It took weeks of treatment before Mr. Li realized the extent of his actions the night of July 30, 2008: that a major psychotic disorder had compelled him to stab, dismember and disembowel a 22-year-old stranger aboard a Greyhound bus bound for Winnipeg.

The story of Mr. Li's descent into murderous psychosis is not just the tale of one man's tragic flaws – but of multiple flaws in the way Canada deals with its mentally ill, of a patchwork mental health system that failed Mr. Li, the public and, under the most dreadful circumstances possible, Tim McLean.

Family, friends and doctors all noted abnormal behaviour at various stages along his five-year plunge into depths of schizophrenia and failed to act. What broke down in the case of Vince Weiguang Li, who was found not criminally responsible this week due to a major psychotic disorder? And will it happen again?

The voices first beckoned Mr. Li five years ago. He'd always been a reclusive man, even before he moved from China to a new country and a new language with his wife Ana in 2001. But these voices added a worrisome dimension to his personality. In the summer of 2004, Ana noticed him “acting weird” after several days of irregular eating and insomnia. “He cried a lot and told me he saw God. I thought he was just tired so I bought him sleeping pills from Shoppers Drug Mart, but that didn't work too well.”

Friends advised Ana to take her husband to a doctor. She refused, citing language and cultural barriers as well as Mr. Li's inevitable opposition to any plan that might label him as mentally ill.

Therein lies the most powerful reason Mr. Li was never treated. “The stigma around the illness is so severe,” said Mary Alberti, executive director of the Schizophrenic Society of Ontario, “that people are afraid to talk about it, afraid to come forward because they are afraid of how they will be treated by society.”

Ana obviously cared deeply for her husband. She took days off work to help him. When Mr. Li briefly returned to China in 2005, she implored his parents to get him medical treatment. Even after the couple divorced in 2005, she gave him money and let him stay with her while he was unemployed.

In March, 2005, Mr. Li abruptly left their Winnipeg home for Thompson, Man., apparently commanded by the voice to buy land there, even though he had no money. Six months later, again compelled by the voice, he hopped a plane to Toronto. “Then God's voice told me to go back to Winnipeg … so I started walking on the highway; I threw out my luggage after God told me to do that,” he told a psychiatrist.

He was picked up by police and taken to William Osler Health Centre in Etobicoke. “He was vague, seemed to be hallucinating, staring into space,” a doctor there noted. “He has not slept or eaten for three days.”

He was diagnosed with schizophrenia and given medications that he refused to take.

Believing Mr. Li was at risk of harming himself or others, doctors placed him on two involuntary admission certificates and could have legally detained him for 14 days. For reasons still unclear, he walked away from the hospital after just 10 days. The hospital said it cannot comment on Mr. Li's case for “privacy and confidentiality” reasons. Mr. Li says he escaped. What's certain is that he left against medical advice.

Of the 60,000 people who are admitted involuntarily to Canadian hospitals every, it's unclear how many escape.

“In most hospitals, this will happen more than once a year,” said Richard O'Reilly, professor of psychiatry at the University of Western Ontario. “Unless we lock all the doors to all the hospitals, people will be able to get out.”

When patients do escape, doctors are generally obliged to alert the authorities.

“In theory the police should always be called because the patient was still on certificate and therefore must have still been a threat to himself or others,” said Phil Klassen, deputy clinical director for the Law and Mental Health Program and the Centre for Addiction and Mental Health in Toronto. “In practice, that does not always happen.”

Several factors can influence whether doctors notify police. The patient may have been responding to treatment or nearing the expiry of a certificate. Or the hospital simply did not have the resources. Since mental health facilities began a massive deinstitutionalization trend 40 years ago, much of the burden of caring for the mentally ill has been placed on general hospitals.

“Most hospitals have enough other people to look after,” said Simon Verdun-Jones, an expert in mental health law at Simon Fraser University. “As a result, these people who refuse treatment are often placed at the back of the line when in fact they are the illest of the ill and should be placed at the very front.”

Ontario's mental health laws could have hindered attempts to detain Mr. Li as well. Other provinces have broad laws that allow them to scoop up anybody thought to pose a harm to themselves or others. Ontario specifies that patients must show potential for physical harm, which is much more difficult to prove, according to John Gray, author of Canadian Mental Health Law and Policy.

“Ontario has a fairly narrow criteria compared to other provinces,” said Dr. Gray, who added that the broader measures used in B.C. and Manitoba might have prevented Mr. Li's release. “We need laws that help people, even when illness doesn't allow them to realize they are ill.”

After fleeing the William Osler Health Centre, Mr. Li headed straight for Manitoba, exposing yet another defect in the country's mental-health system. Health is a provincial jurisdiction. As soon as Mr. Li crossed the provincial boundary, his Form 3 certificate would have lost authority.

“There are no good interprovincial links when it comes to these laws,” Dr. Gray said. “It's not like the Criminal Code where if you are charged in one province it holds in the next.”

After escaping the William Osler centre, Mr. Li returned to Ana looking “like a homeless person,” she said. But he continued to evade treatment. On a visit to China, a doctor there gave him a clean bill of health. In 2007, the couple moved back in together, but he continued to reject treatment.

In late July, 2008, he left their Toronto home and a puzzling note for Ana: “Don't look for me, I wish you were happy.”

Bizarre, but not out of the ordinary. She didn't discover his whereabouts until the RCMP called her late on July 30, as her beloved ex-husband was dismembering Mr. McLean's body.

How the mental health system failed Vince Li