After revelations about Vancouver attack suspect, B.C. mental-health supervision system faces renewed scrutiny

There were signs that Adam Lo’s mental condition was deteriorating.

The Vancouver man accused of using his SUV to kill 11 people at a Filipino festival on April 26 contacted police the day before the attack, complaining of strange smells in his vehicle – one of more than 100 police interactions over the past two decades, most of them self-initiated and in the past few years, according to a source with knowledge of Mr. Lo’s contact with authorities.

Mr. Lo was an involuntary outpatient in the care of a community mental-health team after a forced hospital stint in 2024, which occurred around the time his older brother was killed in a nearby house. Mr. Lo had recently been deemed a high risk for his mental health to decline, the source said. His care team had concerns in the past that he was unwilling to take his medication for schizophrenia.

About two weeks before the attack, his psychiatrist suggested his dosage may be insufficient to be considered therapeutic, the source said. The Globe and Mail is not naming the source because the person was not authorized to speak publicly about Mr. Lo.

Additionally, Mr. Lo’s neighbours and childhood friends noticed he had become increasingly paranoid and delusional.

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Given all this, the question Canadians may have now, then, is: Why wasn’t the attack prevented? Could it have been?

B.C. Premier David Eby has promised answers, including through a public inquiry. The government, he said last week, wants to get to the bottom of the contacts Mr. Lo had with the mental-health system, what services were delivered and what decisions were made along the way. He has also pledged to overhaul the 30-year-old Mental Health Act.

The province’s mental-health system has long been criticized as underfunded and under-resourced, with extremely limited access to voluntary care. The involuntary provisions under the Mental Health Act have been condemned by advocates as inhumane.

At the centre of the Lo case is an aspect of involuntary care known as extended leave. Patients on extended leave have been certified and civilly detained under the Mental Health Act, but they have been released by a clinician from the treatment facility for supervised, mandatory care in the community.

Mr. Lo is among thousands of involuntary patients in B.C. who are released each year on extended leave. The provincial health ministry did not provide a response by deadline regarding the number of patients on extended leave in B.C., but according to data released under freedom-of-information laws, some 2,854 patients were placed on extended leave during fiscal year 2020-21.

Data from a 10-year period shows a steady increase in patients released on extended leave, rising from 848 patients in fiscal year 2008-09 to 2,694 patients in fiscal year 2017-18.

In an effort to understand extended leave and how it works in reality, The Globe reviewed the law and provincial guidance documents, and conducted interviews with psychiatrists, lawyers, community health professionals, advocates and relatives of involuntary patients on extended leave.

To be placed on extended leave, an involuntary patient’s condition must be considered severe enough to warrant being forced to undergo treatment – including, for example, mandatory injections – but not so severe that they must be held at a facility.

Extended leave is intended to help involuntary patients maintain their treatment plans in the community, while at the same time limiting unnecessary infringement on their civil liberties. Mr. Lo, for example, still had a valid driver’s license at the time of the attack.

The involuntary care provisions under the Mental Health Act exist for the safety of the patient and the protection of others. A person can also be held at a facility if a doctor or nurse practitioner is of the opinion that they require in-patient treatment to prevent their substantial mental or physical deterioration.

Extended leave falls under the civil system, not the criminal one. Mr. Lo had no criminal record prior to the attack. The reality is that people with mental illness are much more often the victims of violence than the perpetrators.

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The Mental Health Act allows police to apprehend an individual for medical examination if they believe the person has an apparent mental disorder and is acting in a manner likely to endanger their safety or the safety of others.

The act also gives medical staff the ability to issue an apprehension order for police to return their patients back to a hospital for further treatment. According to figures provided to The Globe by the Vancouver Police Department, there were 457 such apprehensions last year. That number has remained relatively steady in recent years.

In addition, according to provincial authorities, Mr. Lo’s Vancouver Coastal Health care team was of the view that there was no recent change to his condition or non-compliance with his treatment plan that would have warranted involuntary hospitalization.

A patient’s release on extended leave is not an indication that their condition is not serious, however. According to a 221-page provincial guide to the Mental Health Act, extended leave may be considered suitable for an involuntary patient who “has a psychiatric diagnosis with a high level of severity” and “exhibits behaviour (when non-compliant) which places the patient or others at risk of harm.”

Extended leave, the guide says, should be considered an option only when the patient “can be actively monitored for compliance with treatment in the community” and “will be provided appropriate services in the community,” among other prerequisites.

If the patient is unable to follow the plan in place, they can be recalled to the facility. A patient can also appeal their involuntary status to the Mental Health Review Board. Mr. Lo did so last December, the source said, but the independent tribunal denied his request.

An extended leave can be as little as 14 days but may continue for many months or years, so long as the proper renewals are sought. One woman said her adult daughter, who was diagnosed with schizophrenia, has been on and off extended leave for more than two decades. Schizophrenia is a very serious, long-term mental-health condition that can cause hallucinations and delusions; many people who are diagnosed with the condition don’t believe they’re ill.

She said cases such as her daughter’s can be extremely challenging because the patient might be doing so well on extended leave – taking their medications and showing up for psychiatry appointments – that they get discharged, only to relapse when their medications aren’t being mandated and properly monitored.

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Another mother of an extended-leave patient said she keeps in close contact with her adult son’s care team. One day in 2023, after three weeks of providing daily updates to her son’s case manager about his worsening condition, she phoned to say that he was experiencing psychosis. Within a couple of hours, the case manager, a social worker and a plain-clothed police officer arrived at the home to take the man to the hospital for involuntary treatment.

The mothers are not being identified to protect the privacy of their children.

Conditions of extended leave commonly include taking certain medications and having consistent visits with mental-health professionals. The terms may also involve a curfew, a requirement to live at a particular address or with specific people, and no-go zones that the patient must avoid. Care teams have the discretion to do check-ins with the patient in the community, including through unannounced visits.

Ensuring compliance with medication can be done in a number of ways, for example via a monthly appointment to receive an injection, a daily witness at a pharmacy who can ensure the patient is taking their oral medication, or routine bloodwork.

B.C. psychiatrist Diane McIntosh, who did not treat Mr. Lo, said a major issue is the under-resourcing of mental health care in the province. “Because there are so few beds, people are out in the community without adequate care and oversight,” she said. She described an instance in which she certified a patient for involuntary admission to a hospital. The patient’s family managed to get the person to the emergency room, but hospital staff decided to de-certify the patient and send them home.

Dr. McIntosh said the entire mental-health system is anemic and believes the management of involuntary out-patients to be no exception. “I would be very surprised to learn they’re flush with individuals to support people in the community on extended leave,” she said.

Vancouver Coastal Health didn’t respond to questions by deadline about the management of patients on extended leave, including as it relates to staffing levels, the number of involuntary patients in the authority’s care, and the communication between its teams and law enforcement.