A review of physical and mental health in homeless persons.

OBJECTIVE: To review the physical and mental status in homeless people. DATA SOURCES: A MEDLINE database search covering 5 decades was supplemented by tracing back through references from existing review work. Over 200 articles were extracted, and 106 were selected for review. MAIN FINDINGS: Homeless persons suffer frequently from physical health problems like tuberculosis, asthma, bronchitis, HIV infection, and as a consequence, they run an increased risk for premature mortality. The prevalence of mental disorders among homeless individuals varies from 80-95% in the USA, Australia, Canada, Norway, and Germany to 25-33% in Ireland and Spain. The most prominent mental disorders among the homeless, which vary from country to country, are depression, affective disorders, substance abuse, psychotic disorders, schizophrenia, and personality disorders. CONCLUSION: Homelessness is a major public health problem that should have our special interest.     

Mental disorder and comorbidity among runaway and homeless adolescents.

PURPOSE: To investigate prevalence of mental disorder and comorbidity among homeless and runaway adolescents in small to medium sized cities in four Midwestern states. METHODS: The study presents lifetime, 12-month prevalence, and comorbidity rates for five mental disorders (conduct disorder, major depressive episode, posttraumatic stress disorder, alcohol abuse, and drug abuse) based on UM-CIDI and DISC-R structured interviews from the baseline interviews of a longitudinal diagnostic study of 428 (187 males; 241 females) homeless and runaway adolescents aged 16-19 years (mean age = 17.4 years, SD = 1.05). The data were collected by full-time street interviewers on the streets and in shelters in eight Midwestern cities of various populations. Separate logistic regression models were used to investigate factors associated with meeting criteria for any disorder and two or more disorders. RESULTS: Lifetime prevalence rates were compared with rates for same-aged respondents from the National Comorbidity Survey (NCS). Homeless and runaway adolescents were six times more likely than same-aged NCS respondents to meet criteria for two or more disorders and were from two to 17 times more likely to meet criteria for individual disorders than. CONCLUSIONS: Homeless and runaway adolescents in small and mid-sized Midwestern cities report significant levels of mental disorder and comorbidity that are comparable and often exceed that reported in studies of larger magnet cities.     

Drug use disorders and treatment contact among homeless adults in Alameda County, California.

OBJECTIVES: This study estimates the extent and distribution of specific drug problems among homeless adults. METHODS: A countywide probability sample of 564 homeless adults received structured interviews that included a standardized assessment of substance use disorders. RESULTS: Two thirds of the sample (69.1%) had a lifetime history of a substance use disorder (including abuse of or dependence on alcohol [52.6%] or drugs [52.2%]); half had a current (52.4%) substance use disorder (including alcohol [38.8%] or drugs [31.3%]). Current drug disorders were higher among respondents who were younger, homeless longer, or sampled from the city of Oakland, Calif. Alcohol use disorders were higher among men than among women; surprisingly, drug use disorders were not. CONCLUSION: Rates of current drug use disorders for homeless adults were more than eight times higher than general population estimates. However, estimates of drug problems among homeless adults vary as a function of case ascertainment and sampling strategy. Estimates based only on samples from urban areas may overestimate drug problems among the area's larger homeless populations.     

Lifetime prevalence of and risk factors for psychiatric disorders among Mexican migrant farmworkers in California

OBJECTIVES: In this study, the prevalence of and risk factors for 12 psychiatric disorders were examined by sex and ethnicity (Indian vs non-Indian) among Mexican migrant farm-workers working in Fresno County, California. METHODS: Subjects aged 18 through 59 years were selected under a cluster sampling design (n = 1001). A modified version of the Composite International Diagnostic Interview was used for case ascertainment. The effects of sociodemographic and acculturation factors on lifetime psychiatric disorders were tested. RESULTS: Lifetime rates of any psychiatric disorder were as follows: men, 26.7% (SE = 1.9); women, 16.8% (SE = 1.7); Indians, 26.0% (SE = 4.5); non-Indians, 20.1% (SE = 1.3). Total lifetime rates were as follows: affective disorders, 5.7%; anxiety disorders, 12.5%; any substance abuse or dependence, 8.7%; antisocial personality, 0.2%. Lifetime prevalence of any psychiatric disorder was lower for migrants than for Mexican Americans and for the US population as a whole. High acculturation and primary US residence increased the likelihood of lifetime psychiatric disorders. CONCLUSIONS: The results underscore the risk posed by cultural adjustment problems, the potential for progressive deterioration of this population's mental health, and the need for culturally appropriate mental health services.     

Are eating disorders associated with borderline personality disorder? a critical review

Seven studies using structured diagnostic interviews have assessed the prevalence of borderline personality disorder among patients with eating disorders, yielding rates from 0% to 42% in different samples. However, many patients with eating disorders suffer from depression, and there is substantial overlap between the symptoms of depression and those of borderline personality disorder. Thus, structured interviews for borderline personality disorder–most of which are of untested or uncertain specificity–may perhaps frequently produce false-positive diagnoses of borderline personality disorder in patients with eating disorders and hence yield exaggerated estimates of the true prevalence of borderline personality disorder in this population. Considering the grave implications of the borderline diagnosis, one must remain critical of studies in this area until further data, using instruments of documented specificity, blind ratings, and suitable control groups, become available.     

Suicidality in DSM IV cluster B personality disorders. An overview

Personality disorders are a considerable risk factor for suicidal behavior. In psychological autopsy studies, individuals with personality disorders are frequently found among suicide victims. Suicidal attempts (which are a major risk factor for completed suicide) are also an important issue among affected patients. We performed careful MedLine, Excerpta Medica, PsycLit and PsycINFO searches from 1980 to 2004. Search terms were "suicide", "personality disorders", "mortality", "follow-up". We identified studies dealing with suicide and the following areas of interest: borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, comorbidity (especially with affective disorder and substance abuse disorder) and risk factors for suicide in personality disorders. Despite the fact that comorbidity with DSM-IV Axis I disorders often impairs a correct judgment of suicidality in personality disorders, this overview showed that some personality disorders have a stronger link to suicide and that identifiable risk factors may be used for the development of preventive measures. Given the fact that personality disorders have high prevalence in the general population, prediction and prevention of suicide among these individuals is a problem of public health.     

Factors associated with violent victimisation among homeless adults in Sydney, Australia

Objective: To determine the prevalence and correlates of violent victimisation among homeless people in inner-Sydney.
Method: Cross-sectional design. Clients of a shelter for homeless, substance-using adults were interviewed about their drug use, mental health and violent victimisation in the previous 12 months. Logistic regression was used to identify factors associated with victimisation.
Results: Participants reported complex drug use histories and high levels of depression, post-traumatic stress disorder (PTSD) and schizophrenia or other psychotic disorders. Forty-eight per cent of participants reported past year victimisation. In univariate analyses, being female, schizophrenia/psychotic disorder, PTSD, depression and regular use of psychostimulants were associated with increased risk of victimisation. In multivariate analyses, regular use of psychostimulants (odds ratio [95% CI] 5.07 [1.53-16.84]), schizophrenia or other psychotic disorder (3.13 [1.24-7.9], and depression (2.65 [1.07-6.59]) were associated with increased risk of victimisation.
Conclusions and implications: This sample of homeless, substance-using adults experienced high levels of violence. People with poor mental health and regular psychostimulant users were at greater risk of victimisation. A longitudinal study to determine whether victimisation prolongs homelessness is warranted. Clinical staff working with homeless populations need to be aware of the likelihood of past and future victimisation and its effects on mental health. Homeless persons may benefit from learning to identify risk situations for victimisation and how to de-escalate potentially violent situations.     

Lifetime Abstention of Sexual Intercourse and Health in Middle-aged and Older Adults: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions

This study aimed to examine the association of lifetime abstention of sexual intercourse with lifetime Axis I and II psychiatric disorders, attempted suicide, past-year Axis I psychiatric disorder, past-year medical condition, past-year obesity, health-related quality of life, and health service use in middle-aged and older adults in the United States. Face-to-face interviews were conducted in the 2004–2005 Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Analyses were performed for the subsample aged 40 years and older (males = 14,427; female = 19,860). Lifetime abstinence from sexual intercourse, sociodemographic variables, prevalence of lifetime Axis I and II DSM-IV psychiatric disorders, schizophrenia, and attempted suicide, past-year Axis I psychiatric disorders, 14 medical conditions, obesity, health-related quality of life, and health service use were obtained. The prevalence of lifetime abstinence from sexual intercourse was 0.90 % (0.88 % for males; 1.00 % for females). The adjusted risks of any lifetime and past-year Axis I disorder, any lifetime and past-year substance-use disorders, lifetime alcohol-use disorder, lifetime and past-year alcohol-abuse disorder, lifetime nicotine dependence, lifetime drug-use disorder, and lifetime drug-abuse disorder were significantly lower for who abstained from sexual intercourse than for those who did not. However, those who abstained from sexual intercourse were more likely to have a diagnosis of obesity and lifetime avoidant and dependent personality disorders. The unadjusted risk of dysthymic disorder was also significantly greater for those who abstained from sexual intercourse. Results indicate that the effect of lifetime absence of sexual intercourse on psychiatric disorders is mixed.     

Sexual Assaulters in the United States: Prevalence and Psychiatric Correlates in a National Sample

This study presents sociodemographic characteristics and psychiatric correlates of a representative sample of sexual assaulters in the United States. Data were drawn from a nationally representative survey, the National Epidemiologic Survey on Alcohol and Related Conditions. Face-to-face interviews of more than 43,000 adults were conducted between the 2001–2002 period, based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. The prevalence of committing sexual assault in the U.S. was 0.15 %. Sexual assaulters had significantly lower education than their counterparts. Sexual assaulters were significantly more likely to report a wide range of antisocial behaviors. Multivariate logistic regression analyses indicated strong associations between sexual assault and lifetime psychiatric disorders often associated with impaired impulse control, such as antisocial personality disorder, conduct disorder, and cocaine use disorder. In addition, psychotic disorders were consistently associated with sexual assault. Our findings indicate that sexual assault could represent a behavioral manifestation of a broader spectrum, including impairment of impulse control and psychotic disorders.     

The Association of Sexual Dysfunction and Substance Use Among a Community Epidemiological Sample

This study examines the prevalence of DSM-III sexual dysfunctions and their association with comorbid drug and alcohol use in a community epidemiologic sample. The data for these analyses are based on the Epidemiological Catchment Area Project, a multistage probability study of the incidence and prevalence of psychiatric disorders in the general population conducted in 1981-83. Only the sample of 3,004 adult community residents in the St. Louis area was queried on DSM-III sexual dysfunctions of inhibited orgasm, functional dyspareunia (painful sex), inhibited sexual excitement (i.e., lack of erection/arousal), and inhibited sexual desire. There was a prevalence rate of 11% for inhibited orgasm, 13% for painful sex, 5% for inhibited sexual excitement, 7% for inhibited sexual desire, and 26% for any of these sexual dysfunctions (14% for men and 33% for women). The prevalence of qualifying lifetime substance use among the population was 37%, with males meeting more drug and alcohol use criteria than females. After controlling for demographics, health status variables, and psychiatric comorbidity (depression disorder, generalized anxiety disorder, antisocial personality disorder, and residual disorders), inhibited orgasm was associated with marijuana and alcohol use. Painful sex was associated with illicit drug use and marijuana use. Inhibited sexual excitement was more likely among illicit drug users. Inhibited sexual desire was not associated with drug or alcohol use.     

Are rates of psychiatric disorders in the homeless population changing?

OBJECTIVES: We examined the prevalence of psychiatric illness among 3 homeless populations in St. Louis, Mo, in approximately 1980, 1990, and 2000. The 3 studies were conducted with the same systemic research methodology. METHODS: We compared selected demographics and lifetime substance abuse and dependence and other mental illness among the 3 populations. RESULTS: Among the homeless populations we studied, the prevalence of mood and substance use disorders dramatically increased, and the number of minorities within these populations has increased. CONCLUSIONS: The prevalence of psychiatric illness, including substance abuse and dependence, is not static in the homeless population. Service systems need to be aware of potential prevalence changes and the impact of these changes on service needs.     

Lifetime prevalence of pathological gambling among american Indian and Hispanic American Veterans

OBJECTIVES: We examined the prevalence and clinical correlates of pathological gambling among 1228 American Indian and Hispanic American veterans in the southwest and north central regions of the United States. METHODS: We surveyed a community sample of American Indian and Hispanic American veterans to obtain data on psychiatric disorder and treatment. RESULTS: American Indian veterans had a 10% lifetime prevalence of pathological gambling. The Hispanic American lifetime prevalence was less than that of the American Indian veterans but higher than the prevalence found for Hispanic American veterans in other surveys. Comorbid conditions associated with pathological gambling included substance, mood, and antisocial personality disorders. Ready access to casino gambling may encourage, support, or contribute to high rates of pathological gambling in both men and women. CONCLUSIONS: A 70% lifetime comorbidity of psychiatric disorders suggests that early interventions for pathological gambling should consider common psychiatric conditions rather than focusing on pathological gambling alone.     

Homeless, mentally ill and addicted: the need for abuse and trauma services

This paper examines an empirical investigation of the lifetime prevalence of trauma (defined as sexual and/or physical abuse) in a cohort of adults enrolled in a federally funded initiative that provides treatment for homeless persons suffering the effects of comorbid substance use and serious mental illness, and considers the impact of this information on clinical programming. Data collected from homeless individuals with co-occurring disorders admitted to the Seeking Treatment and Recovery (STAR) Program during a one year period (n=78) were analyzed for a history of trauma events. Of those individuals evaluated, 79.5% (62/78) acknowledged a history of either physical and/or sexual abuse at some time in their lifetimes. Of this population, 100% of the homeless women (27/27) with co-occurring disorders had experienced a life-altering traumatic event while 68.6% (35/51) of the homeless men also reported trauma histories. We describe the trauma-based interventions made in the STAR Program that have the potential for replication in other initiatives committed to serving homeless individuals with co-occurring disorders.     

The proportion of veterans among homeless men.

This study used data from four surveys conducted in 1986/87 to identify age-race cohorts of homeless men in which veterans are overrepresented. The overall proportion of veterans among homeless men (41%) was somewhat higher than that in the general population (34%). This overrepresentation is largely attributable to the disproportionate representation of veterans in the youngest age cohort (20 to 34 years) of homeless White men. Veterans in this group are 4.76 times more likely to be homeless than nonveterans. Other national data on this cohort reveal higher rates of unemployment, substance abuse, and antisocial personality among veterans than among nonveterans.     

Comorbidity of alcohol dependence and personality disorders: a comparative study

AIMS: To describe the frequency and profile of personality disorders related to alcohol dependence, and to compare them with non-addictive disorders and with normal population. METHODS: In this cross-sectional clinical-epidemiological study, using the International Personality Disorder Examination and the Millon Clinical Multiaxial Inventory-II for personality disorders, 158 consecutively recruited alcohol-dependent patients attending a psychiatric outpatient clinic were compared with 120 consecutively recruited psychiatric patients with non-addictive disorders, and 103 subjects from the general population chosen to match the patient samples for age, gender and socioeconomic level. RESULTS: Of the alcohol-dependent patients, 44.3%, and of the general clinical sample, 21.7% (vs 6.8% of the normative sample) showed at least one personality disorder. Obsessive-compulsive personality disorders were most prevalent (12%), followed by antisocial, paranoid and dependent personality disorders (7% each). Most of them showed only one personality disorder.     

The relationship between compulsive buying and eating disorders

OBJECTIVE: Compulsive buying has received increased research attention in the last decade. The disorder has high rates of comorbidity for other disorders, including eating disorders. This study explored the possible relationship between compulsive buying and eating disorders. METHOD: Twenty women who scored in the pathological range on a measure of compulsive buying and 20 controls were recruited via the media. Various measures of psychopathology and eating disorder symptoms were administered to both groups. RESULT: Compulsive buyers were significantly more likely to have a higher lifetime history of substance abuse or dependence. No differences existed between normal controls and compulsive buyers in prevalence of current or lifetime eating disorders, nor were there differences in scores of eating-related psychopathology. DISCUSSION: This work failed to demonstrate an increased risk for eating disorder in compulsive buyers, although a higher rate of substance dependence or abuse and higher scores on pathological personality dimension scales were seen.     

Arrest Types and Co-occurring Disorders in Persons with Schizophrenia or Related Psychoses

This study examined the patterns of criminal arrest and co-occurring psychiatric disorders among individuals with schizophrenia or related psychosis that were receiving public mental health services and had an arrest history. Within a 10-year period, 65% of subjects were arrested for crimes against public order, 50% for serious violent crimes, and 45% for property crimes. The presence of any co-occurring disorder increased the risk of arrest for all offense categories. For nearly all offense types, antisocial personality disorder and substance use disorders conferred the greatest increase in risk for arrest. Among anxiety disorders, post-traumatic stress disorder was associated with a greater risk of arrest for serious violent crimes but not other offense types. Criminal risk assessments and clinical management in this population should focus on co-occurring antisocial personality disorder and substance use disorders in addition to other clinical and non-clinical factors.     

Taking chances: problem gamblers and mental health disorders--results from the St. Louis Epidemiologic Catchment Area Study.

OBJECTIVES: This study determined prevalence estimates of problem gambling and relationships to other psychiatric and substance use disorders. METHODS: In 1981, the Diagnostic Interview Schedule was used to collect epidemiological information on problem gambling and other disorders from 3004 adults in St. Louis, Mo. RESULTS: The lifetime prevalence of pathological gambling was 0.9%; 46% of those surveyed gambled recreationally. Problem gamblers (those reporting at least one gambling-related problem) were 9.2% of the sample and were predominately White (69%), male (78.2%), and young than nongamblers. They were at increased risk for several psychiatric diagnoses, especially for antisocial personality disorder, alcoholism, and tobacco dependence. CONCLUSIONS: Clinicians treating alcoholism and tobacco dependence may need to screen for problem gambling. Additional research in the context of increased gambling opportunities is needed.     

Violence and psychiatric morbidity in a national household population--a report from the British Household Survey

This study measured the prevalence of self-reported violence and associations with psychiatric morbidity in a national household population, based on a cross-sectional survey in 2000 of 8,397 respondents in Great Britain. Diagnoses were derived from computer-assisted interviews, with self-reported violent behavior over the previous 5 years. The 5-year prevalence of nonlethal violence in Britain was 12% (95% confidence interval: 11, 13). The risk of violence was substantially increased by alcohol dependence (odds ratio=2.72, 95% confidence interval: 1.85, 3.98), drug dependence (odds ratio=2.63, 95% confidence interval: 1.45, 4.74), and antisocial personality disorder (odds ratio=6.12, 95% confidence interval: 3.87, 9.66). Low prevalences of these conditions (7%, 4%, and 4%, respectively) contrasted with their relatively high proportions of attributed risk of violence (23%, 15%, and 15%). Hazardous drinking was associated with 56% of all reported violent incidents. Screening positive for psychosis did not independently increase risk (odds ratio=3.20, 95% confidence interval: 0.35, 29.6). The study concluded that psychiatric morbidity makes a significant public health impact on violence exerted primarily by persons with any personality disorder, substance dependence, and hazardous drinking. Population interventions for violent behavior are appropriate for hazardous drinking as are targeted interventions for substance dependence and antisocial personality disorder. Despite public concern, the risks of violence from persons with severe mental illness were very low.