Review of programs for persons who are homeless and mentally ill

Despite recent prosperity in the U.S., homelessness is still a widespread social problem. It is estimated that 25% of homeless persons have a serious mental illness. This article will review the literature evaluating prevention services and specialized outreach, treatment, and housing programs designed to reduce homelessness for individuals who are mentally ill. Although these interventions have been helpful in addressing the complex needs of the homeless mentally ill, it is difficult to measure how they have improved outcomes. It is even more challenging to determine whether the programs are cost-effective. Since public resources are used to maintain services for the homeless mentally ill, policy-makers must be informed about whether the best outcomes are achieved at the lowest possible cost. Following a discussion of the successes of the individual programs and the challenges they confront, several important questions are identified related to improving the efficiency of these programs. Although the establishment of such programs indicates that progress has been made toward alleviating the burdens facing people who are homeless and mentally ill, collaboration among all stakeholders-especially between the mental health community and consumer advocates-needs to be further enhanced. New research can be conducted in a way that improves how information is evaluated and used.     

Assessing homeless mentally ill persons for permanent housing: Screening for safety

Although placement in community housing is a frequent intervention with populations of seriously mentally ill homeless individuals, there has been little formal investigation of the criteria used by clinicians in screening individuals for such placement. In this paper, we describe screening a population of 303 homeless people with severe mental illness for placement in independent apartments. We assess subjects' level of risk along multiple dimensions and determine the contribution of each risk dimension to the final safety decision. In addition, we evaluate the validity of the risk measures with other measures of clinical condition. Two-thirds of the sample were judged as safe for independent living. Assaultiveness was the most frequent risk identified, followed by self-destructiveness, substance abuse, and medication non-compliance. The final safety decision was associated most strongly with assaultiveness, self-destructiveness, and medication non-compliance. We conclude that it is possible to assess risk with measures that are available from shelter and medical records, and call for more research on the role of medication non-compliance in safety decisions and for longitudinal research to validate risk assessments.This research was funded by NIMH McKinney Grant #1R18MH4808001.Stephen M. Goldfinger, M.D., is affiliated with the Massachusetts Department of Mental Health and the Department of Psychiatry, Harvard Medical School. Russell K. Schutt, Ph.D., is affiliated with the Department of Sociology, University of Massachusetts, Boston and the Department of Psychiatry, Harvard Medical School. Winston M. Turner, Ph.D., is affiliated with the Addictions Service, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School. George S. Tolomiczenko, Ph.D., is affiliated with the Department of Psychiatry, Harvard Medical School. Mark Abelman, M.S.W., is affiliated with the Solomon Carter Fuller Mental Health Center, Boston, MA.     

Suicidal ideation and suicide attempts in homeless mentally ill persons

BACKGROUND: Despite reports of high rates of suicidal behavior among mentally ill homeless persons, it remains unknown whether the well-established suicide risks of increased age and comorbid psychiatric and substance abuse disorders ("dual diagnosis") documented in the general population are also markers for increased suicide risk among homeless persons. METHODS: Data from a multi-site outreach program (ACCESS) (N = 7,224) were used to investigate whether rates of serious suicidal ideation and recent suicide attempts varied with the age and substance abuse diagnosis(es) (drug abuse and/or alcohol abuse disorders) among homeless mentally ill clients. RESULTS: The prevalence of 30-day suicidal ideation and suicide attempts (37.5 % and 7.9 %, respectively) was extremely high. Although the risk of serious suicidal ideation and suicide attempts was greater among the younger compared with the older homeless mentally ill clients, risks were not significantly increased by co-morbid alcohol and/or drug abuse. However, a significant interaction between age and co-morbid substance abuse was observed showing that among older clients but not younger clients, those with drug and alcohol abuse were at significantly greater risk of suicidal ideation than those without substance use problems, controlling for confounding factors. CONCLUSION: Efforts to prevent suicide should recognize that among homeless people with mental illness, young-middle-aged (30- to 39-year-old) clients are at greatest risk of suicidal behavior. Among older clients the presence of both drug and alcohol abuse significantly increases suicide risk. These patterns are of special importance because they are quite different from those that are well documented in non-homeless populations.     

Homeless mentally ill or mentally ill homeless?

Mainstream psychiatry conceptualizes people who are homeless and mentally ill as distinct from other homeless persons because it is thought that their status stems from their mental disorder and the poor implementation of deinstitutionalization. The authors believe this dichotomy is illusory. They present data indicating that recent socioeconomic and political shifts contributed greatly to homelessness among all groups, regardless of mental illness; that those with and without mental illness have similar biographical and demographic profiles; that high levels of mental distress are common to all homeless persons; and that few mentally ill homeless persons require involuntary hospitalization. This perspective suggests novel responses that de-emphasize clinical solutions and focus on empowerment, consumerism, entitlement, community-level interventions, and closer alliances with other advocates for the homeless.     

How do mentally ill homeless persons evaluate their quality of life

Besides pronounced deficiencies in psychiatric research concerning homeless mentally ill in Germany, studies concerned with the quality of life of homeless mentally ill were missing until now. This study reveals in a representative sample of 102 homeless people from the City of Mannheim, Germany that--compared to the homeless without psychiatric disorders of the sample--the mentally ill homeless (prevalence 68.6%) have significantly different subjective views of their quality of life regarding the items "state of health", "physical capabilities" and "support from others". The differences were even stronger if the homeless mentally ill were compared to a group of non-homeless mentally ill schizophrenic patients (n = 104), cared for in the City's well-equipped community care services. Community care patients reported a significantly better quality of life in respect of 11 items. These results were seen as a success of the concept of community-based mental health care. The consequences for improving care strategies for homeless mentally ill are discussed.     

Deinstitutionalization and the homeless mentally ill

Although homelessness among the chronically mentally ill is closely linked with deinstitutionalization, it is not the result of deinstitutionalization per se but of the way deinstitutionalization has been carried out. The lack of planning for structured living arrangements and for adequate treatment and rehabilitative services in the community has led to many unforeseen consequences such as homelessness, the tendency for many chronic patients to become drifters, and the shunting of many of the mentally ill into the criminal justice system. It has become clear after two decades of deinstitutionalization that what is needed is a vast expansion of community housing and other services and a whole revamping of the mental health system to meet the needs of the chronically mentally ill for support and stability. In addition, mental health professionals must accept the full extent of the dependency needs of many chronic patients.