Tenure in supportive housing for homeless persons with severe mental illness

OBJECTIVE: The study examined the long-term effectiveness of approaches to housing homeless persons with serious mental illness. METHODS: A total of 2,937 persons placed in high-, moderate, -and low-intensity housing were followed for up to five years. Intensity reflected on the amount of structure and degree of clients' independence. The outcome variable was tenure in housing. Cox stepwise regression was used to calculate risk ratios of becoming discontinuously housed. RESULTS: Thirty percent of the sample were initially placed in high-intensity settings, 18 percent in moderate-intensity settings, and 52 percent in low-intensity settings. Those in high-intensity settings tended to be younger, to be referred from hospitals, and to have a history or diagnosis of substance abuse. Individuals in moderate-intensity settings were more likely to be female and were least likely to have substance abuse problems. Individuals in low-intensity settings were more likely to be referred by municipal shelters and to have lived in municipal shelters for four or more months. After one, two, and five years, 75 percent, 64 percent, and 50 percent, respectively, of the sample were continuously housed. Older age was associated with longer tenure, and having a history of substance abuse was associated with shorter tenure. Individuals referred from a state psychiatric center had a greater risk of shorter tenure than other types of referrals. CONCLUSIONS: Results show that homeless persons with serious mental illness can remain in stable housing for periods of up to five years, supporting the premise that long-term residential stability can be enhanced by providing access to safe and affordable supportive housing.     

Comparison of offenders with mental illness only and offenders with dual diagnoses

OBJECTIVE: The study compared offenders who had severe mental illness only and offenders who had severe mental illness and substance abuse problems-dual diagnoses-to determine whether these groups differed. Offenders with dual diagnoses who were involved with the criminal justice system at different levels were compared to explore their profiles and experiences after release. METHODS: Secondary data collected on offenders who had diagnoses of severe mental illness and of substance abuse in Massachusetts were used to examine sociodemographic, clinical characteristics, and criminal justice characteristics, service needs, and community reentry experiences in the first three months postrelease of 265 offenders with major mental illness and 436 with dual diagnoses. RESULTS: Offenders with dual diagnoses were more likely to be female and to have a history of being on probation and of using mental health services. On release from correctional custody, they had more immediate service needs than offenders with mental illness alone, including a need for housing and sex offender treatment, and they were more likely to require an assessment for dangerousness. They were also more likely to return to correctional custody. CONCLUSIONS: The data do not suggest that offenders with dual diagnoses have a distinct clinical background, but rather that substance abuse is an important feature that affects their real or perceived level of functioning, engagement with the criminal justice system, and dependence on social service institutions in the community.     

Independent housing for persons with chronic mental illness

This paper describes and assesses the housing component of The Robert Wood Johnson Foundation Program on Mental Illness, an attempt to test the effects of increasing the supply of affordable, permanent housing available to those with chronic mental illness. Four features of the organization and delivery of independent housing are examined: (1) the structure of the housing development entity; (2) linkages between the housing and mental health systems; (3) targeting of tenant applicants for independent housing; and (4) special issues in providing housing assistance to the homeless mentally ill.This paper was prepared as part of the National Evaluation of the Robert Wood Johnson Foundation Program on Chronic Mental Illness. The national evaluation is supported by grants from the Foundation, the NIMH, several federal agencies, and the Ohio Department of Mental Health, to the Mental Health Policy Studies Program of the Department of Psychiatry at the University of Maryland School of Medicine. Coinvestigators are with the Health Services Research Center of the University of North Carolina, the Johns Hopkins University Institute for Policy Studies, and the Health Services Research and Development Center for the Johns Hopkins University School of Hygiene and Public Health.     

Employment histories of homeless persons with mental illness

This study examined the work histories of 7,228 homeless persons with mental illness who were enrolled into the multi-site Access to Community Care and Effective Services and Supports (ACCESS) research demonstration program. Multiple logistic regression analyses suggest that use of vocational services is significantly associated with increased likelihood of paid employment. The role of vocational rehabilitation services in removing persons from homelessness and improving their quality of life is discussed.     

A collaborative community-based treatment program for offenders with mental illness

OBJECTIVE: The paper describes initial results of collaboration between a mental health treatment program at a community mental health center in Baltimore and a probation officer of the U.S. federal prison system to serve the mental health needs of offenders on federal probation, parole, supervised release, or conditional release in the community. METHODS: A forensic psychiatrist in the treatment program and a licensed social worker in the probation office facilitate the close working relationship between the agencies. Treatment services provided or brokered by the community mental health center staff include psychiatric and medical treatment, intensive case management, addictions treatment, urine toxicology screening, psychosocial or residential rehabilitation services, intensive outpatient care, partial hospitalization, and inpatient treatment. RESULTS: Among the 16 offenders referred for treatment during the first 24 months of the collaborative program, 14 were male and 14 were African American. Three of the 16 violated the terms of their release due to noncompliance with stipulated mental health treatment; only one of the three had been successfully engaged in treatment. One patient died, two completed their terms of supervision, and ten remained in treatment at the time of the report. CONCLUSIONS: The major strength of this collaboration is the cooperation of the treatment and monitoring agencies with the overall goal of maintaining the offender in the community. Further research is needed to confirm the effectiveness of the clinical model in reducing recidivism and retaining clients.     

Service utilization, incidents, and hospitalizations among people with mental illnesses and incarceration histories in a supportive housing program

This study compared the service utilization, incidents, and hospitalizations of forensic clients and non-forensic clients in a supportive housing program for the mentally ill. 28 forensic consumers were compared to 28 non-forensic consumers matched on age, sex, ethnicity, diagnosis, and hospitalization history across four quarters of services data via ANOVA with repeated measures and substance abuse history as a covariate. Multiple and logistic regression evaluated the contributions of age, sex, length of stay, type of case management, substance abuse history, and incarceration history to the variance of 123 clients for incidents and hospitalizations. Forensic clients modestly utilized more services during their first year in the residence. Incarceration history was the dominant predictor of incidents, but not hospitalizations. These findings may help in determining if a jail diversion program should include a specialized community-housing component.     

Cost-effectiveness of supported housing for homeless persons with mental illness

BACKGROUND: Supported housing, integrating clinical and housing services, is a widely advocated intervention for homeless people with mental illness. In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) program. METHODS: Homeless veterans with psychiatric and/or substance abuse disorders or both (N = 460) were randomly assigned to 1 of 3 groups: (1) HUD-VASH, with Section 8 vouchers (rent subsidies) and intensive case management (n = 182); (2) case management only, without special access to Section 8 vouchers (n = 90); and (3) standard VA care (n = 188) Primary outcomes were days housed and days homeless. Secondary outcomes were mental health status, community adjustment, and costs from 4 perspectives. RESULTS: During a 3-year follow-up, HUD-VASH veterans had 16% more days housed than the case management-only group and 25% more days housed than the standard care group (P<.001 for both). The case management-only group had only 7% more days housed than the standard care group (P =.29). The HUD-VASH group also experienced 35% and 36% fewer days homeless than each of the control groups (P<.005 for both). There were no significant differences on any measures of psychiatric or substance abuse status or community adjustment, although HUD-VASH clients had larger social networks. From the societal perspective, HUD-VASH was 6200 US dollars (15%) more costly than standard care. Incremental cost-effectiveness ratios suggest that HUD-VASH cost 45 US dollars more than standard care for each additional day housed (95% confidence interval, -19 US dollars to 108 US dollars). CONCLUSIONS: Supported housing for homeless people with mental illness results in superior housing outcomes than intensive case management alone or standard care and modestly increases societal costs.     

Gender and violence against people with severe mental illness

Men and women with severe mental illness (SMI) are at significantly increased risk of violent victimisation, but the gender pattern for this has not been systematically examined. In the general population, men are at higher risk of overall and physical victimisation, whilst women are at increased risk of domestic and sexual violence. We re-examined published victimisation studies from a gender perspective, and found that, compared to the general population, women with SMI are at greater excess risk than men, leading to a narrowing in the 'gender gap'. We discuss theoretical explanations for this and implications for prevention and research.     

Gender and violence against people with severe mental illness

Men and women with severe mental illness (SMI) are at significantly increased risk of violent victimisation, but the gender pattern for this has not been systematically examined. In the general population, men are at higher risk of overall and physical victimisation, whilst women are at increased risk of domestic and sexual violence. We re-examined published victimisation studies from a gender perspective, and found that, compared to the general population, women with SMI are at greater excess risk than men, leading to a narrowing in the ‘gender gap’. We discuss theoretical explanations for this and implications for prevention and research.     

Crime victims and criminal offenders among adults with serious mental illness

OBJECTIVE: This study compared crime victimization rates with rates of criminal offending among adults with serious mental illness. METHODS: Statistical estimation determined caseload overlap between anonymous extracts from public mental health and criminal justice databases for 13 rural Vermont counties. Participants included 2,610 adults who received community-based services during the study year (July 2005 through June 2006). RESULTS: Among the 2,610 adults 6.6% were identified by police as criminal offenders and 7.1% were identified as crime victims. Compared with the general population, however, their elevated risk of being identified as a victim (2.4) was lower than their elevated risk of being identified as an offender (2.6). These categories are not mutually exclusive. CONCLUSIONS: To better understand involvement in the criminal justice system among adults with serious mental illness, research should consider rates of criminal offending and victimization and compare these with rates for the general population.     

Premorbid risk factors for violence in adult mental illness

The role of premorbid factors in the violence associated with adult mental illness has received little attention. We previously found that the premorbid onset of substance abuse in early adolescence or childhood was a more powerful predictor of violence in adult patients with chronic mental illness than comorbid substance abuse. In the present study, we retrospectively assessed patients with chronic mental illness for a history of childhood conduct disorder. Consecutive referrals to a community treatment team were evaluated with a standardized protocol that included questions about violent behavior. Patients who met DSM-IV criteria for a primary diagnosis of major axis I disorder (N = 64) were assessed for behavior prior to age 15 with a checklist for DSM-IV criteria of conduct disorder using self-report data, supplemented by collateral information from charts and relatives when possible. About half of the sample had a history of committing violent acts in the community, and 26% met criteria for childhood conduct disorder. The odds of violence in adulthood was 10-fold higher for subjects with a history of childhood conduct disorder. Not surprisingly, there was considerable overlap between conduct disorder and early-onset substance abuse. About half of the patients with a history of substance abuse prior to age 15 also had a history of conduct disorder. However, these two premorbid conditions appear to be at least partially independent in predicting adult violence in this population.     

Understanding causal paths between mental illness and violence

The stigma associated with mental illness is a major concern for patients, families, and providers of health services. One reason for the stigmatization of the mentally ill is the public perception that they are violent and dangerous. Although, traditionally, mental health advocates have argued against this public belief, a recent body of research evidence suggests that patients who suffer from serious mental conditions are more prone to violent behaviour than persons who are not mentally ill. It is a point of contention, however, whether the relationship between mental illness and violence is only one of association, or one of causality; that mental illness causes violence. A proven causal association between mental illness and violence will have major consequences for the mentally ill and major implications for caregivers, communities, and legislators. This paper outlines the key methodological barriers precluding casual inferences at this time. The authors suggest that a casual inference about mental illness and violence may yet be hasty. Because a premature statement advocating a causal relationship between mental illness and violence could increase stigma and have devastating effects on the mentally ill the authors urge researchers to consider the damage that may be produced as a result of poorly substantiated causal inferences.