Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse

OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.     

Psychiatric emergency services and the system of care

OBJECTIVE: Admissions to psychiatric emergency services have frequently been cited as a gauge of how well a mental health system manages behavioral disorders. However, few measurements of the longitudinal association between psychiatric emergencies and characteristics of a mental health system have been described. The purpose of this study was to assess whether weekly admissions to psychiatric emergency services would increase when outpatient services were reduced, whether weekly admissions would increase when greater effort was made to identify and treat persons with acute mental illness, and whether weekly admissions would decrease when emergency services were enhanced to include postrelease case management. METHODS: Time-series methods were applied to approximately 29,010 admissions to three psychiatric emergency services of the San Francisco Department of Public Health over a 180-week period. RESULTS: Reduced outpatient services, efforts to identify acutely ill persons, and changes in emergency services themselves were found to affect admissions to emergency services. However, community events such as extreme weather, holidays, job loss, and the scheduling of receipt of income also affected the workload of the emergency service. CONCLUSIONS: The causes and course of mental illness inextricably tie a psychiatric emergency service to the overall mental health system and to events in the community it serves. These connections make it possible for managers to anticipate the use of emergency services and to detect disruptions in the remainder of the mental health services systems.     

Perceived reasons for loss of housing and continued homelessness among homeless persons with mental illness

OBJECTIVE: The objective of this study was to examine the reasons for the most recent loss of housing and for continued homelessness as perceived by homeless persons with mental illness. METHODS: A total of 2,974 currently homeless participants in the 1996 National Survey of Homeless Assistance Providers and Clients (NSHAPC) were asked about the reasons for their most recent loss of housing and continued homelessness. The responses of participants who had mental illness, defined both broadly and narrowly, were compared with responses of those who were not mentally ill. The broad definition of mental illness was based on a set of criteria proposed by NSHAPC investigators. The narrow definition included past psychiatric hospitalization in addition to the NSHAPC criteria. RESULTS: A total of 1,620 participants (56 percent) met the broad definition of mental illness, and 639 (22 percent) met the narrow definition; 1,345 participants (44 percent) did not meet any of these criteria and were categorized as not having a mental illness. Few differences in reasons for the most recent loss of housing were noted between the participants with and without mental illness. Both groups attributed their continued homelessness mostly to insufficient income, unemployment, and lack of suitable housing. CONCLUSIONS: Homeless persons with mental illness mostly report the same reasons for loss of housing and continued homelessness as those who do not have a mental illness. This finding supports the view that structural solutions, such as wider availability of low-cost housing and income support, would reduce the risk of homelessness among persons with mental illness, as among other vulnerable social groups.     

Mental health, alcohol and drug use, and criminal history among homeless adults

As part of a community-based survey of 529 homeless adults, the authors analyzed factors associated with their use of mental health services. Homeless persons who had had a previous psychiatric hospitalization were the least likely to sleep in an emergency shelter, had been homeless nearly twice as long as the rest of the sample, had the worst mental health status, used alcohol and drugs the most, and were the most involved in criminal activities. The majority had not made an outpatient mental health visit in 5 years. It is suggested that diverse systems of care are needed for homeless persons.     

Outcomes of homeless adults with mental illness in a housing program and in case management only

OBJECTIVE: The effectiveness of two types of service programs in ameliorating homelessness among individuals with severe mental illness was compared. METHODS: Homeless persons with severe mental illness were recruited into the study on their entry into one of two types of homeless service programs. The first was a comprehensive housing program, in which consumers received guaranteed access to housing, housing support services, and case management. The second was a program of case management only, in which consumers received specialized case management services. In a quasi-experimental or nonrandom-assignment design, participants responded to instruments measuring housing status, mental health symptoms, substance use, physical health, and quality of life at baseline (program entry) and at six months and 12 months after entry. The baseline interview was completed by 152 participants and at least one of the two follow-up interviews by 108 participants. High-, medium-, and low-impairment subgroups, based on psychiatric symptoms and degree of alcohol and illegal drug use, were formed by means of a propensity score subclassification. RESULTS: Persons with high psychiatric symptom severity and high substance use achieved better housing outcomes with the comprehensive housing program than with case management alone. However, persons with low and medium symptom severity and low levels of alcohol and drug use did just as well with case management alone. CONCLUSIONS: The results suggest that the effectiveness, and ultimately the cost, of homeless services can be improved by matching the type of service to the consumer's level of psychiatric impairment and substance use rather than by treating mentally ill homeless persons as a homogeneous group.     

Factors predicting choice of provider among homeless veterans with mental illness

OBJECTIVE: Homeless persons with serious mental illness are especially likely to lack access to comprehensive medical and psychiatric care. This study examined the relative importance of predisposing factors, illness factors, and enabling factors as determinants of the use of Veterans Affairs (VA) health care services by mentally ill homeless veterans seeking services from a non-VA program. Predisposing factors included demographic characteristics and wartime service; illness factors were related to the type of medical problem and the need to seek medical care; and enabling factors included entitlement to VA medical services and location of VA facilities. METHODS: Logistic regression analysis was used to analyze data for 698 homeless veterans with mental illness who were enrolled in the Access to Community Care and Effective Services and Supports (ACCESS) program. RESULTS: About 56 percent of the mentally ill homeless veterans had used VA services at some time in their lives. Homeless veterans were almost twice as likely as other poor veterans to use VA services; those with a dual diagnosis were also more likely to use VA services. Enabling factors were more important than either predisposing or illness factors in predicting VA service use. Veterans most likely to use VA services were those who received VA benefits that gave them priority access to VA services and those who lived near a VA medical center. CONCLUSIONS: Specific characteristics of the service system and of veterans' entitlement were more important than clinical needs or predisposing factors in predicting service use.     

Utilization of psychiatric emergency services by homeless persons in Spain

OBJECTIVE: Studies examining the relationship between homeless persons and the use of psychiatric emergency services (PES) in a country with universal access to health care are lacking. This study aimed to determine the prevalence of homelessness in adults visiting a PES in Spain, identify the differences between homeless and non-homeless patients in the use of PES and analyze the factors associated with homelessness and the decision to hospitalize. METHOD: The study included a total of 11 578 consecutive admissions to a PES in a tertiary hospital in Barcelona, Spain, over a 4-year period. Data collected included socio-demographic and clinical information, and score on the Severity of Psychiatric Illness (SPI) scale. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness and the decision to hospitalize. RESULTS: Five hundred sixty (4.8%) admissions were considered homeless. Homeless patients had more psychotic and drug abuse disorders, greater severity of symptoms, more risk of being a danger to others and more frequent hospitalization needs than non-homeless patients. Factors related to homelessness were male gender, substance abuse and immigrant status from North Africa, Sub-Sahara Africa and Western countries. The decision to hospitalize homeless patients was associated with psychosis diagnosis, suicide risk, danger to others, symptom severity, medical problems and noncompliance with treatment. CONCLUSIONS: In an attempt to decrease the use of emergency resources and prevent the risk of homelessness, mental health planners in a universal healthcare system should improve outpatient access for populations with risk factors such as substance abuse and immigration.     

Clinical characteristics and service use of persons with mental illness living in an intermediate care facility.

OBJECTIVE: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services. METHODS: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses. RESULTS: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services. CONCLUSIONS: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.     

Use of mental health services in Chile

OBJECTIVE:S: To address the growing burden of mental illness in Latin America, a better understanding of mental health service use and barriers to care is needed. Although many Latin American countries have nationalized health care systems that could potentially improve access to care, significant barriers to care remain. The authors report the results of a study examining mental health service utilization in the general population of Chile. METHODS: The data were drawn from the Chile Psychiatric Prevalence Study, a national household survey of 2,987 persons aged 15 years and older conducted in 1992-1999. As part of the survey, psychiatric diagnoses were obtained by using the Composite International Diagnostic Interview, and respondents were asked about their use of general and mental health care services in the past six months and about their experience of barriers to treatment. RESULTS: More than 44 percent of respondents reported use of any health care services in the past six months, and 20 percent reported use of mental health services. Of the respondents who met criteria for a psychiatric disorder, a large proportion (62 percent) did not receive mental health care. Increasing severity of the psychiatric disorder correlated with increasing frequency of overall help seeking, but only a small proportion of the respondents with a psychiatric disorder sought specialized mental health services. Regional disparities and inequities in access to care were found. In addition, indirect barriers to mental health care, such as stigma and misconceptions about the course of psychiatric disorders, were important deterrents to service utilization, particularly among persons with lower socioeconomic status. CONCLUSIONS: To reduce the burden of mental illness in Chile, additional efforts are needed to address both the direct and the indirect barriers to mental health care, including regional inequities in access to care.     

Help-seeking behaviours of individuals with mood disorders.

OBJECTIVES: This study had the following objectives: 1) to estimate the 12-month prevalence of conventional and unconventional mental health service use by individuals with major depressive disorder (MDD) or mania in the past year, and 2) to identify factors associated with the use of conventional mental health services by individuals with MDD or mania in the past year. METHODS: We examined data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Respondents with MDD (n = 1563) or manic episodes (n = 393) in the past 12 months were included in this analysis. RESULTS: An estimated 63.9% of respondents with MDD and 59.0% of those with manic episodes reported having used some type of help in the past 12 months; 52.9% of those with MDD and 49.0% of those with manic episodes used conventional mental health services. Approximately 21% of respondents with either MDD or manic episodes used natural health products specifically for emotional, mental health, and drug or alcohol use problems. Respondents who reported comorbid anxiety disorders and long-term medical conditions were more likely to have used conventional mental health services. CONCLUSIONS: Relative to previous Canadian literature, our analysis suggests that the frequency of conventional mental health service use among persons with MDD has not increased significantly in the past decade. Further, the rate of conventional mental health service use by persons with manic episodes is unexpectedly low. These findings may reflect the lack of national initiatives targeting mood disorders in Canada. They have important implications for planning future education, promotion, and research efforts.     

Trends in discharge disposition,mortality, and service use among long-stay psychiatric patients in the 1990s

OBJECTIVE: This study examined changes in discharge disposition, mortality, and service use among three cohorts of highly vulnerable long-stay psychiatric patients in the Department of Veterans Affairs (VA) mental health system during the 1990s, a period of extensive bed closures. METHODS: National VA administrative databases were used to identify and prospectively follow three long-stay cohorts: mental health inpatients who had been hospitalized for at least one year as of the end of fiscal year 1991 (N=2,343), 1994 (N=1,853), and 1997 (N=1,156). The cohorts were compared in baseline demographic and diagnostic characteristics as well as discharge disposition, mortality, and service use over a three-year follow-up period. RESULTS: Nationally, the number of occupied long-stay beds decreased by 50 percent between 1991 and 1997. Over time, significant changes were noted in long-stay patients' principal diagnoses and discharge dispositions. Compared with the 1991 cohort, the 1994 and 1997 cohorts had a higher proportion of patients with psychotic disorders (69 percent, 77 percent, and 75 percent, respectively) and were more likely to be discharged from the hospital during the three-year follow-up period (33 percent, 54 percent, and 53 percent, respectively). However, among patients who were discharged, no substantial differences were noted in either mortality or overall VA service use across the three cohorts. CONCLUSIONS: The delivery of inpatient VA mental health services changed dramatically during the 1990s. This study provided evidence that continuing efforts to close VA mental health beds have not resulted in substantially adverse changes in mortality rates or in the extent to which long-term inpatients remain connected with the VA system after discharge.     

Homelessness,Behavioral Health Disorders and Intimate Partner Violence: Barriers to Services for Women

Homeless women comprise a significant portion of the homeless population and may encounter multiple life stressors including mental illness, substance abuse, and trauma. Women who are homeless may experience difficulty gaining access to resources such as shelter and health care. In addition, the interaction of behavioral health problems with intimate partner violence (IPV) may create extraordinary barriers to their engagement in services. This paper explores the co-occurrence of homelessness, behavioral health problems, and IPV and lessons learned through a gender-specific homeless services program designed to reach women who are unengaged in traditional services. Recommendations for providing gender-responsive services are discussed.     

Psychotic disorders among homeless subjects attending a psychiatric emergency service

Background Homelessness is an increas- ing problem among subjects with severe mental illnesses and little is known about the characteristics of homeless subjects with psychosis using emergency psychiatric services. The aims of the present study were to assess the frequency of psychotic disorders among subjects attending a psychiatric emergency service and to explore the clinical and demographic characteristics of these subjects and the management proposed by the emergency staff. Methods All homeless patients (n = 104) consecutively attending a psychiatric emergency service were included over a 6-month period. Patients were categorised according to ICD-10 diagnoses as presenting with psychotic disorder (schizophrenia and other non-affective psychotic disorders) versus other disorders. A random sample of matched non-homeless controls (n = 71) was included over the same period. Results Nearly one out of three homeless subjects (32.7%) presented with a psychotic disorder, a higher proportion than that found in non-homeless subjects (15.7%). Compared to non-homeless subjects with psychosis, homeless subjects with psychosis were more likely to be male and to present with drug use disorder. The likelihood of being hospitalised after attending the psychiatric emergency services did not significantly differ between the two groups. Compared to homeless subjects with other psychiatric disorders, homeless subjects with psychosis were more likely to be single, to have a history of psychiatric hospitalisation and presented less frequently with anxiety or depressive symptoms motivating admission. Conclusion Most homeless subjects with psychosis attending a psychiatric emergency service were already identified as suffering from a severe mental illness, suggesting that homelessness was a consequence of a break in contact with mental health services. Since homelessness is incompatible with the adequate management of psychosis, strategies have to be developed in mental health organisations in combination with outside partnerships, to drastically reduce the frequency of this condition in subjects with psychosis.     

A national survey of care for persons with co-occurring mental and substance use disorders

OBJECTIVE: The delivery of appropriate treatment to persons who have mental and substance use disorders is of increasing concern to clinicians, administrators, and policy makers. This study sought to describe use of appropriate mental health and comprehensive substance abuse care among adults in the United States with probable co-occurring disorders. METHODS: Data from the Healthcare for Communities survey, which is based on a national household sample studied in 1997 and 1998, were used to identify individuals who had probable co-occurring mental and substance use disorders. The sociodemographic and clinical characteristics of these individuals and their use of services were recorded. Logistic regression analysis was used to identify variables associated with receipt of mental health and substance abuse treatment and with receipt of appropriate treatment. RESULTS: Estimates for the U.S. adult population based on the weighted survey data indicated that 3 percent of the population had co-occurring disorders. Seventy-two percent did not receive any specialty mental health or substance abuse treatment in the previous 12 months; only 8 percent received both specialty mental health care and specialty substance abuse treatment. Only 23 percent received appropriate mental health care, and 9 percent received supplemental substance abuse treatment. Perceived need for treatment was strongly associated with receipt of any mental health care and with receipt of appropriate care. CONCLUSIONS: Despite the availability of effective treatments, most individuals who had co-occurring mental health and substance use problems were not receiving effective treatment. Efforts to improve the care provided to persons who have co-occurring disorders should focus on strategies that increase the delivery of effective treatment.     

Correlates of health insurance among persons with schizophrenia in a statewide behavioral health care system

This study explored the demographic and service use correlates of insurance status among 539 persons with schizophrenia-spectrum disorders by using the administrative data set of a statewide behavioral health care system. Lack of health insurance was prevalent in the sample (20 percent) and was associated with younger age, Latino ethnicity, and male sex. Persons who did not have insurance were less likely to use a community-based service and more likely to use only crisis or emergency services than persons who had public or private insurance. The findings are consistent with the results of previous research demonstrating that lack of insurance is associated with decreased use of community-based services among persons with severe mental illness.     

A Comparative Study of the Twelve-Month Prevalence of Physical Health Problems Among Homeless People in Madrid and Washington,D.C.

This paper examines and compares the physical health of homeless people in samples from Madrid and Washington, D.C. The study used two random samples of people who met a definition of literal homelessness (i.e., no place to live or living in an emergency shelter) or who were considered at high risk of becoming homeless because they were using soup kitchens. The sample includes 289 people drawn during 1997 from shelters and soup kitchens in Madrid, and 908 people drawn during 1991 from shelters, soup kitchens, outdoor encampments, and the streets of the Washington, D.C., metropolitan area.

Homeless individuals in Madrid were more likely to be male, older, and to have more extensive histories of homelessness. Though high in both, the Spanish and Americans samples had different rates of past year problems related to their respiratory system (40 percent vs. 53 percent), heart and circulatory system problems (22 percent vs. 23 percent), bone and muscle problems (25 percent vs. 18 percent), nervous system (11 percent vs. 13 percent), stomach and digestive system (18 percent vs. 12 percent), skin ulcers or rashes (15 percent vs. 11 percent), hepatitis and yellow jaundice (9 percent vs. 1 percent), AIDS, ARC or HIV (10 percent vs. 2 percent) sexually transmitted diseases (8 percent vs. 3 percent), and tuberculosis (3 percent vs. 1 percent).

Although conducted in two very different countries, these studies demonstrate a high correlation between homelessness and health problems. In both samples, over 70 percent of the homeless people reported one or more significant health problems in the past year, and the rates of individual problems were several times higher than those in their respective household populations. The higher rates of HIV in the Spanish sample were attributed to the Spanish sanitary/health system's failure to provide HIV outreach, prevention and treatment. The paper concludes with a discussion of the importance of health services in programs for homeless people and other implications for local health care systems.     

The New York-New York housing initiative and use of public shelters by persons with severe mental illness

OBJECTIVE: The study examined changes in the use of shelters in New York City by mentally ill persons with a history of homelessness who received housing placements through the New York-New York (NY/NY) housing initiative between 1990 and 1999 and the impact of the initiative on the overall demand for shelter beds in the city. METHODS: Computerized service records on housing, shelter use, and health care services were linked to create an integrated data set for 3,167 persons who received NY/NY housing placements, which provided mental health services, and for a matched control group of persons with mental illness who used shelters but did not receive housing placements. Regression analyses were used to assess the relationships between shelter use and receipt of a placement. Differences in postplacement shelter use between NY/NY housing recipients and the matched control group were then examined at an individual level and a population level. RESULTS: Heavy users of the shelter system were more likely to be placed in NY/NY housing. In the two-year postplacement period, persons who received a NY/NY housing placement used, on average, 128.2 fewer shelter days than those in the control group. In 1996, the NY/NY housing initiative reduced the average nightly census in New York City shelters by an estimated 4.6 percent. CONCLUSIONS: Providing housing combined with mental health services is an effective approach to reducing shelter use among mentally ill persons who have a history of homelessness.     

Factors associated with high use of public mental health services by persons with borderline personality disorder

OBJECTIVE: The research presented here was a pilot study to identify clinical factors associated with high use (as opposed to lower use) of inpatient psychiatric services by persons with borderline personality disorder. METHODS: The initial sample was a random sample of English- and Spanish-speaking persons aged 18 to 60 years who had received at least one outpatient mental health service in the previous 90-day period and were enrolled in one of the participating mental health centers in King County, Washington. A random sample of persons who met selection criteria was randomly drawn; persons with high levels of use were oversampled to ensure adequate representation. Twenty-nine participants met full criteria for borderline personality disorder on the Personality Disorders Examination structured interview and completed all measures. Fifteen (52 percent) of these had a high level of use of inpatient services, and 14 did not. RESULTS: High use of inpatient psychiatric services was predicted by a history of parasuicide in the previous two years but not by the number or severity of parasuicides; by the presence and number of anxiety disorders but not by depression or psychotic or substance use disorders; and by poorer cognitive functioning. Life stressors, global functioning, and health service variables did not differentiate patients with high levels of service use from other patients with borderline personality disorder. CONCLUSIONS: Further research should explore these predictors of service use to determine whether they are replicated in larger samples, and treatments that target these variables should be evaluated.