Case management with homeless mentally ill people

This article reports the findings of a National Institute of Mental Health (NIMH) services demonstration project that used a mobile case management team to serve homeless mentally ill clients. The project examined three issues: (1) factors associated with client engagement in case management, (2) clients' perceptions of how case management affected their quality of life, and (3) significant differences between clients who remained engaged in case management services and those who discontinued involvement. The results indicated that clients who received more frequent case management contact, had higher assessed independent living skills, were older, were less likely to be substance abusers, and had experienced fewer periods of homelessness and fewer prior psychiatric hospitalizations were more likely to remain engaged in case management services. After six months of case management, clients perceived significant improvement in their global well-being, living situation, use of leisure time, finances, and physical health. Implications for providing case management services to homeless mentally ill people are presented.     

Community care for people who are homeless and mentally ill

This qualitative longitudinal study documents the experiences of 60 people who are homeless and mentally ill from their state mental hospital discharge through their first two years in community housing. The study explores the personal, cultural, and environmental contexts of life for adults who are homeless and mentally ill and examines the interaction between an individual's needs and community resources. The research identifies forces that perpetuate homelessness and traces the struggles that people who are homeless and mentally ill encounter during the transition from the streets to stable housing. The findings describe a culturally based pattern of mutual avoidance between homeless mentally ill clients and caregivers, which limits delivery of services to the population. Recommendations include development of alternative systems of care delivery, expansion of educational experiences with underserved populations, and increased funding for service or research with people who are homeless and mentally ill.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Lifestyle and health status of homeless people around Shibuya Station, Tokyo]

The number of homeless people in Tokyo is estimated to be 3,200-3,300. While studies on the health status of homeless people, including illness, injury and deaths have been previously reported, most of these reports concern the homeless who resided in housing facilities for the homeless or who admitted to hospitals. We undertook a comparison of lifestyle and health status between homeless people and people who live in houses (as a control group). Health status was also analyzed for differences among homeless people. Subjects were asked by questionnaire regarding their age, the length of being homeless, former and present employment, sleeping condition, food, whether they have friends or not, the amount of smoking per day, and Short-Form-36 Health Survey (SF36). As objective findings, measurement of blood pressure and blood testing were also performed. Fifty-three homeless people, 49 male, 4 female, average age 52, from the areas around Shibuya station and Yoyogi park, were enrolled. While 98% of the homeless people had previous employment, 73% were not working when the study was performed. Compared with control group, the homeless had fewer meals per day, fewer friends, excessive smoking, greater history of gastro-duodenal ulcer and injury, greater limitation due to physical problems, and higher general mental health as measured by SF36. The diastolic blood pressure of the homeless was higher than that of the control. The blood testing showed higher white blood cell counts and platelet counts. It was suggested that changes in the social structures were largely influential in causing life, and that access to health care was limited because of financial and social barriers. Further studies with more samples, survey of social volunteers involved in care of homeless and qualitative data would be necessary to find and develop better support system for the homeless.     

Treatment issues and treatment configurations for mentally ill homeless women.

This article reviews and discusses various issues pertinent to effective delivery of treatment services to mentally ill homeless women. The central emphasis is upon the gender-specific issues unique to this population and includes attention to distinctive features of effective case management, utilization of group therapy techniques, and greater integration of the psychiatrist into the treatment team. The article concludes with a discussion of the future issues relevant to community based services to homeless mentally ill women.     

Housing costs for adults who are mentally ill and formerly homeless

The goal of this study was to evaluate the costs, under two different housing conditions, to the state mental health agency of caring for adults who are homeless and mentally ill. One hundred and twelve clients of the Massachusetts Department of Mental Health, living in psychiatric shelters, were randomly assigned to one of two housing types: Evolving Consumer Households or Independent Living apartments. For the next 18 months each client was followed so that the cost of treatment, case management, and housing could be collected and compared. The authors found that treatment and case management costs did not vary by housing type, but housing costs were significantly higher for those assigned to Evolving Consumer Households. Regardless of original housing assignment, treatment costs were lower for clients who remained where they were originally placed. The authors conclude that providing support for clients that increases housing stability reduces their need for treatment and that independent living arrangements may be a more costeffective policy choice.     

Barriers to adequate care for mentally ill people

A serious and chronic problem that confronts mentally ill people and mental health professionals is the inability of society to provide the requisite resources for adequate care-giving systems. This difficulty has been evident for almost two hundred years. The present paper summarizes the major causal processes as these were revealed in the course of a case study of a mental health centre and its catchment area in Nova Scotia. These barriers to adequate care systems are then considered in historical perspective in order to illustrate how they function more generally. The historical perspective reveals a further handicap in the fact that experiences gained in one reform movement are not transmitted and utilized in subsequent efforts.     

Effect of Social Security payments on substance abuse in a homeless mentally ill cohort

OBJECTIVES: To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use. DATA SOURCES/STUDY SETTING: Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill. DESIGN: Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months. DATA COLLECTION METHODS: Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings. PRINCIPAL FINDINGS: Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits. CONCLUSIONS: In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.     

Disease patterns of the homeless in Tokyo

In recent years, homelessness has been recognized as a growing urban social problem in various countries throughout the world. The health problems of the homeless are considerable. The purpose of this study was to elicit, with sociodemographic profiles, the disease patterns among Tokyo's homeless. The subjects were 1,938 men who stayed at a welfare institution from 1992 to 1996. Diagnosed diseases/injuries and sociodemographic profiles were analyzed. The disease patterns of the homeless were compared to those of the male general population. Of the subjects, 8.3% were admitted to the hospital; 64.0% received outpatient care. Their observed morbidity rates by disease category were greater than those of the male general population in both Japan and Tokyo. Comorbidity of alcoholic psychosis/alcohol-dependent syndrome to both liver disease and pulmonary tuberculosis were greater than the average (P<.01). Construction work brought a higher risk of pulmonary tuberculosis (odds ratio=2.0) and dorsopathies (odds ratio=1.4) than did other jobs (P<.05). Disease patterns among the homeless in Tokyo were characterized by alcoholic psychosis/alcohol-dependence syndrome; liver disease; pulmonary tuberculosis; diabetes mellitus; fractures, dislocations, sprains, strains; hypertension; and cerebrovascular disease. Although the sociodemographic backgrounds of Tokyo's homeless have become more diverse, the principal occupation of the homeless was unskilled daily construction work, which underlay the characteristics of their disease patterns.     

Capturing intervention effects over time: reanalysis of a critical time intervention for homeless mentally ill men

OBJECTIVES: We analyzed whether a method for identifying latent trajectories--latent class growth analysis (LCGA)--was useful for understanding outcomes for individuals subject to an intervention. METHODS: We used LCGA to reanalyze data from a published study of mentally ill homeless men in a critical time intervention (CTI) program. In that study, 96 men leaving a shelter's on-site psychiatric program were randomly assigned to experimental and control groups. The former received CTI services and the latter usual services. Each individual's housing circumstances were observed for 18 months after program initiation. Our outcome measure was monthly homelessness: a person was considered homeless in a month if he was homeless for even 1 night that month. RESULTS: Four latent classes were found among the control group, but just 3 among the experimental group. Control, but not experimental, group individuals showed a small class of chronically homeless men. The size of the never-homeless class was 19 percentage points larger for the experimental than for the control group. J- and inverted-U-shaped patterns were also found among both groups, but with important differences in timing of patterns. CONCLUSIONS: Our results reveal effects not apparent in the original analysis, suggesting that latent class growth models improve intervention evaluation.