Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.     

Homelessness in the state and federal prison population

AIMS: This study sought to investigate the rates and correlates of homelessness (i.e. living on the street or in a homeless shelter), including mental illness, among US adult state and federal prison inmates (ASFPIs). METHOD: Data from a national survey of ASFPIs based on a random sampling survey (N = 17,565) were used to compare the homelessness rate among AFSPIs with that in the general population. Logistic regression was then used to examine the association of homelessness among ASFPIs with factors including symptoms, treatment of mental illness, previous criminal justice involvement, specific crimes, and demographic characteristics. RESULTS: Nine percent of ASFPIs reported an episode of homelessness in the year prior to arrest, 4-6 times the estimated rate in the general US adult population after allowing for age, race/ethnicity, and gender. In comparison to other inmates, these homeless inmates were more likely to be currently incarcerated for a property crime, but also to have had previous criminal justice system involvement for both property and violent crimes, to suffer from mental health and/or substance abuse problems, and to be more likely to have been unemployed and with a low income. CONCLUSIONS: Recent homelessness is far more common among ASFPIs than the general population. Prior incarceration, mental illness, substance abuse and disadvantageous socio-demographic characteristics were all found to be associated with homelessness among prison inmates, suggesting that there are several important factors in addition to efforts to survive with limited resources through criminal acts that influence the rates of homelessness among incarcerated individuals.     

Homelessness and indicators of mental illness among inmates in New York City's correctional system.

Data from three cross-sectional samples of inmates in the New York City correctional system (N = 299, 236, and 151) were analyzed to determine the prevalence of homelessness among detainees. One-fourth to one-third of each sample had been homeless at some time during the two months before arrest, and 20 percent of the primary sample of 299 inmates had been homeless the night before arrest. Further analysis of the primary sample showed that homelessness was strongly associated with mental illness: 50 percent of those who had ever been homeless during the past three years responded positively to at least one mental illness screening question, compared with 25 percent of the never-homeless inmates. More than a third of the ever-homeless group had received mental health treatment, compared with a fifth of those who had never been homeless.     

Commentary: substance abuse and criminality in the mentally disordered defendant

This commentary discusses the main findings of the research study by Friedman et al. entitled, "Gender Differences in Criminality: Bipolar Disorder with Co-occurring Substance Abuse." Moreover, it shows that the role of substance use should be determined in studies that assess outcomes among co-occurring disorders, such as bipolar disorder and criminal behavior. High rates of substance-related problems were recorded in the study by Friedman et al. Fifty-six percent of the patients with dual-diagnosis, rapid-cycling bipolar disorder had been charged with drug- or alcohol-related offenses. Significantly more men (69%) had incurred substance-related charges than had women (38%). Women who abused cocaine were more likely to be charged with a crime than were those who had not. Sixty-five percent of the women in the study who abused cocaine had been previously charged with a crime, compared with 38 percent of the women who did not; but this finding did not hold true for the men. The number of crimes committed by the men who abused cocaine and by those who did not was about the same. This article also provides an overview of the role of substance use in criminal behavior and how substances of abuse can affect bipolar disorder and criminal outcomes.     

Prediction of homelessness within three months of discharge among inpatients with schizophrenia.

OBJECTIVE: The authors' goal was to identify factors that place inpatients with schizophrenia at risk of becoming homeless after hospital discharge. METHODS: Patients with schizophrenia or schizoaffective disorder (N=263) were assessed at discharge from general hospitals in New York City and reassessed three months later to evaluate whether they had become homeless. Sociodemographic and clinical characteristics associated with homelessness were identified using likelihood ratio chi square analysis and logistic regression. RESULTS: Twenty patients (7.6 percent) reported an episode of homelessness during the follow-up period. Patients who had a drug use disorder at hospital discharge were significantly more likely to report becoming homeless than those without a drug use disorder. Patients with a total score above 40 on the Brief Psychiatric Rating Scale (BPRS) at hospital discharge were more likely to report becoming homeless than patients with lower scores, as were those with Global Assessment Scores less than 43. Twelve of 30 patients with a drug use disorder, a BPRS score above 40, and a GAS score less than 43 at hospital discharge reported becoming homeless. CONCLUSIONS: The combination of a drug use disorder, persistent psychiatric symptoms, and impaired global functioning at the time of hospital discharge poses a substantial short-term risk of homelessness among patients with schizophrenia. Patients who fit this profile may be candidates for community-based programs that are specifically aimed at preventing homelessness among patients with severe mental illness.     

Availability of behavioral health treatment for women in prison

OBJECTIVES: This study examined whether women with behavioral health needs are more likely to receive treatment for these problems in prison or in the community and to what extent prison disrupts or establishes involvement in treatment for these women. METHODS: Data were collected in August 2004 as part of a population survey of female inmates in the only state correctional facility for women in New Jersey. RESULTS: A total of 908 women were surveyed. Fifty-six percent of the women surveyed reported needing behavioral health treatment before incarceration, but only 62 percent of this group reported receiving such treatment in the community. The rate at which treatment matched need within this population before incarceration varied by type of treatment needed: it was the highest (58 percent) for women who needed treatment for mental health problems, lower (52 percent) for those who needed substance abuse treatment, and lowest (44 percent) for those who needed treatment for comorbid mental health and substance abuse problems. In comparison, the rate of match between need for and receipt of treatment in prison was higher for all three types of behavioral health treatment (78 percent, 57 percent, and 65 percent, respectively). Additionally, the findings suggest that prison did not disrupt the type of behavioral health treatment that inmates had previously received in the community. CONCLUSIONS: At least in New Jersey, prison appears to improve access to behavioral health treatment among female inmates. Although this conclusion is consistent with the rehabilitation goals of incarceration, it also suggests that some women may have been able to avoid prison if treatment had been provided in the community, especially for substance-related problems.     

Psychiatric disorders in homeless men and women in inner Sydney

OBJECTIVE: To determine the 12-month prevalence of mental disorders among homeless people in inner Sydney and compare this data with data collected on homeless populations in other Western cities. METHOD: Representative sample of 210 homeless men and women in Sydney were interviewed using the Composite International Diagnostic Interview (2.0). RESULTS: Seventy-three percent of men and 81% of women met criteria for at least one mental disorder in the past year and 40% of the men and 50% of the women had at least two mental disorders. The prevalence rate of schizophrenia among men and women was 23% and 46%, respectively. There was considerable comorbidity between mental disorders with one in five men (20%) and 29% of women meeting criteria for two mental disorders. The prevalence of any mental disorder is four times higher among homeless men and women in inner Sydney than within the Australian general population. International comparisons demonstrated significant cross-cultural differences in the prevalence of mental disorders among the homeless. CONCLUSIONS: This paper highlights the need for comparable epidemiological data when examining an international problem such as homelessness.     

Risk of Reincarceration Among Prisoners with Co-occurring Severe Mental Illness and Substance Use Disorders

This study examined whether the presence of a comorbid substance use disorder increased the risk of criminal recidivism and reincarceration in prison inmates with a severe mental illness. Our analyses of more than 61,000 Texas prison inmates showed that those with a co-occurring psychiatric and substance use disorder exhibited a substantially higher risk of multiple incarcerations over a 6-year period compared to inmates with psychiatric disorders alone or substance use disorders alone. Further research is needed to identify the factors associated with criminal recidivism among released prisoners with co-occurring disorders.     

Health status,service use,and costs among veterans receiving outreach services in jail or community settings

OBJECTIVE: This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS: Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS: The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS: Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.     

A public health perspective on violent offenses among persons with mental illness

OBJECTIVE: This study reanalyzed existing data to assess the extent to which persons with mental illness might contribute to criminal violence in the community. METHODS: Data were examined from a representative sample of 1,151 remanded offenders who underwent a full structured diagnostic interview that was used to provide one-month prevalence rates of mental illnesses as defined by the Structured Clincal Interview for DSM-III-R. Diagnoses of interest were mood, psychotic, anxiety, psychoactive substance use, adjustment, and miscellaneous axis I disorders and axis II personality disorders. Criminological data describing the number of offenses against persons and property and the number of victimless crimes were abstracted from police arrest reports and warrants. A violent crime was defined as any crime against a person. RESULTS: The one-month prevalence of major mental and substance use disorders of newly admitted inmates was 61 percent. About 3 percent of violent offenses could be attributed to individuals who had a principal diagnosis of any non-substance use-related disorder. An additional 7 percent of violent offenses could be attributed to individuals who had a primary diagnosis of a substance use disorder. CONCLUSIONS: The results of the study support the hypothesis that people with mental and substance use disorders are not major contributors to police-identified criminal violence. Public perceptions of mentally ill persons as criminally dangerous appear to be greatly exaggerated.     

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.     

The Nexus of Trauma,Victimization, and Mental Health Disorders Among Incarcerated Adults in Spain

Victimization and exposure to trauma, commonly linked to co-occurring mental health disorders, are prevalent among prison populations. The purpose of this study is to shed light on the prevalence of various kinds of victimization and trauma exposure at distinct life stages (childhood, adulthood and during prison) among incarcerated persons in Spain. The research team surveyed a random sample of 453 male and female inmates, serving time in two Spanish prisons, to gather information on experiences of physical and sexual victimization in both childhood and adulthood along with the presence or absence of in-prison treatment for a mental health disorder(s). More than 80% of participants reported experiencing some kind of traumatic/shocking life event – and this was significantly higher for those receiving in-prison mental health treatment than their non-treated counterparts (96.3 versus 83.3%, respectively). Logistic regression analyses revealed that inmates who were receiving in-prison treatment for a mental health disorder reported significantly higher rates of both physical and sexual victimization in prison, prior to prison, and during childhood. The results of this study strongly suggest the importance of comprehensive and accurate identification of inmates’ traumatic, victimization, and mental health histories that necessitate treatment during incarceration. We discuss the implications of our study for correctional practice, policy and future research in order to reduce victimization in the Spanish Prison System.     

Homelessness and child welfare involvement: risks for co-occurring mental health symptoms and substance use?

The association between homelessness, current or past history of child welfare involvement and substance use is a concern in Canada. As a result, the youth often share common experiences of maltreatment, victimization, mental health symptoms and substance use. This study was designed to examine the factors associated with co-occurring mental health symptoms and substance use among 219 youth participants aged 16–21: 150 were homeless and 69 currently involved with child welfare. Two data sets were used to conduct the analyses: The Youth Pathways Project and the Maltreatment and Adolescent Pathways Longitudinal Study. The results indicate that youth who were homeless experience significant mental health symptoms and substance use, particularly when there is a history of involvement in child welfare. Homelessness is also associated with co-occurring mental health symptoms and substance use when there is a history of child welfare involvement whereas current child welfare involvement without homelessness appears to be protective. Implications for interventions and policy development are discussed, with reference to strategies targeting both youth who are homeless and those with a history of child welfare involvement.     

Gambling disorders among homeless persons with substance use disorders seeking treatment at a community center

OBJECTIVES: Epidemiological research suggests that homelessness is a risk factor for elevated levels of psychiatric comorbidity and other health risks. This study examined the prevalence of disordered gambling and its association with treatment of psychiatric and substance use disorders among a cohort of homeless people seeking treatment at a community services program. METHODS: Between 1998 and 2000, intake workers evaluated the level of gambling disorder among 171 consecutive homeless persons with substance use disorders who sought treatment at the Moving Ahead Program in Boston. Program staff administered the DSM-IV subscale of the Massachusetts Gambling Screen at intake. RESULTS: The prevalence rates of level 2 and level 3 gambling disorders were 12.8 percent and 5.5 percent, respectively. These rates are higher than that of the general adult population but comparable to those of other patients with substance use disorders and psychiatric diagnoses. Program participants with level 3 gambling disorders had been homeless more often and at a younger age and had had less substance abuse treatment and more psychiatric treatment than participants with level 1 or level 2 gambling disorders. Participants with level 2 gambling disorders had been homeless more often and for a longer duration than participants without gambling disorders. CONCLUSIONS: These findings should encourage clinicians working with homeless people to screen for gambling-related problems and disorders.     

Alcoholism in homeless men in the mid-nineties: results from the Bavarian Public Health Study on homelessness

Summary Parallel to structural economic changes homelessness has become publicly more visible and has received increased media attention in Western industrialized countries. Most studies on mental illness and homelessness in recent years were carried out in North America but only few studies in Europe have dealt with these issues. The goals of the present study were (1) to assess alcohol abuse and dependence as well as other mental disorders in a representative sample of homeless men in Munich using reliable methods of case identification (Structured Clinical Interview for DSM-IV (SCID)), (2) to compare homeless alcoholics with homeless non-alcoholics in our sample on relevant variables, and (3) to compare our data from the Munich sample with data obtained by others. According to our results, the life-time prevalence of any SCID-DSM-IV Axis I diagnoses was 93.2% and the life-time prevalence of substance use disorder was 79.6%. The single most prevalent diagnosis among homeless males in Munich was alcohol dependence (life-time 72.7%); alcohol abuse (life-time 5.5%) and drug abuse/dependence were considerably lower in prevalence (life-time 19.1%) (weighted data). A higher rate of psychotic disorders was found for non-alcoholic homeless men. Data show that alcoholism and its consequences were more severe in the Munich as compared to North American samples. Homeless alcohol dependent men showed a high comorbidity with other mental disorders (life-time) such as mood disorders (36.4%), anxiety disorders (16.4%), drug abuse/dependence (18.9%) and psychotic disorders (4.5%). Of those with alcohol dependence at some time during their life 59.1% had experienced at least one other life-time mental disorder. Alcohol-related behavioral patterns and symptoms as well as general social functioning are described. Considering the very high prevalence of alcohol dependence (frequently in combination with other mental disorders), the participation in alcohol rehabilitation and other services as well as self-help groups was rather low among Munich homeless alcoholics. Currently homeless men in Germany are adequately supplied with food, clothes, and shelter but psychiatrically (and medically) neglected. Existing concepts and programs for dealing with these problems need to be implemented. Received: 8 June 1998 / Accepted: 13 October 1998     

Housing instability and homelessness among rural schizophrenic patients

OBJECTIVE: The authors examined housing instability among treated schizophrenic patients in a rural area and compared the findings with those from their previous study of urban patients. METHOD: Seventy-five patients with schizophrenia or schizoaffective disorder who were treated in a rural mental health center were assessed with research interviews and ratings by their clinical case managers. The patients were followed for 1 year to identify episodes of psychiatric hospitalization, incarceration, and literal homelessness. RESULTS: Of the 75 patients, 19 (25%) had housing situations characterized as unstable by their case managers. For the majority, housing instability signified tenuousness of living arrangements rather than literal homelessness. Noncompliance with medications, alcohol use, and negative symptoms accounted for 30% of the variance in unstable housing. During follow-up, the unstably housed patients, compared to those in stable living situations, were no more likely to be rehospitalized but were somewhat more likely to be jailed and significantly more likely to be literally homeless. CONCLUSIONS: In the authors' previous study of urban psychiatric patients, unstably housed patients were more likely to be literally homeless, highly symptomatic, and rehospitalized during follow-up than the rural patients with unstable housing. Better outcomes in the rural area appeared to be related to the greater availability of housing alternatives and to intensive case management. For patients with unstable housing in both settings, noncompliance with medications and substance abuse, as well as housing arrangements, should be assertively addressed.     

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.     

Childhood risk factors for criminal justice involvement in a sample of homeless people with serious mental illness

It has been suggested that criminal justice involvement among the homeless, particularly those with mental illness, is largely situational. The objective of this study was to assess, in a sample of homeless seriously mentally ill people, the prevalence of childhood conduct disorder behaviors as a risk factor for adult criminal activity as well as the extent and types of adult criminal justice contact. Data were taken from the national ACCESS program, which conducted extensive baseline interviews with 7,222 homeless seriously mentally ill adults. The interview assessed demographics, childhood risk factors for criminal activity such as conduct disorder behaviors, foster care, and parental abuse, as well as current illness severity and recent criminal justice contact. The 2-month arrest rate in this sample was much higher than national rates (11% compared with 1% annually in the general population). Although most arrests were for minor crimes (10.8%), there were also substantial rates of arrest for major (2.7%) and substance-related charges (2.0%). The prevalence of a history of conduct disorder behavior was also substantial (55% in male subjects, 40% in female subjects), and conduct disorder was a strong predictor of recent criminal justice involvement, even after controlling for other predictors of arrest (odds ratio = 1.76 for major crimes, 1.49 for minor crimes, and 1.98 for substance-related crimes). Recent literature has criticized a trend to criminalize homeless mentally ill persons for attempting to get needed food, shelter, or medical attention. However, these data indicate that at least some proportion of arrests in this population are of people who have been exhibiting antisocial behavior since early adolescence, and that early antisocial behavior is a strong predictor of all types of recent arrests in this population.