Risk of incarceration and clinical characteristics of incarcerated veterans by race/ethnicity

Purpose

Unprecedented growth in the US prison population has highlighted the overrepresentation of racial/ethnic minorities in prisons. This study examined the hypothesis that veteran status is protective against incarceration for veterans of different racial/ethnic minorities and compared the clinical characteristics of incarcerated veterans by race/ethnicity.

Methods

Using national data from a prisoner re-entry program and data from the 2010 National Survey of Veterans, this study examined the risk of incarceration among veterans who were racial/ethnic minorities and compared sociodemographic and clinical characteristics to White incarcerated veterans.

Results

Of a sample of 30,834 incarcerated veterans, 52 % were White, 39 % African American, 7 % Hispanic, and 2 % were categorized as “Other.” African American veterans were 5.6 times and Hispanic veterans 4.3 times more likely to be incarcerated than White veterans across age groups. However, the published odds of being incarcerated as an African American in the general population compared to Whites (6.7 times) is higher, suggesting that veteran status may be somewhat protective against incarceration for African Americans, particularly among certain age groups. Among incarcerated veterans, multivariate analyses found that African American veterans were significantly more likely to have a drug/abuse dependency diagnosis and be currently incarcerated for a drug offense than Whites. Hispanic veterans were significantly more likely to be chronically homeless and also more likely to be incarcerated for a drug offense.

Conclusions

Racial/ethnic differences in incarceration persist among veterans, although are slightly attenuated. Efforts to connect incarcerated veterans with mental health services post-release should be supported, especially in connecting veterans to substance abuse treatment.     

Incarceration Histories of Homeless Veterans and Progression Through a National Supported Housing Program

There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.     

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.     

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.     

Factors Associated with Receipt of Pension and Compensation Benefits for Homeless Veterans in the VBA/VHA Homeless Outreach Initiative

Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.     

Changes in Satisfaction with Mental Health Services Among Blacks,Whites, and Hispanics in the Department of Veterans Affairs

This paper presents an analysis of changes in satisfaction of minorities with inpatient mental health services provided by the Veterans Health Administration (VHA) during a period of major system change (1995-2001). Post discharge data from 16,223 veterans who received inpatient VHA mental healthservices at 87 medical centers during this period was examined using hierarchical linear models. Blacks were found to have higher satisfaction levels on most measures over the period of study while the satisfaction of whites and Hispanics were not significantly different. There was little change over the study period in the relative satisfaction of minorities and whites. Changes in patterns of VHA mental health care have not adversely affected the satisfaction of minority veterans.     

Conduct disorder behaviors, childhood family instability, and childhood abuse as predictors of severity of adult homelessness among American veterans

Purpose

Despite US federal efforts to end and prevent homelessness among veterans, there has been limited examination of pre-military factors like childhood problems, associated with adult homelessness. This study examined childhood problems among homeless veterans and its relation to severity of homelessness and outcomes in supported housing.

Methods

Using data from 1,161 homeless veterans at 19 sites enrolled in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program, three types of childhood problems were examined: conduct disorder behaviors, family instability, and childhood abuse. Multiple regressions were conducted to examine the association between childhood problems and severity of homelessness before supported housing, and childhood problems and outcomes after supported housing.

Results

About one-third reported conduct disorder behaviors, over half reported family instability, and 40 % reported childhood abuse. Greater childhood problems were found in this sample compared to published samples of non-homeless veterans. Conduct disorder behaviors, family instability, and childhood abuse were each weakly associated with lifetime homeless episodes. One year after enrollment in the HUD-VASH program, past conduct disorder behaviors and family instability were not predictive of outcomes, except childhood abuse was related to less social support and lower quality of life.

Conclusions

These findings demonstrate not only the potential impact of childhood abuse on social relationships and quality of life in adulthood, but also the resilience of homeless veterans from adverse childhoods to be successfully housed in a supported housing program.     

Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans.

Clinical data were gathered on 627 homeless Vietnam veterans evaluated in a Department of Veterans Affairs clinical program for homeless mentally ill veterans. More than two-fifths (43 percent) of the 627 veterans showed evidence of combat stress that was associated with more severe psychiatric and substance abuse problems, although not with greater social dysfunction. In comparison with Vietnam veterans assessed in a national epidemiological study, homeless veterans were severely socially and vocationally dysfunctional. While homeless mentally ill veterans with combat stress used VA mental health services more frequently than did homeless mentally ill Vietnam veterans with other disorders, many received no mental health services. Combat stress appears to be a significant problem among homeless mentally ill Vietnam veterans.     

Psychiatric illness and substance abuse among homeless Asian-American veterans

OBJECTIVES: This study examined the proportion of Asian Americans among homeless veterans and among veterans in the general population to calculate the relative risk of homelessness among Asian-American veterans. It also examined differences in rates of psychiatric and substance use disorders between homeless racial and ethnic subgroups. METHODS: Data were gathered between 1997 and 2001 from the Health Care for Homeless Veterans program and included data from administrative intake, patients' self-reports, and clinicians' diagnostic assessments of substance use disorders and psychiatric illness. RESULTS: Data were examined for 67,441 veterans. Asian-American veterans had a significantly lower risk of homelessness than veterans of other ethnic groups. Alcohol abuse was significantly and consistently less prevalent among Asian Americans compared with blacks and Hispanics. However, drug abuse was less prevalent among Asian Americans than among blacks and Hispanics, but rates were similar to those of whites. CONCLUSIONS: Lower rates of alcohol abuse may protect Asian-American veterans from becoming homeless.     

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.     

Who is served by programs for the homeless? Admission to a domiciliary care program for homeless veterans

Demographic and clinical data are presented on 4,138 veterans assessed in the 20-site Department of Veterans Affairs (VA) Domiciliary Care for Homeless Veterans program during its first year of operation. More than two-thirds of the veterans who were screened had been hospitalized in VA medical centers during the year before assessment, and 34 percent were hospitalized at the time of assessment. Compared with veterans who were not admitted for residential treatment, veterans who were admitted were more likely to be previously involved in mental health treatment, literally homeless rather than at risk for homelessness, and without public financial support. Specialized service programs for the homeless such as the VA domiciliary care program may also be called on to play a broader role in the discharge and rehabilitative efforts of public mental health service systems.     

Posttraumatic Stress Disorder and Use of Psychiatric and Alcohol Related Services: The Effect of the 2004–2005 Florida Hurricane Seasons on Veterans

The purpose of this study was to document preliminary findings of the association between posttraumatic stress disorder (PTSD), mental health service use, and alcohol related health visits among veterans following 2004–2005 Florida hurricane seasons. A retrospective review of the Veterans Health Administration Medical SAS Outpatient Dataset was conducted to identify veterans residing in Florida during the 2004–2005 hurricane seasons with a history of PTSD and/or PTSD and a substance use disorder. It was found that veterans with PTSD residing in counties affected by hurricanes demonstrated an immediate 28 % increase in use of mental health services following hurricane landfall versus veterans residing in non-hurricane affected counties (+28.0 vs. ?6.5 %, p = 0.001). Additionally, veterans residing in affected counties were found to use more group psychotherapy treatment sessions overall (30.3 vs. 27.2 %, p = 0.001). Of note, veterans with PTSD experienced a ?0.16 per month (p = 0.114) decrease in alcohol related visits following the 2004 hurricane season. These findings provide insight into the mental health needs of veterans with PTSD following a disaster and can inform delivery of services to veterans with PTSD and alcohol related issues in disaster prone areas.     

The relative health related quality of life of veterans with Parkinson's disease

OBJECTIVES: To use databases of the US Veterans Health Administration (VHA) to describe the impact of Parkinson's disease on health related quality of life (HRQoL) of veterans; to compare the HRQoL of veterans with Parkinson's disease with that of veterans reporting eight other neurological or chronic conditions; and to estimate the unique effect of Parkinson's disease on HRQoL. METHODS: Respondents to the VHA 1999 large national health survey of veteran enrollees with a diagnosis of Parkinson's disease in VHA treatment files for the fiscal years 1997-1999 were identified by merging databases. The survey incorporated the Veterans SF-36, a well validated generic measure of HRQoL and functional status. This was used to compare patient groups. Mean physical (PCS) and mental (MCS) component summary scores were calculated for Parkinson's disease and eight other diseases by multivariable regressions that adjusted for age, sex, race, education, and 15 mental and physical co-morbid conditions that were self reported in the survey. RESULTS: Of 887 775 survey respondents, 14 530 (1.64%) had a Parkinson's disease diagnosis. Controlling for sociodemographic factors and co-morbidities, veterans with Parkinson's disease had PCS and MCS below veterans with angina/coronary heart disease, arthritis, chronic low back pain, congestive heart failure, diabetes, and stroke. Veterans with spinal cord injury reported slightly lower PCS than veterans with Parkinson's disease (32.38 v 32.72; 0.03 of 1 SD). Veterans with depression reported markedly lower MCS than veterans with Parkinson's disease (35.94 v 41.48; 0.55 of 1 SD). The unique effect of having Parkinson's disease on HRQoL was to lower PCS and MCS by 4.10 and 3.42 points (0.41 and 0.34 of 1 SD), respectively. CONCLUSIONS: The analysis quantifies the negative impact of Parkinson's disease on HRQoL, after controlling for sociodemographic factors and co-morbidities. Compared with eight other chronic conditions, Parkinson's disease imposes a relatively heavy burden on US veterans in the VHA health care system.     

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.     

The Use of Data to Assist in the Design of a New Service System for Homeless Veterans in New York City

OBJECTIVE: Operation Home is an agreement between the City of New York and the US Department of Veterans Affairs to design a new service system to help end veteran homelessness in New York City. The authors' task was to obtain data to inform the design of this new system. METHODS: A variety of methods were used. The group reviewed relevant literature and data from street homeless survey samples, analyzed shelter data, and consulted with VA homeless program staff on the findings. We then surveyed case managers at a veterans' shelter regarding their clients and determined their housing eligibility using a standardized logic model, and led two focus groups of veterans at this shelter regarding their views of the current shelter system and services for homeless veterans and how these might be improved. RESULTS: Among those resident in shelters during 2006, 37.2% of self-identified veterans compared to 0.9% of others reported their prior residence as supported housing, suggesting the need for more intensive case management at veterans' supported housing sites to help them sustain their tenure. The lack of interconnectedness among the various information systems made it more difficult to collect and analyze pertinent data. To begin to address this, a data match was undertaken to estimate the proportion of veterans resident in the veterans' shelter who were not in receipt of VA benefits to which they may be entitled. CONCLUSION: The data obtained through collaboration between staff from NYC's Department of Homelessness Services, US Department of Veterans Affairs facilities in the New York/New Jersey region and Common Ground Community led to information that informed the evaluation design of the new system. The identification of gaps in available data on homeless veterans will lead to projects both to improve and share data.     

Rates and Correlates of Suicidality in VA Intensive Case Management Programs

There has been extensive concern about suicide among veterans, but no study has examined rates and correlates of suicidality in the highly vulnerable group of veterans receiving Veterans Health Administration (VHA) intensive case management services. Veterans participating in a national program evaluation were surveyed at the time of program entry and 6 months later. Sociodemographic and clinical characteristics were documented along with elements of program service delivery. Chi square tests were used to compare rates of suicidality (defined as either having made or threatened an attempt) at baseline and at the 6-month follow-up. Analysis of variance was also used to compare suicidal and non-suicidal veterans at follow-up. Logistic regression analysis was then used to identify independent correlates of suicidality 6 months after program entry. Among the 9921 veterans who later completed follow-up assessments 989 (10.0%) had reported suicidal behavior at program entry as compared to only 250 (2.51%) at 6 months (p?<?0.0001). Multivariable logistic regression analysis showed suicidality at 6 months to be associated with suicidality at admission, increased subjective distress on the Brief Symptom Inventory (especially on depression items), violent behavior and decreased quality of life since admission, along with a greater likelihood of receiving crisis intervention, but not other services. Among veterans receiving intensive case management services from VHA, suicidal behavior declined by 75% from admission to 6 months (10–2.5%) and was associated with suicidality prior to program entry, worsening subjective symptoms and greater receipt of crisis intervention services.

     

上海流浪精神分裂症患者心血管危险因素患病率的回顾性评估(英文)

背景:心血管疾病在中国日益增长,但是贫困精神病患者心血管疾病的危险因素患病率尚不明确。目标:评估无家可归的精神分裂症患者中心血管疾病四个主要危险因素的患病率-高血压,高血糖,高血脂及吸烟-并确定与这些危险因素相关的因素。方法:我们回顾了从2007年5月到2013年4月期间,在上海嘉定精神卫生中心住院的精神分裂症以及分裂样精神病患者病历,包括181名无家可归的患者和181非无家可归的患者。比较了两组间人口学特征和心血管事件的危险因素。使用逻辑回归模型确定了与四个风险因素中一种或多种存在关联的因素。结果:两组患者的高血压和高血脂症的患病率范围为19%到20%(男性和女性的患病率范围相同);这些比率和一般人群报道的相似。两组患者的高血糖患病率介于11%和15%之间(男性和女性的患病率范围相同)。在男性患者中吸烟是非常普遍的(无家可归男性吸烟率82%,非无家可归男性吸烟率78%),但是在中国女性患者吸烟远没有那么普遍(无家可归女性吸烟率7%,非无家可归女性吸烟率5%)。Logistic回归分析发现,男性,年龄,城市(与农村相比)与四大心血管危险因素中的一种或多种独立相关。无家可归与心血管危险因素的患病率不相关。结论:本研究是对中国流浪精神病患者的心血管危险因素的第一个研究报告。这项研究有几个重要因素没有评估(如抗精神病药物的类型、剂量和使用时间),尽管如此,该研究还是能表明在中国,流浪与精神疾病患者心血管疾病风险增高无关,与高等收入国家不同。对于中国不断增多的流浪者而言,还需要进一步的前瞻性研究来探索他们所需的最佳医疗服务模式。     

Suicidal behavior among homeless people in Japan

Purpose

The purpose of this study is to investigate the frequency and correlates of suicidal behavior among homeless people in Japan.

Methods

A face-to-face survey was conducted in two districts of Tokyo, Japan, with 423 subjects who resided on streets and riversides and in urban parks and stations (street homeless) or who were residents of shelters, cheap hotels, or welfare homes for homeless people (sheltered homeless).

Results

When questioned about suicidal ideation in the previous 2 weeks, 51 subjects (12.2 % of valid responses) had a recurring wish to die, 29 (6.9 %) had frequent thoughts of suicide, and 22 (5.3 %) had made suicide plans. In addition, 11 (2.9 %) subjects had attempted suicide in the previous 2 weeks and 74 (17.7 %) reported that they had ever attempted suicide. In univariate logistic regression analyses, street homelessness, lack of perceived emotional social support, poor subjective health perception, visual impairment, pain, insomnia, poor mental well-being, and current depression were significantly associated with recurrent thoughts of suicide in the previous 2 weeks. Among these, current depression had the greatest significance. In multivariate logistic regression analyses after controlling for depression, street homelessness and lack of perceived emotional social support were significantly associated with recurrent thoughts of suicide in the previous 2 weeks.

Conclusion

Comprehensive interventions including housing and social support as well as mental health services might be crucial as effective strategies for suicide prevention among homeless people.