The International Journal of Psychosocial Rehabilitation

 

Homeless Mentally Ill Persons: A bibliography review

 

Garcia Nieto, R., Ph.D1

Gittelman, M., Ph.D2,3.

Abad, A., MD4.

1 Clinical Psychologist. “Doctor Villacian” Mental Hospital (Spain)

2 NYU-OMH- Program for Advanced Studies in Psychosocial Rehabilitation, USA.

3 Department of Psychiatry, NYU, Medical Center. Manhattan Psychiatric Center, New York, NY 10035.

4 Assisstant Professor in Psychiatry- Research Unit 20 North Chief
   NYU School of Medicine- Department of Psychiatry, Bellevue Hospital Center, New York



Citation:
Nieto G., Gittelman M., Abad A.   (2008). Homeless Mentally Ill Persons: A bibliography review.
  International Journal of Psychosocial Rehabilitation. 12 (2),

 



Abstract
In this article, some of the most important worldwide studies concerning the homeless mentally ill persons are reviewed. Firstly, the psychosocial and demographic characteristics of homeless people in different countries are compared. A historical overview of the issue is also provided so that the reader can fully grasp the complexity of this current problem. Secondly, the relationship between homelessness and mental illness is examined. As we put forward in the fourth and fifth parts of our study, the findings of many studies support the conclusion that the homeless mentally ill  are at a higher risk for dying prematurely in comparison with the general population due to the mental illness they are suffering from and owing to their homelessness situation as well. Not only, do they die early, but also they have a poorer quality of life than that of the general population.  Later on, the main conclusions reached in the articles that have been reviewed are analyzed. Our literature review sheds light on some of the causes of the complex phenomenon of homelessness. These causes should be taken into account when fighting against homelessness and developing preventive programs. Finally, some of the initiatives that have been carried out to end up with this huge problem are studied in-depth in order to suggest recommendations for best practices.
Key words:  Homelessness, Mentally-ill people, Mortality rates, Bibliographic review, Preventive programs.


Homeless People: A worldwide vision
Completely accurate and comprehensive statistics are difficult to acquire for any social study, but this is especially true when it comes to the ambiguous, hidden, and erratic reality of homelessness. Although each country has a different approach to counting homeless people and, therefore, comparisons should be made with caution, some of the most recent statistics (1) indicate that the approximate average number of homeless people at any given time in the European Union is 3,000,000; 750, 000 in the U.S. (1% of the entire U.S. population); 200,000 in Canada and 99,000 in Australia.
 
Canada is viewed by many as having far too high a number of homeless people, with some of the highest per capita rates of any developed nation. For instance, Canada has about 200,000 homeless, while the United States, with nine times Canada's population, has only 750,000.
 
Besides, the number of homeless people worldwide has grown steadily in recent years. In some Third World nations such as Brazil, India, Nigeria, and South Africa, homelessness is rampant, with millions of children living and working on the streets. In spite of their growing prosperity, homelessness has also become a problem in the cities of China, Thailand, Indonesia, and the Philippines.
 
The number of Americans living below the poverty threshold, officially defined on the basis of a standard of consumption updated every year to take inflation into account, rose from 29 million in 1980 to 39 million in 1993 (2). The rate of poverty has risen from 11.4% in 1978 to 15.1% in 1993 for the entire American population, from 30.6% to 33.1% for Blacks, from 21.6% to 30.6% for Hispanics.
 
Regarding ethnicity (3), it is estimated that, in the U.S., 49% are African-American (compared to 11% of general population); 35%  are Caucasian (compared to 75% of general population), 13% are Hispanic (compared to 10% of general population), 2% are Native American (compared to 1% of general population) and 1% are Asian-American (compared to 3% of general population).
 
40% are families with children, 41% are single males, 14% are single females and 5% are minors unaccompanied by adults. It is noteworthy that 1.37 million (or 39%) of the total homeless population are children under the age of 18 (3).  
 
With regard to their educational level, 38% have less than a High School diploma , 34% have a High School diploma or equivalent (G.E.D.); 28% have more than a High School education (3).
 
Only 13% have regular jobs and 50% receive less than $300 per month as income. Regarding their location: 71% reside in central cities; 21% are in suburbs and 9% are in rural areas (3).
 
With regard to health concerns (4), it is estimated that 22% are considered to have serious mental illnesses; 30% have substance abuse problems; 3% report having HIV/AIDS; 26% report acute health problems other than HIV/AIDS such as tuberculosis, pneumonia or sexually transmitted infections; 46% report chronic health conditions such as high blood pressure, diabetes or cancer and 55% report having no health insurance (compared to 16% of general population).
 
Traditionally, single men have constituted the overwhelming majority of the homeless. In the 1980s there was a sharp rise in the number of homeless families in certain parts of the United States; notably New York City. Most homeless families consist of an unmarried mother and children. A significant number of homeless people are teenagers and young adults, mostly runaways or street children. A 1960 survey by Temple University of Philadelphia's poor neighborhoods (5) found that 75% of the homeless were over 45 years old, and 87% were white. In 1986, 86% were under age 45, and 87% were minorities.
 
The increasing numbers of homeless in the cities raises the question of the extent and causes of this situation. As it has been shown above, homelessness has become a worldwide problem. The increase of "borderline" or "at risk" situations are accompanied by a fall in the low cost housing and other rooms that might be accessible to the poorest. A policy of prevention must remain a priority objective to avoid them finding themselves on the street.
 
By comparing the sociodemographic characteristic of homeless people living in different countries, some studies have tried to shed light on the causes of this growing problem. One example of this approach is the study carried out by Marpsat (6). The author of the study came to the conclusion that the age, sex and marital status of homeless people living in France were similar to those of the homeless who lived in the U.S. The homeless on both sides of the Atlantic had a very poor state of health, but alcohol and drug-related problems appeared to be fewer in France. Finally, poverty and structural factors such as a reduction in the availability of low cost housing or the shortage of jobs played a vital role in both countries. From one country to another, some of the characteristics of the homeless were close, like the similarity in the way they lose their housing, but also in the consequences of this situation, for example in terms of health. Other features such as the presence of certain ethnics or national minorities depended on the characteristics of the country. For instance, in the United States, some people who have had a rough passage like the Vietnam War veterans, and ethnic minorities (Blacks, Hispanics, etc.) are worse hit than others. For example, over three years, the likelihood of a Black using a public shelter in New York or Philadelphia is fifteen to twenty times greater than for a White man. In the U.S., it is estimated that 500,000 veterans experience homelessness at some time during the year. Veteran Affairs only provides housing to chronically sick veterans. Summing up, the analysis of the structural causes of the situation in both countries and the individual characteristics of the persons affected bore many similarities.
 
In the United States as well as in France there are fewer older persons among the homeless than among the population with a place to live. The main reason for this is the effect of high mortality among the homeless. In the United States, the mean age on dying scarcely gets beyond fifty for the homeless (2). In this respect, a detailed analysis is carried out in the fourth and fifth parts of our study.
 
Regarding the sex and marital status, the study (6) revealed that, in both countries the proportion of women is well below that of men. More than one-half of the homeless are single, and around a third are divorced or widowers.

HISTORICAL BACKGROUND
Most experts in the field generally agree that modern homelessness began in the U.S. in the 1980s. During Ronald Reagan’s duel-term presidency (1981-1989) a variety of drastic budget reductions are credited with undermining many urban populations, most notably those of poor and minority demographics (7). In his first year of office Reagan halved the budget for public housing and Section 8 (the government’s housing voucher subsidization program). Such changes resulted in an inadequate supply of affordable housing to meet the growing demand of low-income populations.
 
Not only did this situation occurr in the U.S., but also happened in other countries. In the U.K., the Conservative government introduced a programme of “Care in the Community” that provided neither adequate care for the mentally ill nor community support. Between 1988 and 1995 the average daily number of long-stay beds available in hospitals for the mentally ill was cut by half to 18,644. During the same period the proportion of the average hospital budget spent on mental health fell from 14.4 percent to 12 percent.
 
The 1980s also witnessed a continuing trend of deinstitutionalizing mental-health hospitals in the U.S. It is believed that a large percentage of these released patients ended up in the homeless system. The movement in state mental health systems shifted towards community-based treatment as opposed to long-term confinement in institutions. Unfortunately, as a result of the lack of local community programs, many patients ended up in the streets.
 
In response to the ensuing homelessness crisis of the 1980s, concerned citizens across the country demanded that the federal government provide assistance. After many years of advocacy and numerous revisions, Reagan signed into law the McKinney-Vento Homeless Assistance Act in 1987—this remains the only piece of federal legislation that allocates funding to the direct service of homeless people.
 
The McKinney-Vento Act paved the way for service providers in the coming years. During the 1990s homeless sherlters, soup kitchens, and other supportive services sprouted up in cities and towns across the nation. However, despite these efforts and the dramatic economic growth marked by this decade, homeless numbers remained stubbornly high. It became increasingly apparent that simply providing services to alleviate the symptoms of homelessness (i.e. shelter beds, hot meals, psychiatric counseling, etc.), although needed, were not successful at solving the root causes of homelessness.
 
Besides, critics claim that Bill Clinton’s 1996 welfare reforms increased the number of families entering homelessness. At any rate, policies set into motion in the 1980s were never adequately reversed during the Bush Senior or Clinton administrations and disparities between rich and poor continued to widen. Conditions, therefore, remain ripe for becoming homeless.
 
Now, for the first time, government officials are calling for an end to homelessness. To accomplish this goal the Interagency Council on Homelessness (ICH), the federal branch that was created under the McKinney-Vento Act, has adopted a strategy largely devised by the National Alliance to End Homelessnes (one of many homeless advocacy organizations), which centers on the production and implementation of local 10-year plans to end chronic homelessness. The idea is to get all of the necessary parties—local/state governmental agencies, businesses, non-profit organizations, service providers, faith-based entities, and homeless individuals—working in collaboration to devise and implement a 10-year plan for their respective community.
 
Rather than channeling funds into direct services that seemingly sustain homeless lifestyles, these result-oriented plans are designed to focus efforts and funds on the creation of permanent supportive housing (PSH) for the most troubled and difficult, “chronic” homeless population. Considering that it is actually cheaper to house someone than it is to fund the otherwise needed myriad services, this approach is touted as being a cost-effective solution.  
 
Many service providers applaud the government’s focus on ending homelessness, as opposed to managing it, and realize the necessity of incorporating all sectors of society in order to accomplish such a goal. However, critics express concern that the majority of the homeless population, who are not considered “chronic,” will be neglected; if federal funds are stipulated only for this 10% demographic—although no doubt deserving—what will become of the other 90%? These concerns are exacerbated by a failure to receive sufficient additional allocations while already struggling with budgets spread extremely thin.
 
Historically, the main features of homelessness have changed with the passing of time. Over the last two decades the face of homelessness has changed substantially. For instance, in the early 1980s the homeless population in Canada was mostly made up of older men the majority of which had mental health problems or were alcoholics. Today younger men and children make up a large segment of the homeless population. Less than 20% of the homeless have drug or alcohol abuse problems. Almost half of all homeless people have jobs. This change has been attributed to changing economic circumstances that have seen minimum wage jobs no longer be able to pay for accommodation in some of Canada's cities. The federal government has not built subsidized housing since the early 1990s and families and the poor who used to take advantage of these services are now forced to live on the streets.
 
Presently, no plan has been in effect for a full 10-years so achievement is difficult to gauge; the best indications reveal mixed success. Although many cities have seen chronic numbers dip, it is unclear whether or not homelessness as a whole is decreasing. The hope is that necessary modifications can be made to existing plans, and that newly devised plans can implement the strategies that work and avoid the ones that don’t.

THE RELATIONSHIP BETWEEN HOMELESSNESS AND MENTAL ILLNESS
With regard to the link between homelessness and mental illnesses, some studies have been carried out all over the world. In the U.K., the “Pressure Points” report (8) estimates that in a third of all cases, those who lose their accommodation are suffering from mental illness. This perpetuates a vicious cycle in which the stress of homelessness often exacerbates the illness and makes it difficult for those suffering to gain access to housing and healthcare in the future. Once homeless, many mentally ill people can remain without permanent housing for several years. Many local doctors are reluctant to accept the homeless onto their lists.
 
People suffering from serious mental disorders (such as psychotic disorder, severe depression…) find it difficult to maintain a household. It has been estimated that half of all homeless persons have some form of mental illness. In some cases, it is not always clear which came first; the homelessness or the mental illness. According to the National Alliance for the Mentally Ill (NAMI), there are 50,000 mentally ill homeless people in California alone because of deinstitutionalization between 1957 and 1988 and a lack of adequate local service systems (9). The deinstitutionalization has led, according to many authors, to an increase in homelessness. Many mentally ill persons ended up in the strets after being released from mental hospitals.
 
On the other hand, it is estimated that 38% of homeless suffer from a substance abuse problem. Debate also exists about whether drug use is a cause or consequence of homelessness. However, regardless when it arises, an untreated addiction makes moving beyond homelessness extremely difficult.
 
In the U.K., the “Pressure Points” report (8) estimates that:
 
1* Six out of ten homeless people experience some form of mental distress. The homeless are 11 times more likely to suffer from illnesses such as depression, than the general population.
2* One person in five sleeping rough has a severe mental health problem, such as schizophrenia. More than one in six rough sleepers has stayed in a psychiatric hospital as an inpatient.
3* People who sleep rough are 35 times more likely to kill themselves than the general population. The average age of death by suicide for rough sleepers is 37 years old.
 
Mental health problems often start before homelessness and can directly cause a loss of accommodation, but they can also be the reason people remain homeless for many years. In the U.S. 80% of those who experience homelessness do so for less than 3 weeks; 10% are homeless for up to two months 10% are so called “chronic” and remain without housing for extended periods of time on a frequent basis. The “chronic” homeless struggle with mental illness, substance abuse, or both. It appears that suffering from a mental illness or a substance abuse problem might make homeless a chronic problem.
 
The author of the study conducted in France (6) reached the following conclusions:
 
 
MORTALITY RATES AMONG THE MENTALLY ILL
The burden of mental illness on health and productivity in the United States and throughout the world has long been underestimated. Data developed by the massive Global Burden of Disease study (10) conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers.
 
This study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia.
 
Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders.
 
The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020.
 
The facts are that major depression is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older. For women throughout the world depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women.
 
The following chart shows the disease burden in Established Market Economies. This burden is measured in DALYs (lost years of healthy life regardless of whether the years were lost to premature death or disability).
 
 
The Leading Sources of Disease Burden in Established Market Economies.
  Total
(millions)*
Percent
of Total
All Causes 98.7  
1. Ischemic heart disease 8.9 9.0
2. Unipolar major depression 6.7 6.8
3. Cardiovascular disease 5.0 5.0
4. Alcohol use 4.7 4.7
5. Road traffic accidents 4.3 4.4
6. Lung & UR cancers 3.0 3.0
7. Dementia & degenerative CNS 2.9 2.9
8. Osteoarthritis 2.7 2.7
9. Diabetes 2.4 2.4
10. COPD 2.3 2.3
Disease Burden by Selected Illness Categories in Established Market Economies.
    Percent
of Total
All cardiovascular conditions 18.6
All mental illness including suicide 15.4
All malignant disease (cancer) 15.0
All respiratory conditions 4.8
All alcohol use 4.7
All infectious and parasitic disease 2.8
All drug use 1.5
Mental Illness as a Source of Disease Burden in Established Market Economies.
  Total
(millions)*
Percent
of Total
All Causes 98.7  
Unipolar major depression 6.7 6.8
Schizophrenia 2.3 2.3
Bipolar disorder 1.7 1.7
Obsessive-compulsive disorder 1.5 1.5
Panic disorder 0.7 0.7
Post-traumatic stress disorder 0.3 0.3
Self-inflicted injuries (suicide) 2.2 2.2
All mental disorders 15.3 15.4
*Measured in DALYs (lost years of healthy life regardless of whether the years were lost to premature death or disability).
 
The chart reveals that all mental illnesses including suicide account for the 15.4% of the total disease burden. The National Institute of Mental Health has estimated that, in 2002, 31, 655 people died by suicide in the U.S. More than 90 percent of people who kill themselves have a diagnosable mental disorder such as depressive disorders or a substance abuse disorder. In addition, mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44.  Furthermore, it is estimated that over 3 million persons with mental illness are dying prematurely each year on account of risk factors which can be prevented.
 
According to the Global Burden of Disease study (10), schizophrenia ranks among the top causes of disability in developed and developing countries worldwide. People with schizophrenia have a 50 times higher risk of attempting suicide than the general population. Suicide is the number one cause of premature death among people with schizophrenia, with an estimated 10 percent to 13 percent killing themselves and approximately 40% attempting suicide at least once. Other figures that should not be overlooked are that as much as 60% of males attempt suicide and teenagers with schizophrenia have approximately a 50% risk of attempted suicide. These suicides rates can be compared to the general population, which is somewhere around 0.01%. The Treatment Advocacy Center states that the extreme depression and psychoses that can result due to lack of treatment are the usual causes. Drug or alcohol abuse raises the risk of violence in people with schizophrenia, particularly if the illness is untreated. Most people with schizophrenia are far more likely to harm themselves than be violent toward others.
 
Besides a higher rate of suicide, people with mental illness have high rates of physical illness and are at and increased risk of developing, and die prematurely from coronary heart disease, obesity and some cancers (11). Additionally, medication used in treating mental illness has marked side effects including weight gain, hyperglycemia, diabetes and gastrointestinal problems. On the other hand, malnutrition is frequently a consequence of self-neglect, which can be a common feature of mental illness. Mentally ill people can have a lifestyle involving inadequate and disordered eating, high caffeine intakes, little physical activity and smoking, which contributes to poor physical and mental health.
 
People with mental illness are at particular risk for developing the so-called “Metabolic syndrome” (11). This may be the result of lifestyle impacts cited above; may be due to the impact state on motivation and energy levels; may be an effect of the medications… Although the relative contribution of the various factors to increase the risk of developing metabolic syndrome and cardiovascular disease in this population is poorly understood, the evidence suggests that the psychotropic medications may play an important role.
 
On the other hand, most authors agree that the earlier that schizophrenia is diagnosed and treated, the better the outcome of the person and the better the recovery. Early intervention and early use of new medications lead to better medical outcomes for the individual. The earlier someone with schizophrenia is diagnosed and stabilized on treatment, the better the long-term prognosis for their illness. Recent research increasingly shows that the disease process of schizophrenia gradually and significantly damages the brain of the person, and that earlier treatments (medications and other therapies) seem to result in less damage over time. Therefore, it is vital to make both psychotropic medications and psychosocial rehabilitation more accessible to those in need of them.
 
The National Institute of Mental Health (12) estimates that approximately half of all individuals with severe mental illnesses have received no treatment for their illnesses in the previous 12 months. These findings are consistent with other studies of medication compliance for individuals with schizophrenia and manic-depressive illness (bipolar disorder). The majority (55 percent) of those not receiving treatment have no awareness of their illness and thus do not seek treatment. The 45% who acknowledged that they needed treatment but still were not receiving it, cited as the main reasons for this that their health insurance would not cover treatment and that treatments were too expensive. After 10 years, 10% percent of the people diagnosed with schizophrenia die (mostly because of suicide). After 30 years, 15% of them are dead. Therefore, unless treatments are more available for most people with mental illness, they will continue to lose years of healthy life and die prematurely.
 
Approximately, in the U.S, 200,000 individuals with schizophrenia or manic-depressive illness are homeless, constituting one-third of the approximately 600,000 homeless population (according to data from Department of Health and Human Services) (12). These 200,000 individuals comprise more than the entire population of many U.S. cities, such as Hartford, Connecticut; Charleston, South Carolina; Reno, Nevada; Boise, Idaho; Scottsdale, Arizona; Orlando, Florida; Winston Salem, North Carolina; Ann Arbor, Michigan; Abilene, Texas or Topeka, Kansas. At any given time, there are more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. Besides, as many as one in five (20%) of the 2.1 million Americans in jail and prison are seriously mentally ill, far outnumbering the number of mentally ill who are in mental hospitals. The vast majority of people with schizophrenia who are in jail have been charged with misdemeanors such as trespassing. It is noteworthy that most of these people are not receiving a proper treatment.
 
Although the greatest cost of schizophrenia is the non-economic costs to those who have it and their families, we shouldn’t forget that, regarding the cost of schizophrenia to society, it is estimated that the overall U.S. 2002 cost of schizophrenia was $62.7 billion, with $22.7 billion excess direct health care cost ($7.0 billion outpatient, $5.0 billion drugs, $2.8 billion inpatient, $8.0 billion long-term care). The National Institute of Mental Health has stated that nearly 30 percent ($19 billion) of schizophrenia's cost involves direct treatment and the rest is absorbed by other factors (lost time from work for patients and care givers, social services and criminal justice resources). Schizophrenia, long considered the most chronic, debilitating and costly mental illness, now consumes a total of about $63 billion a year for direct treatment, societal and family costs. Federal costs for the care of seriously mentally ill individuals now total $41 billion yearly and are rocketing upward at a rate of $2.6 billion a year.
 
In economic terms, in the UK, some 80 million working days are lost each year at a cost of £3.7 billion. The NHS spends around £1 billion on treatment and personal social services another £400 million. As many studies have shown, if preventive treatments were carried out these costs would diminish. 
 
On the other hand, anti-psychotic medications are the generally recommended treatment for schizophrenia. If medication for schizophrenia is discontinued, the relapse rate is about 80 percent within 2 years. With continued drug treatment, only about 40 percent of recovered patients will suffer relapses.
 
The American Psychiatric Association (13) published the practice guidelines for the treatment of patients with schizophrenia. Furthermore, experts in the field of schizophrenia reached a consensus regarding the treatment of people suffering from schizophrenia (14). They came to six conclusions supported by scientific evidence and liable to lead to changes in practice:
 
a)      Continuous treatment with a neuroleptic is preferable to discontinuous treatment.
b)      Only one neuroleptic need be administered.
c)      The systematic prescription of antiparkinsonian anticholinergic medication is not recommended.
d)      Antidepressants should not be prescribed during the acute phase.
e)      Antidepressants are not necessary in chronic schizophrenics with negative symptoms of the deficit state.
f)        Combining psychotherapy with neuroleptic administration yields better results than either of these treatments administered alone.
 
Besides, international guidelines were in agreement on certain recommendations for anti-psychotic prescriptions (14):
 
Theoretically these principles are clear. Yet, in practice studies have shown that psychiatrist only partially comply with these guidelines. High percentages of patients receiving anti-psychotic combinations have been observed (from 34.4 to 54%) (15) and high doses are administered.  In Europe, anti-psychotic prescription in schizophrenia is characterized by frequent associations and high doses (16).
 
            Another study was conducted out in order to examine the putative role of neuroleptics in the known excess mortality of subjects with schizophrenia (17). Such a study assessed the link between mortality and the class of neuroleptic. The authors studied the causes of death (suicide, cardiovascular…) and the exposure to neuroleptics in a cohort of 3474 patients with schizophrenia followed from 1993 to 1997. 178 patients died within that period. The risk of all-cause death and suicide were increased in users of thioxanthenes (alone or associated with other drugs), and increased risk of “other causes” of death was associated with use of atypical neuroleptics. These findings suggest the existence of association between certain classes of neuroleptic and death, all cause or specific.   
           
Taking all these facts into account, it can be concluded that there are a lot of work to be done to provide mentally ill people with the proper treatments they require. It is essential to make psychotropic medications more accesible to those in need of them and also provide them with psychosocial rehabilitation. Finally, it is also vital to study and report long term adverse effects of pharmaceutical products.
MORTALITY RATES AMONG HOMELESS PEOPLE
Background
In a study published in December of the 2005 (18), O´Connell carried out a painstaking review of the existing scientific literature regarding the mortality rates in homeless people. The article cited above reviewed cohort studies conducted in the past 15 years in major cities such as Philadelphia, Boston, New York, Stockholm, Toronto and Copenhagen. Besides, in this paper mortality among several sub-groups of the homeless population is reviewed.
 
Since the 1970s, more attention has been paid to the association between mortality and homelessness. To cite just a few examples: A study published in 1982 (19) found three times greater mortality in the depressed area of Watts and the skid row areas of Los Angeles than in any other place in the country. Another study (20) revealed that one district in Boston had the highest numbers of deaths in the Commonwealth. Such a district was characterized by severe poverty, poor housing with marked overcrowding and homelessness, personal disability and social isolation. Taking into account that 652 more deaths occurred in this small area than would be expected by statewide mortality rates, they came to the conclusion that the number of deaths exceeded that of places declared “natural disaster areas” by the government.
 
CAUSES OF DEATH
The reports from the Offices of the Medical Examiner also provide us with some valuable information in regard to the causes of death among homeless people. In this way, the Office of the Fulton County Medical Examiner (21) found 40 deaths among homeless adults in Atlanta in a review of the 2,380 deaths reported in a one-year period. The median age of the homeless who had died was 44 years old. 44% of these deaths were due to natural causes (disease or normal aging process). 56% of the deaths were due to External causes (injury, drug ingestion, unintentional accidents or intentional deaths due to suicide or homicide). 48% of the deaths due to external causes were caused by unintentional accidents (alcohol intoxication, injuries caused by fire, hypothermia, falls...). There were also 4 homicides and 1 suicide. The Medical Examiner determined that the 70% of these homeless had died owing to a condition related to alcohol.
 
A subsequent report by The Fulton County Medical Examiner’s Office (22) investigated 128 homeless deaths in the three-year period from 1988 through 1990 and found similar results. The average age of death was 46 years old and almost all of the decedents (125) were men. 42% of the homeless deaths resulted from external causes (including 10 homicides and 4 suicides).
           
The records of homeless deaths reported to the ME´s office in San Francisco revealed that the average age of death was 41 years. The 53% of the deaths were due to external causes. One-third of the decedents were legally intoxicated from alcohol at the time of death, and either drugs or alcohol were detected in the 78% of those who died.
 
The patterns of death in Atlanta and San Francisco were very similar in the studies cited above. The two major limitations of such an approach are the failure to document deaths that occur outside the jurisdiction of the ME and the tendency to miss the deaths of homeless persons who die of natural causes in hospitals. A further limitation of these reports is the inability to calculate standard mortality ratios, which require an estimate of the size of the homeless population during a given time period in each of those cities.
 
 STANDARD MORTALITY RATIOS
 
The risk for death among homeless persons when compared to the general population depends on the calculation of standard mortality ratios (SMR). An SMR of 1.0 means that homeless persons have the same risk of dying as the general population; greater than 1.0 indicates a higher risk of dying, and less than 1.0 indicates a reduced risk of death. The calculation of the SMR for homeless persons requires two critical factors. The numerator is an accurate count of the number of homeless deaths per year, and the denominator is a reasonable estimate of the size of the homeless population in a given city or county.
 
In Stockholm, Sweden, it was conducted one of the first studies of mortality among homeless persons (23). The cohort included 6,032 men. In comparison with the national death registry the authors found a mortality rate ratio of 4 times that of the Swedish population. The authors noted that this cohort included men who had been homeless for many years, and most of the deaths were related to alcohol.
           
The first data on mortality in a well-defined cohort of homeless persons in America were published in 1994 (24). It was found that homeless adults in Philadelphia had an age adjusted mortality rate of almost 4 times that of the city´s general population. The study followed 6308 homeless people between 15 and 74 years of age. They were followed in the four-year period from 1985 through 1988. The authors also found that homeless persons lost 3.6 times more years than the general population.
           
Another study carried out in Boston (25) demonstrated that many homeless persons with HIV infection were dying prematurely and before the disease had progressed to frank AIDS.
 
In New York a cohort of 949 homeless men and 311 homeless women was studied (26). This sample was interviewed to determine a baseline profile and to identify predictors of mortality. One fifth reported a disability or medical impairment that limited daily functioning. 54% of the men and 38% of the women had substance abuse problems. A third of the cohort reported no mental health or substance abuse problems. Age-adjusted mortality rates for the homeless cohort was approximately 4 times that of the general US population (SMR= 3.9 for men and 4.7 for women). Regarding the predictors, it is noteworthy that those who died reported poorer health (they were more likely to have a disease such as cancer, hypertension...).
 
A three-year cohort study was conducted in Toronto (27). The most striking finding of this study is that the total mortality rate for homeless men in Toronto was significantly lower than seen in the U.S. cities of Philadelphia, Boston and New York. The findings suggest that men in the middle age groups in Toronto have about half the risk of dying in comparison with the risk of dying in these U.S. cities. 
 
In a study which took place in Copenhagen (28), the SMR obtained for the entire cohort was 3.8., 2.8 for men and 5.6 for women. Mortality was especially high in younger men and women 15–34 years of age. Suicide was six times more common in the cohort than in the general population. Predictors of early death were the misuse of alcohol and sedatives.
 
 STUDIES OF SUB-GROUPS OF HOMELESS PERSONS
 
A 10-year study (29) examined mortality among homeless persons with schizophrenia in Sidney, Australia. The authors assessed a cohort of 708 homeless persons referred to psychiatric outreach clinics. 506 were diagnosed with schizophrenia. 12% in the cohort died, with a mean age of death of 50 for men and 57 for women. The 36% of the deaths were not due to natural causes. Most of these deaths were due to suicide, injuries or overdoses. No deaths were due to homicide, in contrast to studies from American cities. AIDS was an uncommon cause of death. The SMR was 3.8 for homeless men and 3.1 for homeless women, with excess mortality highest among the younger age groups. The authors also found a trend toward higher excess mortality among men without schizophrenia compared to men with schizophrenia.
 
A retrospective cohort study (30) assessed mortality over a 9-year period (1989–1998) in 6714 homeless and 1715 non-homeless male veterans who received care in specialized mental health programs in the Department of Veteran Affairs (DVA). The SMR for veterans of 35-54 years of age who had been homeless less than one year was 4.2 and it was 4.13 for those homeless more than one year. Non-homeless veterans of 35-54 years of age had an SMR of 3.16.This study found no clear relationship between mortality and the length of time being homeless.
 
A prospective cohort study (31) was conducted in Montreal (Canada) in order to examine the mortality of homeless between 14 and 25 years of age. The SMR for this age group was 11.4. The authors note that this finding is consistent with age-related mortality ratios in Boston, Toronto, New York, and Copenhagen. One half of the deaths were due to suicide. Independent predictors of mortality included HIV infection, daily alcohol use in the last month, homelessness in the last 6 months and drug injection in the last month.
 
THE STREET POPULATION
 
The studies above identified cohorts of homeless persons who utilized shelters or specialized clinics for homeless persons. Few studies have been able to assess mortality in the sub-group of homeless individuals who live on the streets. These rough sleepers may have higher mortality rates than homeless persons who utilize shelters.
 
Since 2000, the Boston Health Care for the Homeless Program has prospectively followed a cohort of 119 chronically homeless persons who had been living on the streets for at least six consecutive months (32). 75% of the cohort was male, and the mean age was 47 years. At the end of 5 years, 33 individuals (28%) had died and 6 (7%) were in nursing homes. The average age at death was 51 years. The most common causes of death were cancer and cirrhosis, and only one person died of hypothermia.  During the five years from 1999 through 2003, this group had a total of 18,384 emergency room visits.24 Further analysis of the data from this cohort study is in progress (33), but the observation that more than a quarter of these individuals died in the five-year observation period from 2000 through 2004 suggests a significantly increased risk of death for homeless persons living on the streets.
 
Conclusions
Several studies in major cities across the United States, Canada, Europe, Asia, and Australia have confirmed a persistent relationship between a lack of housing and excess mortality. Despite a diversity of methodologies utilized across multiple continents, the current literature reviewed in this paper demonstrates a remarkable consistency that transcends borders: homeless persons are 3–4 times more likely to die than the general population.
 
* Age-related mortality ratios reveal that homeless persons in all age groups have a higher risk of death than people of similar ages in the general population of the cities cited in this paper.
 
* The most glaring discrepancies in mortality ratios are seen in the younger and middle-aged groups from 18 to 34 years and from 35 to 54 years of age. While elderly homeless persons have a greater risk of dying than their housed counterparts, the standard mortality ratios across these cities are not as dramatic as for the younger age groups.
 
* Younger homeless women have from 4–31 times the risk of dying when compared to housed women, and younger homeless women have similar risks of premature death than younger homeless men. The usual competitive advantage of women over men, with increased life expectancy even in impoverished areas, appears to disappear in these studies, a finding that requires further investigation.
 
* The average age of death in the studies reviewed is between 42 and 52 years, despite an average life expectancy of almost 80 years in this county. The potential years of life lost are incalculable.
 
* The “tri-morbidity” of substance abuse and mental illness together with one or more chronic medical illnesses appears to increase the risk of early death.
 
* Health care utilization prior to death is variable and remains poorly understood, although several studies show high numbers of emergency room visits as well as multiple contacts with medical, mental health, and substance abuse services and facilities in the days and weeks before death.
           
* Many sub-groups of homeless persons appear particularly vulnerable, especially those living with AIDS, street youth, mentally ill veterans, and those who live chronically on the streets.
 
* Most studies to date have been based on cohorts of homeless persons utilizing the shelter or clinic systems, and further study of those “sleeping rough” is required.
 
THE CAUSES OF HOMELESSNESS
The lessons learned from fifteen years of observation of the characteristics of homeless people are that there is not only a great variety in the people and the paths they have followed, but there is also the crushing weight of poverty to explain this situation together with other factors such as mental disorders alcoholism and drug abuse which also appear as "immediate causes". In an attempt to understand why some people in poverty experience homelessness, and why some don’t, both structural and personal dynamics must be considered.
           
Among the structural factors, employment opportunities should be taken into consideration. The job opportunities are dwindling for those on the low end of the employment spectrum in terms of wages, skills, and education. On the other hand, the purchasing power of low wages is decreasing. The housing opportunities is another structural factors that should not be overlooked. The housing costs are rising drastically.The government housing-assistance programs are massively over-burdened. Currently, only one-fourth of all eligible families receive any federal housing assistance due to program funding constraints (35) and the average wait for Section 8 vouchers is 35 months (3).
 
            From our point of view, health care opportunities are essential in the struggle against homelessness. In 2004, 45.8 million Americans (or 15.7% of the population) were without heath insurance, which was an increase from the year before, and was disproportionately represented by poor households (36). The U.S. spends 16% of its GDP on health care, more than any other industrialized nation, and those countries provide health insurance to all of their citizens (37). Heath care costs are skyrocketing. In 2004, total national health expenditures rose 7.9 percent—over three times the rate of inflation—and since 2000, employment-based health insurance premiums have increased 73%.(37). 
 
People working low wage jobs, even if they work full-time, are less likely to be provided with health insurance. Without health insurance and under increasing medical costs, unexpected health emergencies or serious chronic illnesses can quickly overburden the resources of poor households.
 
Among the personal factors, it is noteworthy that untreated mental illness can make it difficult or impossible to maintain employment, pay bills or keep supportive social relationships. People with substance use disorder can drain financial resources, cause job or housing lose, and also erode supportive social relationships. Individuals with co-occurring mental illnesses and substance use disorders are among the most susceptible to the above mentioned loses.
 
In summary, there are a variety of ways that individuals become homeless and many of them occur simultaneously. Economically speaking, the job, housing, and health care markets pose formidable challenges to people without many resources. Politically speaking, in the U.S., dramatic reductions in federally supported housing over the past 25 years coupled with the current reductions in safety net programs leave poor households susceptible to homelessness. Individually speaking, people who have substance abuse problems, mental health issues dramatically increase their likelihood of experiencing homelessness.
 
In a review of some studies carried out in the U.S. (38), the main causes of remaining homeless were examined. The main conclusions of such a review were:
·                          81% of homeless people were unemployed.
·                          38% of the homeless surveyed stated that their poor health was the reason of remaining homeless.
·                          33% considered mental illness as the main reason.
·                          27% regarded alcoholism as the main reason.
·                          31% thought that it was the lack of family contact that explained their situation.
 
If homelessness is inextricably linked to poverty then without alleviation of the most crippling aspects of poverty, homelessness can never be effectively ended. In particular, three main concerns are the focus of both governmental and non-governmental efforts to end homelessness: more affordable housing, livable wages and comprehensive health care.
 
Both mental illness and drug abuse problems should be treated simultaneously. Although many medical, psychiatric, and counseling services exist to address these needs, it is commonly believed that without the support of reliable and stable housing such treatments remain ineffective. Furthermore, in the absence of a universal health-care plan, many of those in need cannot afford such services.
 
The present difficultly is to address these root issues while at the same time providing for the real and immediate needs of people experiencing . Lastly, many critics of social policy assert that a failure to live responsibly and a lack of determination are what place and keep people in homeless situations. Such thinking is largely accredited with fueling a stigmatization of homelessness. It is not uncommon for Americans to think of homeless individuals as lazy, apathetic, immoral, irresponsible, unintelligent, or worthless. Such people typically believe it is only by choice that people are homeless and therefore they can choose not to be if they so desire. As such, there often exists considerable tension and resentment between those that are housed and those that are not. Many Americans complain about the presence of homeless people, and feel that their requests for money or support (usually via begging) are unjustified. Likewise, many homeless people feel they are ignored, despised, or even hated. Most who experience such treatment report low self-esteem, depression, and anger. It is often thought that such feelings encourage substance abuse and/or exacerbate mental-health issues, which in turn increase the difficultly of functioning within mainstream society (i.e. holding a job, paying bills, maintaining relationships). In this way, the series of events—whether substance abuse/mental illness caused, or resulted from, homelessness—is contested and inconclusive. Any attempt to truly end homelessness will have to deal with these pervasive social stigmas.
 
The problems encountered by the homeless often have their origins in childhood. In a comparison of the probability of having suffered childhood problems between the homeless and those having a place to live in the county of Los Angeles, the rates of placing outside the family that were noted were much greater among the homeless, especially Whites, as a much higher proportion of people who had been poor and had even sometimes already been homeless in their childhood, and of those who had been abused or had been victims of rape.
 
In relation to their backgrounds, in the U.S., 23% are veterans (compared to 13% of general population); 25% were physically or sexually abused as children; 27% were in foster care or similar institutions as children; 21% were homeless at some point during their childhood and 54%  were incarcerated at some point in their lives.
 
Furthermore, the reactions of the population towards the homeless can also be a cause of problems, such as the "Nimby syndrome" (rejection of public shelters). It is with this term, Nimby, that the Americans designate the attitude which consists in refusing to allow services intended for the homeless to be set up in a person's neighborhood: "not in my backyard". These reactions from the public are now the subject of specific studies (39) in relation to the recent development of public policies towards making cuts in the budgets allocated to helping the poorest and the raising of the eligibility conditions. The study also show a hierarchical ranking of degrees of acceptance, based on the characteristics of the persons likely to be sheltered, those of the neighborhood, those of the planned shelter, and the proximity of the shelter to the inhabitants of the district and the corporations located there: "The users will tend to be less acceptable particularly if they are more distinguishable from the inhabitants in terms of their demographic characteristics, if they are perceived as being stigmatized in some way and dangerous, and if they attract a considerable amount of attention because of their physical appearance and behavior." (39)
 
Apparently, not only are the homeless mentally ill persons being discriminated against due to their mental illness, but also because of the fact of being homeless. As we are examining in the next two parts of our study, homeless mentally ill people are at risk  for dying prematurely because of the mental illness they are suffering from and also owing to their homeless situation.

 FIGHTING AGAINST HOMELESSNESS: Recommendations for best practices     
The “Pressure Points” report (8) published in the U.K. praises some examples of good practices, such as floating housing support teams, which combine health, housing and social services staff.
 
Many programs that are designed to assist the homeless population have incorporated some type of housing program for their clients In the United States each year, there are around 3.5million people who live their lives without shelter or a stable occupation. For 2006 alone, $28.5 billion is being allotted to homeless programs ran through HUD (Housing and Urban Development). $1 billion is being given for Section 8 housing, and $1.4 billion is being used for Homeless Assistance Grants.
 
For a significant number of homeless Americans with mental or physical impairments, often coupled with drug and/or alcohol use issues, long-term homelessness can only be ended by providing permanent housing coupled with intensive supportive services. Permanent housing provides a “base” for people to move out of poverty.
 
Homeless shelters operated by government, churches, or charities work to provide temporary housing to the homeless. Types of shelters include overnight shelters, warming shelters, transitional shelters, and subsidized housing.  
 
However, without a comprehensive health care program, housing is not often enough to end homelessness. Various agencies, in fact all homeless prevention agencies and programs include substance abuse recovery and prevention programs. For a significant number of homeless Americans with mental or physical impairments, often coupled with drug and/or alcohol use issues, long-term homelessness can only be ended by providing permanent housing coupled with intensive supportive services.
 
It should be a major goal for all the programs that fight against poverty to improve the quality of life and diminish the risk of early dying life for persons who are homeless due to mental illness or substance abuse. Experts agree that the latter two groups tend to comprise the majority of persistent homeless persons. Therefore, treatment for mental illness and substance abuse disorders should be provided unarguably.
 

COST-EFFECTIVENESS OF SUPPORTED HOUSING
Several studies have proved the cost-effectiveness of supported housing programs for this population. The Culhane study (40) assessed the costs for clients placed in the New York/New York (NY/NY) supported housing initiative and a matched control group. The authors of such a study found substancially greater reductions in hospital use among NY/NY clients than controls, offsetting almost the entire $19,000 annual program cost. Although most experts find these findings encouraging, the Culhane study has been criticized due to methodological deficits. Specifically, the absence of random assignment.
 
The research conducted by Rosenheck et al. (41) is a 3-year prospective experimental study. Therefore it is more statistically powerful than the previous one. This study examined the cost-effectiveness of supported housing (integrating clinical and housing services) for homeless persons with mental illness. The sample consisted of 460 homeless people with psychiatric and/or substance abuse disorders. The study took place at VA (Veteran Affairs) medical centers in San Francisco, Calif (n = 107); San Diego, Calif (n = 91); New Orleans, La (n = 165); and Cleveland, Ohio (n = 97). Veterans were eligible if they were literally homeless at the time of outreach assessment (ie, living in a homeless shelter or on the streets), had been homeless for 1 month or longer, and had received a diagnosis of a major psychiatric disorder (schizophrenia, bipolar disorder, major affective disorder, or posttraumatic stress disorder) or an alcohol or drug abuse disorder or both.   They were randomly assigned to 1 of 3 groups:
 
1* HUD-VASH, with Section 8 vouchers (rent subsidies) and intensive case management (n = 182). The participants of the HUD-VASH (Department of Housing and Urban Development and the Department of Veteran Affairs) program were offered priority access to Section 8 housing vouchers administered by local housing authorities. These vouchers authorize payment of a standardized local fair-market rent (established by HUD using surveys of local rents) less 30% of the individual beneficiary's income.
 
2* Case management only, without special access to Section 8 vouchers (n = 90). The case management model used in HUD-VASH was modified from the Assertive Community Treatment (ACT) model  Most of the case managers were experienced social workers and nurses. They also provided substance abuse and employment counseling.
 
3* Standard VA care (n = 188).          
 
Primary outcomes were days housed and days homeless. Secondary outcomes were mental health status, community adjustment, and costs from 4 perspectives:
The VA health care costs were estimated by multiplying the number of units of service consumed by each patient by the estimated unit cost of each type of service.
 
and encouraged at least weekly face-to-face contact, community-based service delivery, and more intensive involvement in crisis situations.
 
The authors hypothesized that HUD-VASH would generate sufficient savings in hospital, halfway house, criminal justice, and emergency shelter costs to offset the additional costs of intensive case management services but that case management alone would be almost as expensive as HUD-VASH but less effective.
 
 
The policy implications of these results were:
The overall conclusion of this study (41) is that supported housing for homeless people with mental illness results in superior housing outcomes than intensive case management alone or standard care and modestly increases societal costs.
 
CASE MANAGEMENT SERVICES DELIVERED ON A TIME-LIMITED BASIS
 
It has been widely documented that persons with serious mental illness experience higher rates of residential instability and homelessness than in general population. Most homeless mentally ill people are capable of living in the community when they are given appropriate services that meet their needs. In spite of this encouraging fact, research has shown difficulties in engaging this population in treatment. Therefore, this is a major factor that should not be overlooked.
 
Over the past three decades, several programs have attempted to decrease homelessness by linking homeless mentally ill people with ongoing mental health services through assertive outreach and case management. One of the most large-scale effort was Access to Community Care and Effective Services and Supports (ACCESS): a 18-site national project that lasted from 1993 to 1998 (42). An essential strategy of ACCESS was to enhance access to mainstream mental health services by adopting the assertive community treatment model of intensive case management. During the ACCESS program a multidisciplinary case management teat that included psychiatrists, nurses, and substance abuse and other support specialists.
 
It was conducted a longitudinal epidemiological study between 1989 and 1995. The data were drawn from the Suffolk County Mental Health Project (43). The authors of the study came to the conclusion that linking interventions that enhance the continuation of aftercare in outpatient settings after the discharge and focused case management have shown promising results. The authors also emphasized the prominent role of families, so they called for greater attention to supportive and educational family interventions.
 
It was also examined the extent to which the use of care management services predicted public shelter use among the homeless mentally ill who took part in the Community Care and Effective Services and Supports (ACCESS) (42). The sample consisted of 475 Philadelphia ACCESS program participants. The study found that the use of specific types of services such as vocational and psychosocial rehabilitation services led to an important reduction of the use of homeless shelters and, thus posed an important contribution in the reduction of the risk of recurrent homelessness. 
 
CRITICAL TIME INTERVENTIONS
 
A study of Susser et al. (44) examined a strategy to prevent recurrent homelessness among mentally ill people. They provided an intervention of transition between institutional and community care. The sample consisted of 96 men. Over a 18-month follow-up period the average number of homeless nights for the “critical intervention” group was 30 and 91 for the usual services groups.
 
PREVENTIVE INTERVENTIONS
 
A study carried out in New York City (45) meant to identify risk factors for long-term homelessness among first-time literally homeless people. 377 people took part in this research. They were evaluated with standardized assessments of psychiatric diagnosis, symptoms and coping skills, social and family history, and service use. 81% of subjects returned to community housing during the follow-up period (18 months).
 
The analysis of the data revealed that a shorter duration of homelessness was related to younger age, current or recent employment, earned income, good coping skills, adequate family support, the absence of a substance abuse treatment history, and the absence of an arrest history. The regression analysis found that older age group (p<0.05) and arrest history (p<0.01) were the strongest predictors of a longer duration of homelessness. The identification of risk factors for long-term homelessness might guide efforts to reduce lengths of stay in homeless shelters and develop new preventive interventions.

 

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