International Journal of Psychosocial Rehabilitation
Mentally Ill Persons: A bibliography review
Nieto, R., Ph.D1
Abad, A., MD4.
Clinical Psychologist. “Doctor Villacian” Mental Hospital (Spain)
NYU-OMH- Program for Advanced Studies in Psychosocial Rehabilitation,
Department of Psychiatry, NYU, Medical Center. Manhattan Psychiatric
New York, NY 10035.
Assisstant Professor in Psychiatry- Research Unit 20 North Chief
NYU School of
Medicine- Department of
Psychiatry, Bellevue Hospital Center, New York
Nieto G., Gittelman M., Abad A. (2008). Homeless Mentally
Ill Persons: A bibliography review.
Journal of Psychosocial Rehabilitation. 12 (2),
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
different countries are compared. A historical overview of the issue is
provided so that the reader can fully grasp the complexity of this
problem. Secondly, the relationship between homelessness and mental
examined. As we put forward in the fourth and fifth parts of our study,
findings of many studies support the conclusion that the homeless
ill are at a higher risk for dying
prematurely in comparison with the general population due to the mental
they are suffering from and owing to their homelessness situation as
only, do they die early, but also they have a poorer quality of life
of the general population. Later on, the
main conclusions reached in the articles that have been reviewed are
Our literature review sheds light on some of the causes of the complex
of homelessness. These causes should be taken into account when
against homelessness and developing preventive programs. Finally, some
initiatives that have been carried out to end up with this huge problem
studied in-depth in order to suggest recommendations for best
words: Homelessness, Mentally-ill
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
it comes to the ambiguous, hidden, and erratic reality of homelessness.
each country has a different approach to counting homeless people and,
therefore, comparisons should be made with caution, some of the most
statistics (1) indicate that the approximate average number of homeless
at any given time in the European Union is 3,000,000; 750, 000 in the
of the entire U.S. population); 200,000 in Canada and 99,000 in
Canada is viewed by many as having far too
number of homeless people, with some of the highest per capita rates of
developed nation. For instance, Canada has about 200,000 homeless,
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
World nations such as Brazil, India, Nigeria, and South Africa,
rampant, with millions of children living and working on the streets.
of their growing prosperity, homelessness has also become a problem in
cities of China, Thailand, Indonesia, and the Philippines.
The number of Americans living below the
officially defined on the basis of a standard of consumption updated
to take inflation into account, rose from 29 million in 1980 to 39
1993 (2). The rate of poverty has risen from 11.4% in 1978 to 15.1% in
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%
general population); 35% are Caucasian
(compared to 75% of general population), 13% are Hispanic (compared to
general population), 2% are Native American (compared to 1% of general
population) and 1% are Asian-American (compared to 3% of general
40% are families with children,
are single males, 14% are single females and 5% are minors
adults. It is noteworthy that 1.37
million (or 39%) of the total homeless population are children under
the age of
With regard to their educational
level, 38% have less than a High School diploma , 34% have a High
diploma or equivalent (G.E.D.); 28% have more than a High School
Only 13% have regular jobs and
receive less than $300 per month as income. Regarding their location:
reside in central cities; 21% are in suburbs and 9% are in rural areas
With regard to health concerns
(4), it is
estimated that 22% are considered to have serious mental illnesses; 30%
substance abuse problems; 3% report having HIV/AIDS; 26% report acute
problems other than HIV/AIDS such as tuberculosis, pneumonia or
transmitted infections; 46% report chronic health conditions such as
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
States; notably New York City.
Most homeless families consist of an unmarried
mother and children. A significant number of homeless people are
young adults, mostly runaways or street children. A 1960 survey by Temple University
poor neighborhoods (5) found
that 75% of the homeless were over 45 years old, and 87% were white. In
were under age 45, and 87% were minorities.
numbers of homeless in the cities raises the question of the extent and
of this situation. As it has been shown above, homelessness has become
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
must remain a priority objective to avoid them finding themselves on
the sociodemographic characteristic of homeless people living in
countries, some studies have tried to shed
light on the causes of this growing problem.
of this approach is the study carried out by Marpsat (6). The author of
study came to the conclusion that the age, sex and marital status of
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
poor state of health, but alcohol and drug-related problems appeared to
fewer in France
Finally, poverty and structural factors such as a reduction in the
of low cost housing or the shortage of jobs played a vital role in both
From one country to another, some of the characteristics of the
close, like the similarity in the way they lose their housing, but also
consequences of this situation, for example in terms of health. Other
such as the presence of certain ethnics or national minorities depended
characteristics of the country. For instance, in the United States,
who have had a rough passage like the Vietnam War veterans, and ethnic
minorities (Blacks, Hispanics, etc.) are worse hit than others. For
over three years, the likelihood of a Black using a public shelter in
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
time during the year. Veteran Affairs only provides housing to
veterans. Summing up, the analysis of the structural causes of the
both countries and the individual characteristics of the persons
the United States as well as in France there are fewer older persons
homeless than among the population with a place to live. The main
this is the effect of high mortality among the homeless. In the United
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.
sex and marital status, the study (6) revealed that, in both countries
proportion of women is well below that of men. More than one-half of
homeless are single, and around a third are divorced or widowers.
experts in the field generally agree that modern
homelessness began in the U.S. in the 1980s. During Ronald Reagan’s
presidency (1981-1989) a variety of drastic budget reductions are
undermining many urban populations, most notably those of poor and
demographics (7). In his first year of office Reagan halved the budget
public housing and Section 8 (the government’s housing voucher
program). Such changes resulted in an inadequate supply of affordable
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
Conservative government introduced a programme of “Care in the
provided neither adequate care for the mentally ill nor community
Between 1988 and 1995 the average daily number of long-stay beds
hospitals for the mentally ill was cut by half to 18,644. During the
period the proportion of the average hospital budget spent on mental
fell from 14.4 percent to 12 percent.
The 1980s also
witnessed a continuing trend of deinstitutionalizing mental-health
the U.S. It is believed that a large percentage of these released
ended up in the homeless system. The movement in state mental health
systems shifted towards community-based treatment as opposed to
Unfortunately, as a result of the
lack of local community programs, many patients ended up in the
In response to
the ensuing homelessness crisis of the 1980s, concerned citizens across
country demanded that the federal government provide assistance. After
years of advocacy and numerous revisions, Reagan signed into law the
McKinney-Vento Homeless Assistance Act in 1987—this remains the only
federal legislation that allocates funding to the direct service of
McKinney-Vento Act paved the way for service providers in the coming
During the 1990s homeless sherlters, soup kitchens, and other
services sprouted up in cities and towns across the nation. However,
these efforts and the dramatic economic growth marked by this decade,
numbers remained stubbornly high. It became increasingly apparent that
providing services to alleviate the symptoms of homelessness (i.e.
beds, hot meals, psychiatric counseling, etc.), although needed, were
successful at solving the root causes of homelessness.
claim that Bill Clinton’s 1996 welfare reforms increased the number of
entering homelessness. At any rate, policies set into motion in the
never adequately reversed during the Bush Senior or Clinton
disparities between rich and poor continued to widen. Conditions,
remain ripe for becoming homeless.
Now, for the
first time, government officials are calling for an end to
accomplish this goal the Interagency Council on Homelessness (ICH), the
branch that was created under the McKinney-Vento Act, has adopted a
largely devised by the National Alliance to End Homelessnes (one of
homeless advocacy organizations), which centers on the production and
implementation of local 10-year plans to end chronic homelessness. The
to get all of the necessary parties—local/state governmental agencies,
businesses, non-profit organizations, service providers, faith-based
and homeless individuals—working in collaboration to devise and
10-year plan for their respective community.
channeling funds into direct services that seemingly sustain homeless
lifestyles, these result-oriented plans are designed to focus efforts
on the creation of permanent supportive housing (PSH) for the most
difficult, “chronic” homeless population. Considering that it is
cheaper to house someone than it is to fund the otherwise needed myriad
services, this approach is touted as being a cost-effective solution.
providers applaud the government’s focus on ending homelessness, as
managing it, and realize the necessity of incorporating all sectors of
in order to accomplish such a goal. However, critics express concern
majority of the homeless population, who are not considered “chronic,”
neglected; if federal funds are stipulated only for this 10%
demographic—although no doubt deserving—what will become of the other
These concerns are exacerbated by a failure to receive sufficient
allocations while already struggling with budgets spread extremely
the main features of homelessness have changed with the passing of
the last two decades the face of homelessness has changed
instance, in the early 1980s the homeless population in Canada was
up of older men the majority of which had mental health problems or
alcoholics. Today younger men and children make up a large segment of
homeless population. Less than 20% of the homeless have drug or alcohol
problems. Almost half of all homeless people have jobs. This change has
attributed to changing economic circumstances that have seen minimum
no longer be able to pay for accommodation in some of Canada's cities.
federal government has not built subsidized housing since the early
families and the poor who used to take advantage of these services are
forced to live on the streets.
plan has been in effect for a full 10-years so achievement is difficult
gauge; the best indications reveal mixed success. Although many cities
seen chronic numbers dip, it is unclear whether or not homelessness as
is decreasing. The hope is that necessary modifications can be made to
plans, and that newly devised plans can implement the strategies that
avoid the ones that don’t.
BETWEEN HOMELESSNESS AND MENTAL ILLNESS
With regard to
the link between homelessness and mental illnesses, some studies have
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
mental illness. This perpetuates a vicious cycle in which the stress of
homelessness often exacerbates the illness and makes it difficult for
suffering to gain access to housing and healthcare in the future. Once
homeless, many mentally ill people can remain without permanent housing
several years. Many local doctors are reluctant to accept the homeless
suffering from serious mental disorders (such as psychotic disorder,
depression…) find it difficult to maintain a household. It has been
that half of all homeless persons have some form of mental
. In some cases, it is not always clear which came
homelessness or the mental illness. According to the National Alliance
for the Mentally
(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
according to many authors, to an increase in homelessness. Many
persons ended up in the strets after being released from mental
On the other
hand, it is estimated that 38% of homeless suffer from a substance
problem. Debate also exists about whether drug use
is a cause or consequence of homelessness. However, regardless when it
an untreated addiction makes moving beyond homelessness extremely
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
to suffer from illnesses such as depression, than the general
2* One person in five sleeping
rough has a severe mental health problem, such as schizophrenia. More
in six rough sleepers has stayed in a psychiatric hospital as an
3* People who sleep rough are 35
times more likely to kill themselves than the general population. The
age of death by suicide for rough sleepers is 37 years old.
problems often start before homelessness and can directly cause a loss
accommodation, but they can also be the reason people remain homeless
years. In the U.S.
80% of those who experience homelessness do so for less than 3 weeks;
homeless for up to two months 10% are so called “chronic” and remain
housing for extended periods of time on a frequent basis. The “chronic”
homeless struggle with mental illness, substance abuse, or both. It
that suffering from a mental illness or a substance abuse problem might
homeless a chronic problem.
The author of
the study conducted in France
(6) reached the following conclusions:
- Among the homeless there are more
people having physical or mental health problems and alcohol and
problems than in the rest of the population. Yet, the research
not indicate with certainty whether these difficulties have been the
the person's homelessness or are a consequence of this situation. The
alcohol and narcotics, and even some forms of mental illness, are seen
authors as forms of adaptation to street life.
- In the USA, the problems of
alcoholism and drug abuse concern men more than women, the latter
more from mental disorders, including depression.
- The rate of stay in a psychiatric
hospital is just 19% for single men, 27% for single women, but only 8%
women with children.
- The results obtained for Paris
seem to show a prevalence of mental health problems among the homeless
that of the United States, with however better access to care, if not
medical follow up.
- In France, the problems of
alcoholism and drug abuse, although higher than for the rest of the
are in fact seemingly lower than those in the USA.
- Several groups stood out because
of specific difficulties: for example, the under 25's suffer more from
dependency on hard drugs and personality disorders; the women have more
been institutionalized for psychiatric problems and have fewer alcohol
personality disorder problems than the men; middle aged men who use the
emergency shelters have more alcohol-related problems.
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
developed by the massive Global Burden of Disease study (10) conducted
World Health Organization, the World Bank, and Harvard University,
mental illness, including suicide, accounts for over 15 percent of the
of disease in established market economies, such as the United States.
more than the disease burden caused by all cancers.
developed a single measure to allow comparison of the burden of disease
many different disease conditions by including both death and
measure was called Disability Adjusted Life Years (DALYs). DALYs
years of healthy life regardless of whether the years were lost to
death or disability. The disability component of this measure is
severity of the disability. For example, disability caused by major
was found to be equivalent to blindness or paraplegia whereas active
seen in schizophrenia produces disability equal to quadriplegia.
DALYs measure, major depression
ranked second only to ischemic heart disease in magnitude of disease
established market economies. Schizophrenia
, and post-traumatic
also contributed significantly to the total
of illness attributable to mental disorders.
projections show that with the aging of the world population and the
of infectious diseases, psychiatric and neurological conditions could
their share of the total global disease burden by almost half, from
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
worldwide among persons age 5 and older. For women
throughout the world
depression is the leading cause of DALYs. In established market
schizophrenia and bipolar disorder are also among the top 10 causes of
chart shows the disease burden in Established Market Economies. This
measured in DALYs (lost years of healthy life regardless of whether the
were lost to premature death or disability).
Leading Sources of Disease Burden in Established Market Economies.
Ischemic heart disease
| 2. Unipolar major depression
| 4. Alcohol use
| 5. Road
| 6. Lung
& UR cancers
Dementia & degenerative CNS
| 10. COPD
Burden by Selected Illness Categories in Established Market Economies.
mental illness including suicide
malignant disease (cancer)
infectious and parasitic disease
| All drug
Illness as a Source of Disease Burden in Established Market Economies.
in DALYs (lost years of healthy life regardless of whether the years
were lost to premature death or disability).
reveals that all mental illnesses including suicide account for the
the total disease burden. The National Institute of Mental Health has
that, in 2002, 31, 655 people died by suicide in the U.S. More than 90
of people who kill themselves have a diagnosable mental disorder such
depressive disorders or a substance abuse disorder. In addition, mental
disorders are the leading cause of disability in the U.S.
Furthermore, it is estimated
that over 3 million persons with mental illness are dying prematurely
on account of risk factors which can be prevented.
the Global Burden of Disease study (10), schizophrenia ranks among the
causes of disability in developed and developing countries worldwide.
with schizophrenia have a 50 times higher risk of attempting suicide
general population. Suicide is the number one cause of premature death
people with schizophrenia, with an estimated 10 percent to 13 percent
themselves and approximately 40% attempting suicide at least once.
figures that should not be overlooked are that as much as 60% of males
suicide and teenagers with schizophrenia have approximately a 50% risk
attempted suicide. These suicides rates can be compared to the general
population, which is somewhere around 0.01%. The Treatment
states that the extreme depression and psychoses that can result due to
treatment are the usual causes. Drug or alcohol abuse raises the risk
violence in people with schizophrenia, particularly if the illness is
Most people with schizophrenia are far more likely to harm themselves
violent toward others.
higher rate of suicide, people with mental illness have high rates of
illness and are at and increased risk of developing, and die
coronary heart disease, obesity and some cancers (11). Additionally,
used in treating mental illness has marked side effects including
hyperglycemia, diabetes and gastrointestinal problems. On the other
is frequently a consequence of self-neglect, which can be a common
mental illness. Mentally ill people can have a lifestyle involving
and disordered eating, high caffeine intakes, little physical activity
smoking, which contributes to poor physical and mental health.
mental illness are at particular risk for developing the so-called
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
the medications… Although the relative contribution of the various
increase the risk of developing metabolic syndrome and cardiovascular
in this population is poorly understood, the evidence suggests that the
psychotropic medications may play an important role.
the other hand, most authors agree that the earlier that
schizophrenia is diagnosed and treated, the better the outcome
the person and the better the recovery. Early intervention and early
use of new
medications lead to better medical outcomes for the individual. The
someone with schizophrenia is diagnosed and stabilized on treatment,
the long-term prognosis for their illness. Recent research increasingly
that the disease process of schizophrenia gradually and significantly
the brain of the person, and that earlier treatments (medications and
therapies) seem to result in less damage over time. Therefore, it is
make both psychotropic medications and psychosocial rehabilitation more
accessible to those in need of them.
Institute of Mental Health (12) estimates that approximately half of
individuals with severe mental illnesses have received no treatment for
illnesses in the previous 12 months. These findings are consistent with
studies of medication compliance for individuals with schizophrenia and
manic-depressive illness (bipolar disorder). The majority (55 percent)
not receiving treatment have no awareness of their illness and thus do
treatment. The 45% who acknowledged that they needed treatment but
not receiving it, cited as the main reasons for this that their health
insurance would not cover treatment and that treatments were too
After 10 years, 10% percent of the people diagnosed with schizophrenia
(mostly because of suicide). After 30 years, 15% of them are dead.
unless treatments are more available for most people with mental
will continue to lose years of healthy life and die prematurely.
in the U.S, 200,000 individuals with schizophrenia or manic-depressive
are homeless, constituting one-third of the approximately 600,000
population (according to data from Department of Health and Human
These 200,000 individuals comprise more than the entire population of
cities, such as Hartford, Connecticut; Charleston, South Carolina;
Nevada; Boise, Idaho; Scottsdale, Arizona; Orlando, Florida; Winston
North Carolina; Ann Arbor, Michigan; Abilene, Texas or Topeka, Kansas.
given time, there are more people with untreated severe psychiatric
streets than are receiving care in hospitals. Besides, as many as one
(20%) of the 2.1 million Americans in jail and prison are seriously
ill, far outnumbering the number of mentally ill who are in mental
The vast majority of people with schizophrenia who are in jail have
charged with misdemeanors such as trespassing. It is noteworthy that
these people are not receiving a proper treatment.
greatest cost of schizophrenia is the non-economic costs to those who
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
excess direct health care cost ($7.0 billion outpatient, $5.0 billion
$2.8 billion inpatient, $8.0 billion long-term care). The National
Mental Health has stated that nearly 30 percent ($19 billion) of
schizophrenia's cost involves direct treatment and the rest is absorbed
other factors (lost time from work for patients and care givers, social
services and criminal justice resources). Schizophrenia, long
most chronic, debilitating and costly mental illness, now consumes a
about $63 billion a year for direct treatment, societal and family
Federal costs for the care of seriously mentally ill individuals now
billion yearly and are rocketing upward at a rate of $2.6 billion a
terms, in the UK, some 80 million working days are lost each year at a
£3.7 billion. The NHS spends around £1 billion on treatment
and personal social
services another £400 million. As many studies have shown, if
treatments were carried out these costs would diminish.
On the other
hand, anti-psychotic medications are the generally recommended
schizophrenia. If medication for schizophrenia is discontinued, the
rate is about 80 percent within 2 years. With continued drug treatment,
about 40 percent of recovered patients will suffer relapses.
Psychiatric Association (13) published the practice guidelines for the
treatment of patients with schizophrenia. Furthermore, experts in the
schizophrenia reached a consensus regarding the treatment of people
from schizophrenia (14). They came to six conclusions supported by
evidence and liable to lead to changes in practice:
Continuous treatment with a neuroleptic
is preferable to discontinuous treatment.
Only one neuroleptic need be
The systematic prescription of
antiparkinsonian anticholinergic medication is not recommended.
Antidepressants should not be prescribed
during the acute phase.
Antidepressants are not necessary in
chronic schizophrenics with negative symptoms of the deficit state.
Combining psychotherapy with neuroleptic
administration yields better results than either of these treatments
international guidelines were in agreement on certain recommendations
anti-psychotic prescriptions (14):
- Monotherapy should be preferred.
- The maintenance dose is the
minimum effect dose with minimum side effects.
these principles are clear. Yet, in practice studies have shown that
psychiatrist only partially comply with these guidelines. High
patients receiving anti-psychotic combinations have been observed (from
54%) (15) and high doses are administered.
, anti-psychotic prescription
schizophrenia is characterized by frequent associations and high doses
study was conducted out in order to examine the putative role of
in the known excess mortality of subjects with schizophrenia (17). Such
assessed the link between mortality and the class of neuroleptic. The
studied the causes of death (suicide, cardiovascular…) and the exposure
neuroleptics in a cohort of 3474 patients with schizophrenia followed
to 1997. 178 patients died within that period. The risk of all-cause
suicide were increased in users of thioxanthenes (alone or associated
other drugs), and increased risk of “other causes” of death was
use of atypical neuroleptics. These findings suggest the existence of
association between certain classes of neuroleptic and death, all cause
these facts into account, it can be concluded that there are a lot of
be done to provide mentally ill people with the proper treatments they
It is essential to make psychotropic medications more accesible to
need of them and also provide them with psychosocial rehabilitation.
it is also vital to study and report long term adverse effects of
RATES AMONG HOMELESS PEOPLE
In a study
published in December of the 2005 (18), O´Connell carried out a
review of the existing scientific literature regarding the mortality
homeless people. The article cited above reviewed cohort studies
the past 15 years in major cities such as Philadelphia
Boston, New York
paper mortality among several sub-groups of the homeless population is
1970s, more attention has been paid to the association between
homelessness. To cite just a few examples: A study published in 1982
three times greater mortality in the depressed area of Watts and the
areas of Los Angeles than in any other place in the country. Another
revealed that one district in Boston
had the highest numbers of deaths in the Commonwealth. Such a district
characterized by severe poverty, poor housing with marked overcrowding
homelessness, personal disability and social isolation. Taking into
that 652 more deaths occurred in this small area than would be expected
statewide mortality rates, they came to the conclusion that the number
deaths exceeded that of places declared “natural disaster areas” by the
from the Offices of the Medical Examiner also provide us with some
information in regard to the causes of death among homeless people. In
way, the Office of the Fulton County Medical Examiner (21) found 40
among homeless adults in Atlanta
a review of the 2,380 deaths reported in a one-year period. The median
the homeless who had died was 44 years old. 44% of these deaths were
natural causes (disease or normal aging process). 56% of the deaths
were due to
External causes (injury, drug ingestion, unintentional accidents or
deaths due to suicide or homicide). 48% of the deaths due to external
were caused by unintentional accidents (alcohol intoxication, injuries
by fire, hypothermia, falls...). There were also 4 homicides and 1
Medical Examiner determined that the 70% of these homeless had died
owing to a condition
related to alcohol.
report by The Fulton County Medical Examiner’s Office (22) investigated
homeless deaths in the three-year period from 1988 through 1990 and
similar results. The average age of death was 46 years old and almost
the decedents (125) were men. 42% of the homeless deaths resulted from
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
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
of death in Atlanta and San Francisco were very similar in the studies
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
to miss the deaths of homeless persons who die of natural causes in
A further limitation of these reports is the inability to calculate
mortality ratios, which require an estimate of the size of the homeless
population during a given time period in each of those cities.
The risk for
death among homeless persons when compared to the general population
the calculation of standard mortality ratios (SMR). An SMR of 1.0 means
homeless persons have the same risk of dying as the general population;
than 1.0 indicates a higher risk of dying, and less than 1.0 indicates
reduced risk of death. The calculation of the SMR for homeless persons
two critical factors. The numerator is an accurate count of the number
homeless deaths per year, and the denominator is a reasonable estimate
size of the homeless population in a given city or county.
it was conducted one of the first studies of mortality among homeless
The cohort included 6,032 men. In comparison with the national death
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
homeless for many years, and most of the deaths were related to
The first data
on mortality in a well-defined cohort of homeless persons in America
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
population. The study followed 6308 homeless people between 15 and 74
age. They were followed in the four-year period from 1985 through 1988.
authors also found that homeless persons lost 3.6 times more years than
carried out in Boston (25) demonstrated that many homeless persons with
infection were dying prematurely and before the disease had progressed
In New York
a cohort of
949 homeless men and 311 homeless
women was studied (26). This sample was interviewed to determine a
profile and to identify predictors of mortality. One fifth reported a
disability or medical impairment that limited daily functioning. 54% of
and 38% of the women had substance abuse problems. A third of the
reported no mental health or substance abuse problems. Age-adjusted
rates for the homeless cohort was approximately 4 times that of the
population (SMR= 3.9 for men and 4.7 for women). Regarding the
is noteworthy that those who died reported poorer health (they were
to have a disease such as cancer, hypertension...).
cohort study was conducted in Toronto (27). The most striking finding
study is that the total mortality rate for homeless men in Toronto
was significantly lower than seen in the U.S.
cities of Philadelphia
and New York
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 a study
which took place in Copenhagen (28), the SMR obtained for the entire
3.8., 2.8 for men and 5.6 for women. Mortality was especially high in
men and women 15–34 years of age. Suicide was six times more common in
cohort than in the general population. Predictors of early death were
misuse of alcohol and sedatives.
OF HOMELESS PERSONS
10-year study (29) examined mortality among homeless persons with
in Sidney, Australia
The authors assessed a cohort of 708 homeless persons referred to
outreach clinics. 506 were diagnosed with schizophrenia. 12% in the
died, with a mean age of death of 50 for men and 57 for women. The 36%
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
studies from American cities. AIDS was an uncommon cause of death. The
3.8 for homeless men and 3.1 for homeless women, with excess mortality
among the younger age groups. The authors also found a trend toward
excess mortality among men without schizophrenia compared to men with
retrospective cohort study (30) assessed mortality over a 9-year period
(1989–1998) in 6714 homeless and 1715 non-homeless male veterans who
care in specialized mental health programs in the Department of Veteran
(DVA). The SMR for veterans of 35-54 years of age who had been homeless
than one year was 4.2 and it was 4.13 for those homeless more than one
Non-homeless veterans of 35-54 years of age had an SMR of 3.16.This
no clear relationship between mortality and the length of time being
cohort study (31) was conducted in Montreal (Canada) in order to
mortality of homeless between 14 and 25 years of age. The SMR for this
group was 11.4. The authors note that this finding is consistent with
age-related mortality ratios in Boston
Toronto, New York
. One half
deaths were due to suicide. Independent predictors of mortality
infection, daily alcohol use in the last month, homelessness in the
months and drug injection in the last month.
above identified cohorts of homeless persons who utilized shelters or
specialized clinics for homeless persons. Few studies have been able to
mortality in the sub-group of homeless individuals who live on the
These rough sleepers may have higher mortality rates than homeless
the Boston Health Care for the Homeless Program has prospectively
cohort of 119 chronically homeless persons who had been living on the
for at least six consecutive months (32). 75% of the cohort was male,
mean age was 47 years. At the end of 5 years, 33 individuals (28%) had
6 (7%) were in nursing homes. The average age at death was 51 years.
common causes of death were cancer and cirrhosis, and only one person
During the five years from
1999 through 2003, this group had a total of 18,384 emergency room
Further analysis of the data from this cohort study is in progress
the observation that more than a quarter of these individuals died in
five-year observation period from 2000 through 2004 suggests a
increased risk of death for homeless persons living on the streets.
studies in major cities across the United States, Canada, Europe, Asia,
Australia have confirmed a persistent relationship between a lack of
and excess mortality. Despite a diversity of methodologies utilized
multiple continents, the current literature reviewed in this paper
a remarkable consistency that transcends borders: homeless
persons are 3–4 times more likely to die than the general
related mortality ratios reveal that
in all age groups have a higher risk of death than people of similar
the general population of the cities cited in this paper.
* The most glaring
discrepancies in mortality ratios are seen in the younger and
groups from 18 to 34 years and from 35 to 54 years of age. While
homeless persons have a greater risk of dying than their housed
the standard mortality ratios across these cities are not as dramatic
the younger age groups.
* Younger homeless women have
from 4–31 times the risk of dying when compared to housed women, and
homeless women have similar risks of premature death than younger
The usual competitive advantage of women over men, with increased life
expectancy even in impoverished areas, appears to disappear in these
finding that requires further investigation.
* The average age of death
in the studies reviewed is between 42 and 52 years, despite an average
expectancy of almost 80 years in this county. The potential years of
* The “tri-morbidity” of
substance abuse and mental illness together with one or more chronic
illnesses appears to increase the risk of early death.
* Health care utilization
prior to death is variable and remains poorly understood, although
studies show high numbers of emergency room visits as well as multiple
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
AIDS, street youth, mentally ill veterans, and those who live
* Most studies to date have
been based on cohorts of homeless persons utilizing the shelter or
systems, and further study of those “sleeping rough” is required.
CAUSES OF HOMELESSNESS
learned from fifteen years of observation of the characteristics of
people are that there is not only a great variety in the people and the
they have followed, but there is also the crushing weight of poverty to
this situation together with other factors such as mental disorders
and drug abuse which also appear as "immediate causes". In an attempt
to understand why some people in poverty experience homelessness, and
don’t, both structural and personal dynamics must be considered.
should be taken into consideration. The job opportunities are dwindling
those on the low end of the employment spectrum in terms of wages,
education. On the other hand, the purchasing power of low wages is
The housing opportunities is another structural factors that should not
overlooked. The housing costs are rising drastically.The government
housing-assistance programs are massively over-burdened. Currently,
one-fourth of all eligible families receive any federal housing
to program funding constraints (35) and the average wait for Section 8
is 35 months (3).
our point of view, health care opportunities are essential in the
against homelessness. In 2004, 45.8 million Americans (or 15.7% of the
population) were without heath insurance, which was an increase from
before, and was disproportionately represented by poor households (36).
U.S. spends 16% of its GDP on health care, more than any other
nation, and those countries provide health insurance to all of their
Heath care costs are skyrocketing. In 2004, total national health
rose 7.9 percent—over three times the rate of inflation—and since 2000,
employment-based health insurance premiums have increased 73%.(37).
low wage jobs, even if they work full-time, are less likely to be
health insurance. Without health insurance and under increasing medical
unexpected health emergencies or serious chronic illnesses can quickly
overburden the resources of poor households.
personal factors, it is noteworthy that untreated mental illness can
difficult or impossible to maintain employment, pay bills or keep
social relationships. People with substance use disorder can drain
resources, cause job or housing lose, and also erode supportive social
relationships. Individuals with co-occurring mental illnesses and
disorders are among the most susceptible to the above mentioned loses.
In summary, there are a variety of ways
individuals become homeless and many of them occur simultaneously.
speaking, the job, housing, and health care markets pose formidable
to people without many resources. Politically speaking, in the U.S.,
reductions in federally supported housing over the past 25 years
the current reductions in safety net programs leave poor households
to homelessness. Individually speaking, people who have substance abuse
problems, mental health issues dramatically increase their likelihood
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
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
31% thought that it was the lack
of family contact that explained their situation.
inextricably linked to poverty then without alleviation of the most
aspects of poverty, homelessness can never be effectively ended. In
three main concerns are the focus of both governmental and
efforts to end homelessness: more affordable housing, livable wages and
comprehensive health care.
illness and drug abuse problems should be treated simultaneously.
medical, psychiatric, and counseling services exist to address these
is commonly believed that without the support of reliable and stable
such treatments remain ineffective. Furthermore, in the absence of a
health-care plan, many of those in need cannot afford such services.
The present difficultly is to address
issues while at the same time providing for the real and immediate
people experiencing . Lastly, many critics of social policy assert that
failure to live responsibly and a lack of determination are what place
people in homeless situations. Such thinking is largely accredited with
of homelessness. It is not uncommon for Americans to think of homeless
individuals as lazy
or worthless. Such people
typically believe it is only by choice that people are homeless and
they can choose not to be if they so desire. As such, there often
considerable tension and resentment between those that are housed and
that are not. Many Americans complain about the presence of homeless
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
It is often thought that such feelings encourage substance abuse and/or
exacerbate mental-health issues, which in turn increase the difficultly
functioning within mainstream society (i.e. holding a job, paying
maintaining relationships). In this way, the series of events—whether
abuse/mental illness caused, or resulted from, homelessness—is
inconclusive. Any attempt to truly end homelessness will have to deal
these pervasive social stigmas.
encountered by the homeless often have their origins in childhood. In a
comparison of the probability of having suffered childhood problems
homeless and those having a place to live in the county of Los Angeles,
rates of placing outside the family that were noted were much greater
homeless, especially Whites, as a much higher proportion of people who
poor and had even sometimes already been homeless in their childhood,
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
population); 25% were physically or sexually abused as children; 27%
foster care or similar institutions as children; 21% were homeless at
point during their childhood and 54%
were incarcerated at some point in their lives.
the reactions of the population towards the homeless can also be a
problems, such as the "Nimby syndrome" (rejection of public
shelters). It is with this term, Nimby, that the Americans designate
attitude which consists in refusing to allow services intended for the
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)
relation to the recent development of public policies towards making
the budgets allocated to helping the poorest and the raising of the
conditions. The study also show a hierarchical ranking of degrees of
acceptance, based on the characteristics of the persons likely to be
those of the neighborhood, those of the planned shelter, and the
the shelter to the inhabitants of the district and the corporations
there: "The users will tend to be less acceptable particularly if they
more distinguishable from the inhabitants in terms of their demographic
characteristics, if they are perceived as being stigmatized in some way
dangerous, and if they attract a considerable amount of attention
their physical appearance and behavior." (39)
not only are the homeless mentally ill persons being discriminated
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
are at risk
for dying prematurely
because of the mental illness they are suffering from and also owing to
AGAINST HOMELESSNESS: Recommendations for best practices
Points” report (8) published in the U.K. praises some examples of good
practices, such as floating housing support teams, which combine
housing and social services staff.
are designed to assist the homeless population have incorporated some
housing program for their clients In the United States each year, there
around 3.5million people who live their lives without shelter or a
occupation. For 2006 alone, $28.5 billion is being allotted to homeless
programs ran through HUD (Housing and Urban Development). $1 billion is
given for Section 8 housing, and $1.4 billion is being used for
significant number of homeless Americans with mental or physical
often coupled with drug and/or alcohol use issues, long-term
only be ended by providing permanent housing coupled with intensive
services. Permanent housing provides a “base” for people to move out of
operated by government, churches, or charities work
provide temporary housing to the homeless. Types of shelters include overnight shelters
and subsidized housing.
without a comprehensive health care program, housing is not often
enough to end
homelessness. Various agencies, in fact all homeless prevention
programs include substance abuse recovery and prevention programs. For
significant number of homeless Americans with mental or physical
often coupled with drug and/or alcohol use issues, long-term
only be ended by providing permanent housing coupled with intensive
It should be a
major goal for all the programs that fight against poverty to improve
quality of life and diminish the risk of early dying life for persons
homeless due to mental illness or substance abuse. Experts agree that
latter two groups tend to comprise the majority of persistent homeless
Therefore, treatment for mental illness and substance abuse disorders
OF SUPPORTED HOUSING
studies have proved the cost-effectiveness of supported housing
this population. The Culhane study (40) assessed the costs for clients
in the New York
(NY/NY) supported housing initiative and a
matched control group. The authors of such a study
substancially greater reductions in hospital use among NY/NY clients
controls, offsetting almost the entire $19,000 annual program cost.
most experts find these findings encouraging, the Culhane study has
criticized due to methodological deficits. Specifically, the absence of
conducted by Rosenheck et al. (41) is a 3-year prospective experimental
Therefore it is more statistically powerful than the previous one. This
examined the cost-effectiveness of supported housing (integrating
housing services) for homeless persons with mental illness. The sample
consisted of 460 homeless people with psychiatric and/or substance
disorders. The study took place at VA (Veteran Affairs) medical centers
in San Francisco, Calif
(n = 107); San Diego, Calif
(n = 91); New Orleans
(n = 165); and Cleveland, Ohio
(n = 97). Veterans were eligible if
they were literally homeless at the time of outreach assessment (ie,
a homeless shelter or on the streets), had been homeless for 1 month or
and had received a diagnosis of a major psychiatric disorder
bipolar disorder, major affective disorder, or posttraumatic stress
an alcohol or drug abuse disorder or both.
were randomly assigned to 1 of 3 groups:
with Section 8 vouchers (rent subsidies) and intensive case management
182). The participants of the HUD-VASH (Department of Housing and Urban
Development and the Department of Veteran Affairs) program were offered
access to Section 8 housing vouchers administered by local housing
These vouchers authorize payment of a standardized local fair-market
(established by HUD using surveys of local rents) less 30% of the
management only, without special access to Section 8 vouchers (n = 90).
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
They also provided substance abuse and employment counseling.
3* Standard VA
care (n = 188).
outcomes were days housed and days homeless. Secondary outcomes were
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
patient by the estimated unit cost of each type of service.
and encouraged at
least weekly face-to-face contact, community-based service delivery,
intensive involvement in crisis situations.
- The VA health service utilization.
- Unit costs for VA inpatient,
residential care and outpatint treatment.
Non-VA health costs.
- Non-health care costs. These costs
were used to estimate costs from the perspective of governmental
taxpayers and of society as a whole (total resource consumption): the
days spent in shelter beds or in jail or prison, cash transfer payments
benefits, Supplemental Security Income, and Social Security
and the cost of the Section 8 vouchers. Although cash transfer payments
(including housing subsidies) were included in the evaluation of costs
perspective of governmental agencies, only the administrative cost of
payments was included in societal cost estimates. Productivity
was also included in the societal cost estimate, as a negative cost.
hypothesized that HUD-VASH would generate sufficient savings in
halfway house, criminal justice, and emergency shelter costs to offset
additional costs of intensive case management services but that case
alone would be almost as expensive as HUD-VASH but less effective.
- The main outcomes were: During a
3-year follow-up, HUD-VASH veterans had 16% more days housed than the
management–only group and 25% more days housed than the standard care
- The case management–only group had
only 7% more days housed than the standard care group (P = .29).
- The HUD-VASH group also experienced
35% and 36% fewer days homeless than each of the control groups
- From the societal perspective,
HUD-VASH was $6200 (15%) more costly than standard care.
The policy implications of these
- The absence of differences between
case management only and standard care in this study raises the
whether housing vouchers could be provided to homeless clients without
linked to intensive case management services. No study or program has
vouchers to people with serious mental illness without some special
supports, so no answer to this question
available. To evaluate case management in an absolute sense, one would
compare outcomes for recipients of those services with outcomes for
were kept from using such services at all, which is not a feasible
- However, as we comment later on,
some studies suggest that case management services might be effectively
delivered on a time-limited basis (7.2)
as in the
critical time intervention (7.3) reducing total health care costs while
ensuring access to necessary services and supports.
- This study demonstrates the
potential benefit of housing vouchers for this population.
conclusion of this study (41) is that supported housing for homeless
with mental illness results in superior housing outcomes than intensive
management alone or standard care and modestly increases societal
MANAGEMENT SERVICES DELIVERED ON A TIME-LIMITED BASIS
It has been
widely documented that persons with serious mental illness experience
rates of residential instability and homelessness than in general
Most homeless mentally ill people are capable of living in the
they are given appropriate services that meet their needs. In spite of
encouraging fact, research has shown difficulties in engaging this
in treatment. Therefore, this is a major factor that should not be
Over the past
three decades, several programs have attempted to decrease homelessness
linking homeless mentally ill people with ongoing mental health
through assertive outreach and case management. One of the most
effort was Access to Community Care and Effective Services and Supports
(ACCESS): a 18-site national project that lasted from 1993 to 1998
essential strategy of ACCESS was to enhance access to mainstream mental
services by adopting the assertive community treatment model of
management. During the ACCESS program a multidisciplinary case
that included psychiatrists, nurses, and substance abuse and other
conducted a longitudinal epidemiological study between 1989 and 1995.
were drawn from the Suffolk County Mental Health Project (43). The
the study came to the conclusion that linking interventions that
continuation of aftercare in outpatient settings after the discharge
focused case management have shown promising results. The authors also
emphasized the prominent role of families, so they called for greater
to supportive and educational family interventions.
It was also
examined the extent to which the use of care management services
shelter use among the homeless mentally ill who took part in the
and Effective Services and Supports (ACCESS) (42). The sample consisted
Philadelphia ACCESS program participants. The study found that the use
specific types of services such as vocational and psychosocial
services led to an important reduction of the use of homeless shelters
thus posed an important contribution in the reduction of the risk of
A study of
Susser et al. (44) examined a strategy to prevent recurrent
mentally ill people. They provided an intervention of transition
institutional and community care. The sample consisted of 96 men. Over
18-month follow-up period the average number of homeless nights for the
“critical intervention” group was 30 and 91 for the usual services
carried out in New York City
to identify risk factors for long-term homelessness among first-time
homeless people. 377 people took part in this research. They were
with standardized assessments of psychiatric diagnosis, symptoms and
skills, social and family history, and service use. 81% of subjects
community housing during the follow-up period (18 months).
of the data revealed that a shorter duration of homelessness was
younger age, current or recent employment, earned income, good coping
family support, the absence of a substance abuse treatment history, and
absence of an arrest history. The regression analysis found that older
group (p<0.05) and arrest history (p<0.01) were the strongest
of a longer duration of homelessness. The identification of risk
long-term homelessness might guide efforts to reduce lengths of stay in
homeless shelters and develop new preventive interventions.
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