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:
- Among the homeless there are more
people having physical or mental health problems and alcohol and
drug-related
problems than in the rest of the population. Yet, the research
available does
not indicate with certainty whether these difficulties have been the
cause of
the person's homelessness or are a consequence of this situation. The
use of
alcohol and narcotics, and even some forms of mental illness, are seen
by some
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
suffering
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%
for
women with children.
- The results obtained for Paris
seem to show a prevalence of mental health problems among the homeless
close to
that of the United States, with however better access to care, if not
better
medical follow up.
- In France, the problems of
alcoholism and drug abuse, although higher than for the rest of the
population,
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
often
been institutionalized for psychiatric problems and have fewer alcohol
and
personality disorder problems than the men; middle aged men who use the
emergency shelters have more alcohol-related problems.
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):
- Monotherapy should be preferred.
- The maintenance dose is the
minimum effect dose with minimum side effects.
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 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
agencies or
taxpayers and of society as a whole (total resource consumption): the
number of
days spent in shelter beds or in jail or prison, cash transfer payments
(eg, VA
benefits, Supplemental Security Income, and Social Security
disability), earnings,
and the cost of the Section 8 vouchers. Although cash transfer payments
(including housing subsidies) were included in the evaluation of costs
from the
perspective of governmental agencies, only the administrative cost of
these
payments was included in societal cost estimates. Productivity
(employment earnings)
was also included in the societal cost estimate, as a negative cost.
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 main outcomes were: During a
3-year follow-up, HUD-VASH veterans had 16% more days housed than the
case
management–only group and 25% more days housed than the standard care
group (P<.001
for both).
- 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
(P<.005 for
both).
- From the societal perspective,
HUD-VASH was $6200 (15%) more costly than standard care.
The policy implications of these
results were:
- The absence of differences between
case management only and standard care in this study raises the
question of
whether housing vouchers could be provided to homeless clients without
being
linked to intensive case management services. No study or program has
offered
vouchers to people with serious mental illness without some special
program
supports, so no answer to this question
is
available. To evaluate case management in an absolute sense, one would
have to
compare outcomes for recipients of those services with outcomes for
clients who
were kept from using such services at all, which is not a feasible
alternative.
- 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.
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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