The Impact of Homelessness on Mental Health

Psychology today, 2021

• 25% of US homeless population suffers from severe mental illness, compared to 6% of general population.
• Combination of poor mental health , physical health and substance abuse make it difficult to maintain employment and housing.
• Improved mental health services will reduce homelessness.
• 2019: 40% of Americans one paycheck away from poverty
• According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2010, 26.2 percent of all sheltered persons who were homeless had a severe mental illness, and 34.7 percent of all sheltered adults who were homeless had chronic substance use issues. Of those who experience chronic/long-term homelessness, approximately 30 percent have mental health conditions and 50 percent have co-occurring substance use problems. Also, they typically endure traumatic experiences that could potentially lead to mental health struggles, and certain environmental factors may increase the likelihood that they encounter future traumas.
• Over 92 percent of mothers who are homeless have experienced severe physical and/or sexual abuseduring their lifetime, and about two-thirds of homeless mothers have histories of domestic violence. Mothers who are homeless have three times the rate of PTSD and twice the rate of drug and alcohol dependence of their low-income housed counterparts. Left untreated, these stressors can further damage their mental health, potentially triggering maladaptive coping and putting them at risk for future traumatic events.
• About 3 percent of Americans experienceat least one episode of homelessness throughout their lives. Many enter an unbreakable cycle of homeless living due to the lack of access to adequate resources.

Homelessness, housing instability and mental health: making the connections

Cambridge University Press Deborah K Padgett ^1,✉

• Literature review of studies on homelessness and mental health concludes the focus on mental health medical issues is too narrow to solve the problem, given the importance of housing and mental health to well-being.
• The deinstitutionalization of psychiatric hospitals beginning in the 1960s contributed to the rise of the homeless mentally ill.
• However, only about 25-30% of the homeless have a severe mental health illness like schizophrenia.
• But researchers have also neglected the impact of homelessness on development of mental health problems. Depression, suicide, drug abuse all much higher among homeless people than comparable people with housing – suggesting homelessness itself contributes to the development of these problems.
• Meta-analysis suggested more than half of homeless and marginally housed people have traumatic brain injuries – both a cause and effect of their homelessness.
• Interviews with homeless people indicate that they face an emotional toll not only from being homeless – but from the scorn of passers-by and police.
• Children are especially vulnerable to the effects of homelessness and housing instability.
• “The gap between mental health needs and service availability for the homeless population is vast”
• Habitat for Humanity estimates global population of people facing homelessness or housing insecurity may be as high as 1.6 billion.
• US homelessness complicated by view of housing as a commodity and the overlay of racial discrimination – with African Americans disproportionately affected.
• Currently half of American households devote more than half their income to housing.
• “Housing First” movement has achieved notable success in providing support services, reducing homelessness and improving mental health and functioning by focusing first on providing housing before tackling the other problems causing or worsened by homelessness.
• Critical Time Intervention (CTI) has also achieved results by doing more to line up housing and support services for people about to be released from treatment and institutional care.
• A recent US report on the alarming lack of access to mental healthcare even for the well insured points to a broad-based crisis in mental health services.³⁷Ignoring laws ensuring parity, insurers provide much lower coverage for mental health treatment than would be tolerated for cardiac or cancer care, and out-of-pocket costs can run as high as $400 per private psychiatrist visit.³⁷
• Despite a plethora of research linking mental and physical health to housing stability, the salience of structural barriers is too often submerged in ‘blaming the victim’ for her or his plight. Physicians and healthcare providers receive little training in social determinants and often view them as off-limits or distracting from attention to signs and symptoms. Yet psychiatrists and other mental health professionals can become agents of change by paying greater attention to the social determinants of mental health and seeking structural competence in their practice. It is difficult to overestimate the benefits of having a stable, safe home as fundamental to mental health and well-being.

The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis

Stefan Gutwinski ^1,#, Stefanie Schreiter ^1,2,#, Karl Deutscher ¹, Seena Fazel ^3,*

Meta-analysis of 39  studies involving 8,000 homeless people in 11 countries.

• Our findings suggest that the burden of psychiatric morbidity in homeless persons is substantial, and should lead to regular reviews of how healthcare services assess, treat, and follow up homeless people. The high burden of substance use disorders and schizophrenia spectrum disorders need particular attention in service development. 
• 37% had alcohol use disorders and much higher rates of schizophrenia and drug use disorders as well.
• US lifetime rate of homelessness about 4%, with 550,000 homeless on any one night.
• Danish study found 70% increase in mortality with comorbidities like mental disorder.
• Mental health diagnosis among homeless linked to higher rates of criminal behavior and victimization, longer periods of homelessness and discrimination – although most such disorders are treatable.
• Surveys suggest 76% of homeless people have diagnosis of at least one mental health disorder.
• Surveys targeting schizophrenia suggested 12% rate.
• 18 studies on depression found rates up to 42%
• 14 studies targeting bipolar had rates up to 13%
• 29 studies targeting alcohol use disorders ranged from 6-71% – with average of about 36%
• 23 studies on drug use disorder averaged about 18%
• 14 studies on Personality disorders around 25%
• Averaging all the studies, alcohol use disorder (37%) about 10 times the general population. Drug use disorders of 22% also about 10 times general population.
• Drug use could be both cause and effect of homelessness.
• High rates of treatable mental illness. 13% had either depression or schizophrenia.
• Conclusion: In summary, we found high prevalence of mental disorders among homeless people in high-income countries, with around three-quarters having any mental disorder and a third having alcohol use disorders. Future research should focus on integrated service models addressing the identified needs of substance use disorders, schizophrenia spectrum disorders, and depression in homeless individuals as a priority. In addition, new work could consider focusing on underrepresented subpopulations like homeless women and migrants.

JAMA Psychiatry

Prevalence of Mental Health Disorders Among Individuals Experiencing HomelessnessA Systematic Review and Meta-Analysis

1. Rebecca Barry, PhD^1,2; Jennifer Anderson, BSc¹; Lan Tran, BA, BKin¹

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2817602

Study documented high rates of mental health disorders among homeless people, especially men through a review of 85 studies, screened from original sample of 291.

• 67% of the currently homes have a mental health disorder – with a lifetime prevalence of 77%. Males had a 86% prevalence compared to females at 69%. This included:
• 44% with substance use disorder
• 26% with antisocial personality disorder
• 19% with depression
• 7% with schizophrenia
• 8% with bipolar disorder
• Conclusion:  The findings demonstrate that most people experiencing homelessness have mental health disorders, with higher prevalences than those observed in general community samples. Specific interventions are needed to support the mental health needs of this population, including close coordination of mental health, social, and housing services and policies to support people experiencing homelessness with mental disorders.
• Mental health disorders (including substance abuse) affect 1 billion people world-wide and cost the world economy $2.5 trillion annually. Rates are highest among the 100 million people experiencing homelessness globally.
• Individual factors, such as substance use, relationship conflicts, and traumatic experiences, may contribute to homelessness among people with mental health disorders.³Poverty, lack of affordable housing, transitions from foster care or institutional settings, stigma, racism, and discrimination may further perpetuate homelessness for these individuals.³ 
• Most population-based studies estimate the current prevalence of mental health disorders to be approximately 13% to 15% and the lifetime prevalence to be between 12% and 47%.^31,32
• North America has the highest mental health disorder prevalence among people experiencing homelessness, likely influenced by various factors like mental health care access, cultural differences, social support, housing affordability, and working conditions.^46,47Additionally, higher-income countries may report higher rates of mental health disorders, possibly due to increased stigma in lower- and middle-income nations, leading to underreporting.⁴⁵
• Housing first strategies are effective at improving housing retention but demonstrate mixed results for outcomes such as reduced substance use and improved mental health.^48,49Critical time interventions are another approach that connects individuals to mental health supports during specific times, such as transitions from shelters or inpatient psychiatric care.^4,10
• Implications: Our findings reveal a high and potentially increasing prevalence of mental health disorders among people experiencing homelessness. Integrated interventions are vital, focusing on substance use disorders, antisocial personality disorder, major depression, and psychotic disorders—conditions more common in people experiencing homelessness than in the general population.