Risk Factors for Homelessness Among Women with Schizophrenia

Article (PDF Available)inAmerican Journal of Public Health 85(8 Pt 1):1153-6 · September 1995with43 Reads
DOI: 10.2105/AJPH.85.8_Pt_1.1153 · Source: PubMed
Abstract
A study of risk factors for homelessness among the severely mentally ill was extended to include women, and a case-control study of 100 indigent women with schizophrenia meeting criteria for literal homelessness and 100 such women with no history of homelessness was conducted. Subjects were recruited from shelters, clinics, and inpatient psychiatric programs in New York City. Clinical interviewers used standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Findings adjusted for ethnicity revealed that homeless women had higher rates of a concurrent diagnosis of alcohol abuse, drug abuse, and antisocial personality disorder. Homeless women also had less adequate family support.
Risk
Factors
for
Homelessness
among
Women
with
Schizophrenia
Carol
L.
M
Caton,
PhD,
Patrick
E.
Shrout,
PhD,
Boanerges
Dominguez,
MS,
Paula
F.
Eagle,
MD,
LewisA.
Opler,
MD,
PhD,
and
Francine
Coumos,
MD
Inlodwtion
In
previous
eras,
women
have
been
found
among
hoboes,
wanderers,
and
inmates
of
almshouses,1-4
and
today
they
constitute
about
20%
of
the
contempo-
rary
adult
homeless
population.5
Home-
less
women
without
kin
have
been
found
to
be
more
psychiatrically
disabled
than
other
subgroups
of
the
homeless,5
particu-
larly
those
in
mid-adulthood
and
older.6
Although
mentally
ill
women
who
are
homeless
are
thought
to
require
special
services,7
little
is
known
about
how
they
differ
from
mentally
ill
women
who
never
experience
homelessness.
Some
studies
that
have
explored
the
differences
between
the
homeless
and
the
residentially
stable
either
have
focused
on
one
sex
or
have
had
such
small
numbers
of
women
subjects
that
comparisons
be-
tween
the
sexes
were
not
possible.10
Studies
that
have
included
adequate
num-
bers
of
both
sexes
have
found
that
the
homeless
or
residentially
unstable
have
greater
alcohol11'12
and/or
drug11'13
abuse;
higher
symptom
levels11'12;
greater
non-
compliance
with
prescribed
treatments11,12;
and
a
greater
prevalence
of
foster
care,
group
home
placement,
and
runaway
episodes
in
childhood.14
While
the
litera-
ture
suggests
that
multiple
factors
distin-
guish
the
homeless
from
the
never-
homeless,
we
know
of
no
prior
attempt
to
study
multiple
risk
factors
in
a
single
investigation
of
women.
We
recently
reported
findings
on
men
with
schizophrenia
from
our
case-
control
study
of
homelessness
designed
to
test
hypotheses
about
three
domains
of
risk:
severity
of
illness,
family
background,
and
prior
mental
health
services
use.15
We
now
report
findings
on
women
with
schizophrenia,
based
on
a
replication
of
the
design
and
the
method
of
the
study
of
men.
Methods
A
case-control
design
was
used
with
100
women
in
a
sheltered
homeless
group
and
100
women
in
a
never-homeless
group.
All
200
subjects
had
experienced
at
least
one
psychiatric
hospitalization,
were
between
the
ages
of
18
and
64
years,
and
were
currently
enrolled
in
a
mental
health
program
targeted
at
the
public
patient
with
severe
mental
illness.
To
be
eligible
for
inclusion,
the
women
were
required
to
meet
DSM-III-R
criteria
for
schizophre-
nia
or
schizoaffective
disorder,
deter-
mined
through
the
Structured
Clinical
Interview
for
DSM-III-R
(SCID).16
For
both
groups,
potential
study
subjects
were
referred
by
clinical
staff
based
on
the
subject's
chart
diagnosis,
treatment
his-
tory,
and
capacity
to
give
voluntary
in-
formed
consent.
Such
referrals
were
con-
sidered
consecutively
by
the
research
staff.
Women
with
a
recent
episode
of
literal
homelessness"7
were
recruited
from
a
shelter,
a
24-hour
drop-in
center,
and
three
transitional
housing
programs
(n
=
93),
as
well
as
from
three
psychiatric
inpatient
units
(n
=
7).
None
were
re-
cruited
from
the
streets.
Women
who
were
never
literally
homeless
were
se-
lected
from
four
outpatient
clinics
(n
=
80)
and
three
inpatient
units
(n
=
20).
All
inpatients
were
ready
for
discharge.
Al-
though
case
subjects
were
matched
with
control
subjects
on
inclusion
criteria,
they
were
drawn
from
different
types
of
mental
health
programs
and
thus
may
not
be
similar
on
all
dimensions.
Of
the
249
women
who
were
asked
to
participate
in
the
study,
19
(7.6%)
refused
and
12
(4.8%)
dropped
out
before
com-
pleting
the
interview
battery.
Refusals
were
nearly
three
times
greater
in
the
never-homeless
group.
Eighteen
(7.2%)
of
homeless
subjects
with
completed
interviews
were
eliminated
from
the
study
because
of
inconsistent
or
poor-quality
data
that
could
not
be
improved
with
a
reinterview.
In
such
cases,
the
subject
was
Carol
L.
M.
Caton,
Boanerges
Dominguez,
Paula
F.
Eagle,
Lewis
A.
Opler,
and
Francine
Coumos
are
with
the
Department
of
Psychiatry
and
School
of
Public
Health
at
Columbia
University's
College
of
Physicians
and
Sur-
geons,
New
York,
NY.
Patrick
E.
Shrout
is
with
the
Department
of
Psychology,
New
York
University,
New
York,
NY.
Requests
for
reprints
should
be
sent
to
Carol
L.
M.
Caton,
PhD,
Department
of
Psychiatry,
Columbia
University,
722
W
168th
St,
Box
114,
New
York,
NY
10032.
This
paper
was
accepted
March
7,
1995.
American
Journal
of
Public
Health
1153
Public
Health
Briefs
TABLE
1
-Background
Characteristics
of
Never-Homeless
and
Homeless
Women
with
Schizophrenia
Never
Homeless
(n
=
100),
%
Place
of
birth
American
born
Foreign
born
Place
of
residence
for
the
greatest
%
of
time
from
birth
to
18
y
New
York
City
area
Other
Race/ethnicity
Black
Hispanic
White
Religion
Protestant
Catholic
Other
None
Marital
status
Single
Married/conjugal
Separated/divorced
Widowed
Veteran
status
Yes
No
Employment
status
Employed
Unemployed
Income
from
entitlements
Yes
No
Earned
income
Yes
No
Income
from
family
Yes
No
74.0
26.0
60.0
40.0
39.0
26.0
35.0
32.0
46.0
13.0
9.0
43.0
17.0
34.0
6.0
2.0
98.0
21.0
79.0
85.0
15.0
19.0
81.0
39.0
61.0
Homeless
(n
=
100),
%
81.0
19.0
55.0
45.0
52.0
10.0
38.0
40.0
41.0
15.0
4.0
49.8
7.0
36.2
8.0
3.0
97.0
26.0
74.0
88.0
12.0
19.0
81.0
8.0
92.0
scale
of
adequacy2l
based
on
the
fre-
quency
of
contact,
quality
of
relationship,
material
support,
emotional
support,
and
companionship
available
from
family
members
regardless
of
living
arrangement
(see
footnote*
for
explanation
of
scale).
Prior
service
use
was
also
explored
with
items
contained
in
the
Community
Care
Schedule.21
Medication
adherence
was
rated
on
a
4-point
scale
based
on
the
subject's
self-report.
Long-term
follow-up
care
was
defined
in
terms
of
the
number
of
months
in
outpatient
treatment
with
the
same
therapist.
For
practical
reasons,
interviewers
had
to
conduct
some
inter-
views
in
the
sites
where
subjects
were
enrolled.
Therefore,
they
were
not
blind
to
the
homeless/never-homeless
status
of
some
study
subjects.
However,
they
were
not
aware
of
the
study
hypotheses.
The
case
subjects
(the
homeless)
were
compared
with
the
control
subjects
(the
never-homeless)
with
respect
to
three
classes
of
study
variables.
In
the
illness
domain,
there
were
six
variables:
premorbid
social
attainment
scale
score,
Positive
and
Negative
Syndrome
Scale
(PANSS)
positive
symptom
score,
PANSS
negative
symptom
score,
and
binary
indi-
cators
of
alcohol
abuse,
drug
abuse,
and
antisocial
personality
disorder.
In
the
family
domain,
there
were
two
variables:
family
disorganization
index
and
ad-
equacy
of
family
support.
In
the
service
use
domain,
there
were
two
variables:
medication
adherence
and
existence
of
a
long-term
therapist.
Case
and
control
subjects
were
ini-
tially
compared
without
taking
into
ac-
count
sampling
characteristics
of
the
Current
age,
y
Mean
Median
Mode
Standard
deviation
Years
of
education
Mean
Median
Mode
Count
Standard
deviation
either
too
delusional
or
too
disorganized
to
function
as
a
reliable
informant.
It
is
possible
that
the
more
disturbed
subjects
were
not
included
in
the
final
sample.
Research
instruments
are
described
in
detail
in
our
initial
report.15
In
sum-
mary,
preillness
social
functioning
was
rated
with
the
UCLA
Social
Attainment
Scale.'8
Positive
and
negative
dimensions
of
schizophrenia
were
assessed
with
the
43.00
42.00
45.00
11.9
11.55
12.00
12.00
100
2.95
42.00
42.00
34.00
9.93
11.53
12.00
12.00
100
2.10
Positive
and
Negative
Syndrome
Scale
(PANSS).19
Current
and
lifetime
alcohol
and
drug
abuse/dependence
were
evalu-
ated
with
the
SCID.16
Antisocial
person-
ality
disorder
was
evaluated
with
the
SCID-II.20
Family
disorganization
in
childhood
was
evaluated
with
4-point
rating
scales
in
the
Community
Care
Schedule.2'
Current
family
support
was
rated
on
a
4-point
*The
scale
of
adequacy
of
family
support:
family
support
was
rated
on
a
4-point
scale
from
1
(adequate)
to
4
(grossly
inadequate).
Ratings
are
based
on
the
following
information
pertaining
to
close
relatives,
usually
parents
and
siblings:
frequency
of
contact,
quality
of
relationship,
material
support,
emotional
sup-
port,
and
companionship.
The
ratings
are
defined
as
follows:
*
Adequate
(1).
Subject
has
frequent
con-
tact
with
family,
who
give
food,
clothing,
and
money
when
able.
Subject
can
talk
to
at
least
one
family
member
about
her
problems.
Sub-
ject
occasionally
goes
to
movie
or
dinner
with
family
member.
*
Fair
(2).
Subject
has
less
frequent
(three
to
four
times
a
year)
contact
with
family,
but
family
assists
with
material
and
emotional
support.
Socialization
takes
place
only
rarely.
*
Poor
(3).
Subject
has
frequent
contact
with
family,
but
family
gives
little
or
no
material
or
emotional
support.
*
Grossly
inadequate
(4).
Subject
has
infre-
quent
contact
with
family,
and
family
gives
no
material
or
emotional
support.
There
is
es-
trangement.
August
1995,
Vol.
85,
No.
8
1154
American
Journal
of
Public
Health
Public
Health
Briefs
groups.
They
were
then
compared
with
statistical
adjustments
made
using
logistic
regression,
with
the
binary
case/control
variable
treated
as
the
outcome,
and
the
risk
variables
and
possible
confounders
treated
as
explanatory
variables.
Possible
confounders
were
chosen
from
those
demographic
variables
in
Table
1
that
were
at
all
related
to
the
case/control
variable
(at
the
P
<
.15
level).
The
only
variable
falling
into
this
category
is
ethnic-
ity.
No
adjustment
was
made
for
current
income
variables
because
they
can
be
expected
to
be
related
to
homelessness
structurally
rather
than
incidentally.
To
facilitate
the
comparison
of
ad-
justed
and
unadjusted
associations
be-
tween
the
risk
variables
and
the
case/
control
distinction,
both
are
presented
using
results
from
logistic
regression
analy-
ses.
The
test
statistic
presented
is
the
likelihood
ratio
chi
square
(LRT)
from
the
logistic
analyses.22
Results
The
homeless
case
group
and
never-
homeless
control
group
had
many
traits
in
common
(see
Table
1),
including
median
age
(42
years),
marital
status
(nearly
two
thirds
had
been
involved
in
a
conjugal
relationship
at
some
time,
but
only
17%
of
the
never-homeless
and
7%
of
the
home-
less
were
currently
married
or
living
with
a
partner),
median
level
of
education
(12
years),
and
employment
status
(more
than
three
fourths
were
unemployed).
Moreover,
most
(62%
of
homeless
and
65%
of
never-homeless)
were
members
of
ethnic
minorities.
However,
there
were
greater
numbers
of
Blacks
among
the
homeless
than
among
the
never-homeless
(52%
vs
39%)
and
greater
numbers
of
Hispanics
among
the
never-homeless
than
among
the
homeless
(26%
vs
10%).
Table
2
summarizes
tests
of
study
hypotheses
on
the
differences
between
never-homeless
and
homeless
women
with
schizophrenia.
Within
the
illness
domain,
there
were
no
significant
differences
be-
tween
the
homeless
and
the
never-
homeless
on
the
UCLA
Social
Attain-
ment
Scale
scores
in
either
unadjusted
or
adjusted
tests.
In
addition,
there
were
no
major
differences
in
PANSS
positive
or
negative
symptom
levels.
However,
a
higher
proportion
of
homeless
subjects
had
a
concurrent
alcohol
abuse
diagnosis
(P
<
.05
for
both
unadjusted
and
ad-
justed
tests)
and/or
a
concurrent
drug
abuse
diagnosis
(P
<
.05
for
both
tests).
Similarly,
a
significantly
greater
number
of
homeless
subjects
had
a
concurrent
diagnosis
of
antisocial
personality
disor-
der
(P
<
.05
for
both
unadjusted
and
adjusted
tests),
a
finding
that
persisted
when
the
criterion
of
lack
of
a
fixed
address
for
a
month
or
more
was
deleted
from
the
diagnostic
algorithm.
We
plan
to
discuss
the
assessment
of
antisocial
per-
sonality
disorder
among
the
severely
mentally
ill
elsewhere
(Caton
CLM,
Shrout
P,
Dominguez
B,
unpublished
manuscript).23
Within
the
family
domain,
there
were
no
differences
on
the
index
of
family
disorganization.
Family
support
was
less
adequate
for
the
homeless
(P
<
.01
for
both
tests).
In
terms
of
service
use
issues,
there
were
no
differences
between
the
homeless
and
the
never-homeless
with
regard
to
medication
adherence
or
the
duration
of
time
in
treatment
with
the
same
therapist.
When
the
data
were
adjusted
for
recruit-
ment
status
(outpatient
or
discharge-
ready
inpatient),
findings
remained
the
same.
When
the
four
variables
that
were
significant
in
Table
2
were
included
as
a
set
in
a
logistic
regression
model
along
with
ethnicity,
only
one
variable-ad-
equacy
of
family
support-remained
sig-
nificant
(Wald
=
14.2;
df
=
1;
P
<
.01).
The
odds
of
homelessness
among
those
at
the
low
end
of
family
support
were
estimated
to
be
about
three
times
larger
than
those
at
the
high
end
of
the
support
measure.
To
determine
if
adequacy
of
family
support
is
itself
sufficient
to
ac-
count
for
the
effects
of
alcohol
abuse,
drug
abuse,
and
antisocial
history,
we
carried
out
a
stepwise
regression
analysis,
with
adequacy
of
family
support
and
ethnicity
entered
in
the
first
step.
In
the
second
step,
antisocial
history
was
statisti-
cally
significant
(Wald
=
4.38;
df
=
1;
P
<
.05)
as
well
as
practically
significant:
the
odds
of
homelessness
were
estimated
to
be
nearly
10
times
greater
among
those
women
with
a
history
of
antisocial
behav-
ior.
Alcohol
abuse
appeared
not
to
have
unique
effects
when
ethnicity,
family
American
Journal
of
Public
Health
1155
August
1995,
Vol.
85,
No.
8
TABLE
2-Test
of
Key
Hypotheses
on
the
Risk
of
Homelessness
among
Urban
Women
with
Schizophrenia
Never
Homeless
Homeless
(n
=
100)
(n
=
100)
Unadjusteda
Adjustedb
Mean
SD
Mean
SD
LRT
P
LRT
P
Illness
domain
UCLA
Social
Attain-
19.3
7.1
20.4
7.4
1.10
0.30
1.20
0.27
ment
Scale
score
PANSS
positive
15.4
6.5
16.5
7.7
1.22
0.27
1.07
0.30
symptoms
score
PANSS
negative
17.6
7.3
18.9
6.5
1.66
0.20
1.32
0.25
symptoms
score
Alcohol
abuse
0.16
0.37
0.30
0.46
5.60
<0.05
5.61
<0.05
(0
=
no,
1
=
yes)
Drug
abuse
(0
=
no,
0.15
0.36
0.29
0.46
5.79
<0.05
5.39
<0.05
1
=
yes)
Antisocial
personality
0.01
0.10
0.08
0.27
6.45
<0.05
7.03
<0.05
disorder
(0
=
no,
1
=
yes)
Family
domain
Index
of
family
disor-
13.1
3.8
13.1
3.9
0.00
0.98
0.15
0.69
ganization
Adequacy
of
family
1.8
1.1
2.6
1.3
18.06
<
0.01
12.96
<
0.01
support
Service
use
domain
Medication
adher-
1.64
0.95
1.57
0.95
0.29
0.59
0.53
0.46
ence
Long-term
therapist
49.4
51.90
39.6
54.40
1.51
0.22
1.00
0.32
Note.
LRT
=
likelihood
ratio
test.
aLikelihood
ratio
test
and
P
value
from
logistic
regression
models
with
no
other
variables
held
constant.
bLikelihood
ratio
test
and
P
value
from
logistic
regression
models
holding
ethnicity
constant.
Public
Health
Briefs
support,
and
antisocial
history
were
con-
trolled,
but
drug
abuse
remained
a
trend.
Discussion
This
study
addressed
risk
factors
for
homelessness
only
among
persons
with
schizophrenia.
It
did
not
probe
the
impor-
tance
of
schizophrenia
itself
or
the
rela-
tive
importance
of
schizophrenia
and
poor
family
support
as
risk
factors
for
homelessness.
Homeless
women
with
schizophrenia
differed
from
their
never-
homeless
counterparts
in
two
of
the
three
domains
we
studied:
family
background
and
illness
characteristics.
Both
the
uni-
variate
(see
Table
2)
and
the
logistic
regression
analyses
revealed
that
poor
family
support
is
a
key
risk
factor
for
homelessness.
Because
this
was
not
a
longitudinal
study,
we
cannot
ascertain
that
poor
family
support
preceded
the
first
episode
of
homelessness.
While
poor
family
support
is
not
a
risk
factor
for
the
initial
onset
of
homelessness,
we
contend
that
it
is
a
risk
factor
for
the
persistence
of
homelessness.
Family
living
settings
are
common
among
the
severely
mentally
ill.
The
loss
of
an
opportunity
to
live
with
kin
creates
the
need
to
find
housing
in
a
market
with
few
available
options.
Like
their
male
counterparts,15
women
who
ended
up
in
our
homeless
group
were
more
likely
to
have
concur-
rent
alcohol
and/or
drug
abuse,
antisocial
personality
disorder,
and
poor
family
support.
In
contrast
to
findings
for
men,15
however,
the
logistic
regression
analysis
revealed
that
adequacy
of
family
support
was
a
more
important
risk
factor
for
women
than
were
any
of
the
variables
in
the
illness
domain.
The
results
were
consistent
with
a
mediation
explanation;
the
effect
of
substance
abuse
may
be
to
decrease
family
support,
which
in
turn
leads
to
homelessness.
Antisocial
history,
while
partially
mediated
by
family
sup-
port,
appears
to
have
an
independent
effect
on
homelessness.
Findings
suggest
that
illness
behavior
and
family
character-
istics
of
women
with
schizophrenia
should
be
closely
monitored
to
prevent
homeless-
ness.
O
Acknowledgment
The
research
on
which
this
report
is
based
was
supported
by
National
Institute
of
Mental
Health
grant
MH44705.
A
more
detailed
presentation
of
the
study
reported
here
is
available
from
Dr
Caton.
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8
    • "Also majority of the patients were young with little or no little education. This is in conformity with previous studies [10,18]. It is pertinent to note that the lack of educational attainment and unemployment may be due to the social drift that often characterize the people with chronic mental illness [12]. "
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