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Mental Health, Concurrent Disorders, and Health Care Utilization in Homeless Women
Abstract
Purpose:
This study assessed lifetime and current prevalence rates of mental disorders and concurrent mental and substance use disorders in a sample of homeless women. Current suicide risk and recent health service utilization were also examined in order to understand the complex mental health issues of this population and to inform the development of new treatment strategies that better meet their specific needs.
Methods:
A cross-sectional survey of 196 adult homeless women in three different Canadian cities was done. Participants were assessed using DSM-IV-based structured clinical interviews. Current diagnoses were compared to available mental health prevalence rates in the Canadian female general population.
Results:
Current prevalence rates were 63% for any mental disorder, excluding substance use disorders; 17% for depressive episode; 10% for manic episode; 7% for psychotic disorder; 39% for anxiety disorders, 28% for posttraumatic stress disorder; and 19% for obsessive-compulsive disorder; 58% had concurrent substance dependence and mental disorders. Lifetime prevalence rates were notably higher. Current moderate or high suicide risk was found in 22% of the women. Participants used a variety of health services, especially emergency rooms, general practitioners, and walk-in clinics.
Conclusion:
Prevalence rates of mental disorders among homeless participants were substantially higher than among women from the general Canadian population. The percentage of participants with moderate or high suicide risk and concurrent disorders indicates a high severity of mental health symptomatology. Treatment and housing programs need to be accompanied by multidisciplinary, specialized interventions that account for high rates of complex mental health conditions.
... 11 Adults who experience homelessness and substance use problems have an increased risk of mental illness, 12 and evidence shows that 25%-70% of this population have co-occurring substance use and mental health problems. 13,14 Although coverage for mental illnesses is available in some states through Medicaid, (but not in Oklahoma where the current study took place), vague insurance policies can present a persistent barrier for those who otherwise would qualify. Other barriers that limit healthcare use by homeless individuals with mental health diagnosis (MHD) include the difficulties registering with a general physician, inability to provide a permanent address to medical staff upon registration, stigma surrounding mental health, personal perception of treatment needs, poor connection to the healthcare system, and lack of family support. ...
... For example, one study on homeless women with concurrent substance use and mental health disorders assessed 3 areas: (1) whether individuals met with a healthcare provider; (2) whether they participated in self-help groups; and/or (3) whether they sought substance use treatment. 14 In another work, researchers measured the utilization of healthcare services and case management. 29 Whereas these services are important, they do not cover the entire scope of services that are provided at shelters. ...
... Most of the previous studies examining the use of shelter services have focused mainly on use of mental health or substance use treatments, meeting a doc- tor, or use of healthcare. 14,28,29 This study is unique as it examines the perceived usefulness and utilization of a wide range of services offered by the shelters including counseling services, case management services, educational groups, employment training, legal aid, referrals for services and assistance to get vital documents, and connect adults experiencing homelessness with their families, in addition to spending the night at a shelter and receiving meals at shelters. According to the reported perceived usefulness of shelter services, providing a shelter (ie, housing), job training or job searching help, and general healthcare were the reported priority requirement for adults experiencing homelessness. ...
... There is a known association between social inequity and increased risk of mental health disorders (WHO and Calouste Gulbenkian Foundation 2014). Compared to the general Canadian population, women who experience homelessness have substantially higher prevalence rates of mental disorders (Strehlau et al. 2012) and women in shelters have reported experiencing 'dark thoughts' that emerge from feelings of resentment, powerlessness, and marginalization (Grabbe et al. 2013). Men who experience homelessness may struggle with gender role conflict, such as not expressing emotions, resulting in higher levels of psychological distress and resistance to seeking mental health supports (Nguyen et al. 2012). ...
... Women identified very few psychological quality of life variables that improved their mental well-being, which is perhaps not surprising given women report higher rates of mental disorders (Strehlau et al. 2012) and 'dark thoughts' (Grabbe et al. 2013). Men, however, showed a dichotomous relationship between the positive feelings and negative feelings variables, such that a decrease in one led to an increase in the other. ...
Homelessness has negative implications for mental well-being and quality of life. This paper identifies the quality of life variables that contribute to positive or negative wellbeing, reporting on a regression analysis from 343 individuals experiencing homelessness in Canada. Results indicate that a lack of sleep duration and quality reduced mental well-being for both genders, not having access to food and/or hygiene facilities decreased men’s well-being, and engaging in illegal subsistence strategies, such as selling drugs, negatively impacted women’s mental well-being. For persons experiencing homelessness, mental well-being and quality-of-life are gendered outcomes of their limited access to social determinants of health.
... Mental and physical health issues Strong links exist between homelessness and psychological distress. The incidence of both mental and physical health issues are higher for homeless women than the general population including depression, anxiety and substance use as well as asthma, high blood pressure, skin problems, gynaecological problems and dental problems (Arangua et al., 2005;Bassuk et al., 1996;Bonugli et al., 2013;Chambers et al., 2014;Craft-Rosenberg, Powell, & Culp, 2000;Greifenhagen & Fichter, 1997;Ingram et al., 1996;Strehlau, Torchalla, Kathy, Schuetz, & Krausz, 2012;Upshur, Jenkins, Weinreb, Gelberg, & Orvek, 2017). Furthermore, stable housing is a primary indicator of health with homelessness or housing instability shown to worsen health outcomes (Gilroy, McFarlane, Maddoux, & Sullivan, 2016) and is an important social determinant of health. ...
... Homeless women experience lifetime diagnoses of substance use disorders, affective disorders, anxiety disorders, post-traumatic stress disorder (PTSD) and schizophrenia at higher rates than women who are stably housed (Banyard & Graham-Bermann, 1998;Gilroy et al., 2016;Greifenhagen & Fichter, 1997;San Agustin et al., 1999;Strehlau et al., 2012;Upshur et al., 2017). These mental health issues may be multidirectional. ...
Homelessness is an increasingly prevalent issue worldwide. Women represent the fastest growing segment of the homeless population and have differing needs to men. These differences need to be considered by service providers and other stakeholders working with homeless women. A scoping review was conducted to address the question “What is known about issues relating to homeless women in the existing literature?” PubMed, PsycInfo, Embase, CINAHL, Scopus and Web of Science were searched up until March 2018 with no date limits. The final sample of articles included in this scoping study was 232 from which six themes were extracted: (1) pathways into homelessness, (2) trauma, victimization and adverse childhood experiences, (3) mental and physical health issues, (4) barriers to accessing treatment and experiences with service providers, (5) social support and life satisfaction and (6) strengths, hopes and leaving homelessness. This review suggests a strengths-based approach to addressing women’s homelessness. This approach emphasizes people’s self-determination and strengths and views clients as resilient to problems they encounter in their lives. Future research and service provision should take into account the complexities in the lives of homeless women and recognize the autonomy of women to move out of homelessness.
... The present study shows that the prevalence rate of psychiatric disorders in homeless subjects was 79.1%, three times higher than the general Bangkok population (prevalence rate of 25.3%) (10) . The result is similar to the previous studies conducted in USA, England, Germany, France, Scotland, Australia, Canada, Japan, and Hong Kong in the way that the prevalence of psychiatric disorders in homeless group is 1 to 40 times higher than the general population (2)(3)(4)(5)(6)(11)(12)(13)(14)(15)(16)(17) . ...
... All of the findings in the present study were corresponding to researches conducted in USA, England, Germany, France, Scotland, Australia, Canada, Japan, and Hong Kong as mentioned above (2)(3)(4)(5)(6)(11)(12)(13)(14)(15)(16)(17) . ...
Objective: To find the prevalence of psychiatric disorders in the homeless population in Bangkok, Thailand Materials and Methods: In an epidemiological survey of the prevalence of psychiatric disorders in homeless individuals at Lan Khon Meaung, Sao Chingcha in Bangkok, Thailand, a probability sample of 113 homeless people were interviewed using a Mini-International Neuropsychiatric Interview [MINI]. Results: There was a high prevalence rates of psychiatric disorders among homeless people (76%). The most frequent psychiatric disorders were major depressive episode (current two weeks prevalence rate 35.7%) psychotic disorders (lifetime prevalence rate 31.0%), psychotic disorders (current two weeks prevalence rate 23%), alcohol dependence (past 12 months prevalence rate 22.1%), and major depressive episode melancholic features (current two weeks prevalence rate 19.5%). The prevalence of suicidal risk and two or more psychiatric comorbidities factors in severe psychiatric disorders group were higher than the others, with a statistical significance (p-value 0.003 and 0.001, respectively). Conclusion: Prevalence of psychiatric disorders in homeless population in Bangkok is higher among the homeless than in the general population, especially severe psychiatric disorders. An urgent need for adequate medical and psychiatric care and the development of concepts for rehabilitation should be established.
... High alcohol consumption leads to serious public health issues (Fang & McNeil, 2017). In addition, homelessness is a significant public health issue, since individuals experiencing homelessness are more likely than the general population to have chronic physical and mental health conditions (Sleet & Francescutti, 2021;Strehlau et al., 2012). The use of alcohol and other drugs are associated with a higher use of emergency departments with associated health 1969). ...
This article uses the latest Spanish Survey on Homeless People to address whether traumatic experiences, sociodemographic characteristics, and homeless categories are associated with being an abstainer, a risky drinker, or a high-risk drinker. The sample was composed of 3,407 Spanish homeless adults ranging from 18 to 93 years old ( M age = 41.30, SD = 13.86). A multinomial logistic regression model was used. Results showed that experiencing childhood problems and demographic factors, such as being male, single, over 50, living in insecure or inadequate housing, and having lived in a shelter for less than three months were associated with alcohol consumption. Likewise, traumatic life events, such as a parent having been in prison, illness, disabilities, and alcohol problems in the family or themselves, are also risk factors in alcohol use. The findings from Spain support that early intervention strategies both disrupt cumulative inequality and empower those at risk of homelessness to develop their skills and improve their wellbeing.
... The growing homeless population in the U.S.A. [1] is disproportionately impacted by poor mental and physical health status [2][3][4][5], including a higher incidence of acute and chronic health problems, increased hospitalizations, and premature mortality compared to the general population [6][7][8][9][10][11][12][13] as well as higher healthcare costs [14,15]. Further, studies have shown that past experiences of trauma are highly prevalent among the homeless [16,17], resulting in a higher prevalence of post-traumatic stress disorder (PTSD) compared to the population at large [18]. ...
Purpose
The growing homeless population in the U.S.A. is disproportionately impacted by poor mental and physical health status, including a higher incidence of acute and chronic health problems, increased hospitalizations, and premature mortality compared to the general population. This study examined the association between demographic, social, and clinical factors and perceptions of general health status among the homeless population during admission to an integrated behavioral health treatment program.
Methods
The study sample included 331 adults experiencing homelessness with a serious mental illness or co-occurring disorder. Participants were enrolled in services at a day program for unsheltered homeless adults, a residential substance use treatment program for males experiencing homelessness, a psychiatric step-down respite program for those experiencing homelessness following psychiatric hospitalization, permanent supportive housing for formerly chronically homeless adults, a faith-based food distribution program, and homeless encampment sites in a large urban area. Participants were interviewed using The Substance Abuse and Mental Health Services Administration’s National Outcome Measures tool and a validated health-related quality of life measurement tool, SF-36. Data were examined using in elastic net regression.
Results
The study found seven factors to be particularly strong predictors of SF-36 general health scores. Male gender, “other” sexual identity, stimulant use, and Asian race were all associated with better perceptions of health status, while transgender status, inhalant use, and number of times arrested were associated with poorer perceptions.
Conclusion
This study suggests targeted areas for health screening within the homeless population; however, more studies are necessary to demonstrate generalizability of the results.
... According to the 2018 point-in-time estimates, 552,830 people experienced homelessness in the United States [1]. Compared to domiciled adults, those experiencing homelessness are disproportionately affected by poor mental and physical health [2][3][4][5]. According to previous research, 48-65% of adults experiencing homelessness reported diagnoses of depression, and 43% reported diagnoses of Post-Traumatic Stress Disorder (PTSD) [2,3,6]. ...
Traditionally, intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) have been studied separately rather than simultaneously. In the current study, we address this gap by simultaneously examining these characteristics as potential indirect associations linking established urban stress–depression and urban stress–Post-Traumatic Stress Disorder (PTSD) relationships. Adults experiencing homelessness were recruited from six homeless shelters in Oklahoma City (n = 567). Participants self-reported urban life stress (Urban Life Stress Scale), distress tolerance (Distress Tolerance Scale), social support (Interpersonal Support Evaluation List 12), major depressive disorder (Patient Health Questionnaire-8), and PTSD symptoms (Primary Care Post-Traumatic Stress Disorder screener). Covariate-adjusted structural equation models indicated a significant indirect effect of distress tolerance on the urban stress–depression (b = 0.101, 95% CI = 0.061, 0.147) and urban stress–PTSD (b = 0.065, 95% CI = 0.023, 0.112) relationships. Additionally, a significant indirect effect of social support on the urban stress–depression (b = 0.091, 95% CI = 0.053, 0.133) and urban stress-PTSD relationships (b = 0.043, 95% CI = 0.006, 0.082) was evident. Further, both the urban stress–depression (b = 0.022, 95% CI = 0.011, 0.037) and urban stress–PTSD relationships (b = 0.014, 95% CI = 0.005, 0.026) were associated indirectly through social support to distress tolerance. Interventions that aim to increase social support may also increase distress tolerance skills and indirectly reduce depressive and PTSD symptoms in the context of urban stress among adults experiencing homelessness.
... Furthermore, to confirm whether the results of our final meta-analyses were heavily affected by study with greater relative weight, we performed a sensitivity analysis by removing a study with a higher relative weight [34] and the results revealed no significant variation in our final results. The prevalence was 10.0% (95% CI 6.5-15.1) ...
Background:
Bipolar disorder (BD) is a common severe mental disorder among homeless people and is associated with an increased risk of disability and mortality from suicide, medical causes (including HIV/AIDS, hepatitis infection, hypertension, and tuberculosis), as well as substance use disorders. However, a systematic synthesis of the existing evidence on the subject is lacking. To fill this gap in the literature, this study aimed to carry out systematic review and meta-analysis to determine the consolidated prevalence of BD among homeless people.
Methods:
In this systematic review and meta-analysis, we searched Embase, PubMed, and Scopus to identify pertinent studies that reported the prevalence of BD among homeless people in March 2019. Random effect meta-analysis was employed to pool data from the eligible studies. Subgroup and sensitivity analysis was conducted and Cochran's Q- and the I2 test were utilized to quantify heterogeneity. Publication bias was assessed by using Egger's test and visual inspection of the symmetry in funnel plots.
Results:
Of 3236 studies identified, 10 studies with 4300 homeless individuals were included in the final analysis. Among the 10 studies, five studies used the Diagnostic Statistical Manual of Mental disorders (DSM), three studies used Mini-International Neuropsychiatric Interview (MINI), one study used Schedule for Clinical Assessment of Neuropsychiatry (SCAN), and one study used Composite International Neuropsychiatric Interview (CIDI) to assess BD among homeless individuals. Based on the results of the random effect model, the prevalence of BD among homeless people was 11.4% (95% CI; 7.5-16.9). The prevalence of BD was 10.0% (95% CI; 3.1-27.9) in Europe and it was 13.2% (95% CI; 8.9-19.3) in other countries. Moreover, the prevalence of BD was 11.5% (95% CI; 5.5-22.3) for studies that used DSM to assess BD and it was 11.0% (95% CI; 6.1-19.2) for studies that used other instruments (MINI, SCAN, and CIDI).
Conclusion:
Our meta-analysis demonstrated that BD is highly prevalent among homeless individuals, underlying the importance of early screening and targeted interventions for BD among homeless individuals.
... Individuals who were homeless prior to age 18 were at an increased risk of being homeless as an adult, as were Indigenous people. Those recently discharged from a medical, addiction, or correctional facility were at much higher risk (Greysen et al., 2012;Strehlau et al., 2012;Tulloch et al., 2012). Transitions out of relationships were frequently destabilizing (Christensen, 2013;Waegemakers Schiff et al., 2016). ...
Rural homelessness is an emergent social concern in Canada but it remains overshadowed by urban homelessness policy and research agendas. Thus, it is rare to find extended academic discussions of rural homelessness and its causes. In this paper, we report on the findings of a mixed-method rural homelessness study in a small Alberta prairie town (Canada). We explore the nature of transitions and how they place individuals at risk of housing risk and/or homelessness, particularly in a rural context. Findings reveal a complex interplay between external and internal resources and drivers that cast an individual into the liminal space of housing risk and into homelessness, and that the rural context accentuates housing risk.
... Studies were conducted in seven countries representing a total of 20,364 participants. Among the 19 studies, most of the studies (11 studies) were from the USA [6,10,12,13,18,22,31,38,43,45,48], three from Canada [21,38,51], two from Australia [32,49], one from German [16], one from Ireland [42], and one from France [44]. The included articles were published between 2001 and 2017, with the sample size ranging between 38 participants in Ireland and 8844 participants in the USA. ...
Post-traumatic stress disorder (PTSD) is common among homeless people and is associated with an increased risk of mortality from suicide, medical causes, and drug-related problems. However, there are no previous systematic review and meta-analysis studies that reported the consolidated magnitude of PTSD among homeless people. A literature search was conducted on PubMed, Embase, and Scopus to discover pertinent studies that determined the prevalence of PTSD among the homeless. Articles were evaluated by titles, abstracts, and full-text. Comprehensive meta-analysis software was used to conduct the meta-analysis. Subgroup and sensitivity analysis were performed and Cochran’s Q- and the I2 test were used to assess heterogeneity. The evidence of publication bias was evaluated by using Egger’s test and visual inspection of the symmetry in funnel plots. From the total, 19 studies with 20,364 participants across seven countries were included in the final analysis. Our meta-analysis revealed that the pooled prevalence of PTSD among homeless people was 27.38% (95% CI; 21.95–33.57). In our subgroup analysis, we found that the prevalence of PTSD was considerably high as measured by the screening instrument (35.93%) than the diagnostic instrument (23.57% %). The prevalence of PTSD among homeless showed a significant variation by the location of the studies, the instruments used to measure PTSD as well as the quality of the included studies. This review showed that the pooled prevalence estimate of PTSD among homeless peoples was remarkably high (27.38%). Early screening and treatment of PTSD among homeless peoples are warranted to alleviate suffering.
... Merely identifying mental illness among homeless individuals alone is insufficient, as they often do not receive care once problems are identified (Edidin, Ganim, Hunter, & Karnik, 2012;Kim et al., 2007). Studies throughout the U.S. have found that only 16-21% of homeless individuals meeting criteria for a mental health condition receive care in the form of medication management (Krausz et al., 2013;Nickasch & Marnocha, 2009;Strehlau, Torchalla, Kathy, Schuetz, & Krausz, 2012;Weber, Thompson, Schmiege, Peifer, & Farrell, 2013). Researchers have identified several financial reasons homeless individuals may not receive the health care they need, including lack of health coverage, transportation problems, lack of time, stigma, and not feeling comfortable in the healthcare system (Edidin et al., 2012;Kim et al., 2007). ...
The high prevalence of mental health problems among homeless individuals has been well-documented. However, studies have shown significant variability among regions and even cities. As a result, it is necessary to study the mental health of local populations in order to best meet their needs. The current study examined mental health and barriers to accessing care using a cross-sectional, mixed methods, approach. The aims of this study were to describe the prevalence of mental health problems, multiple morbidities, and barriers to accessing mental healthcare in a Midwestern sample of homeless individuals. We recruited 127 individual staying in a homeless shelter in Lincoln, Nebraska and matched them with 127 controls from a national normative data set. We also conducted three focus groups. Mixed methods analysis techniques were used to examine the results. Homeless participants had higher rates of most mental health problems when compared with controls. The greatest disparities were seen in the prevalence of thought problems, internalizing problems, externalizing problems, and obsessive symptoms. Numerous barriers to accessing care were commonly reported with a lack of access being the most commonly cited challenge. Homeless individuals require additional consideration when establishing and providing care given their high rates of multiple morbidities and apparent treatment resistance. Given all the barriers homeless people face, it would be beneficial to establish more accessible methods for individuals to get the help they need.
... Their poor health status is marked by chronic conditions, mental health problems, and substance use problems [7][8][9]. Prevalence rates for mental disorders go from 30% to more than 60%, and more than 50% of homeless people have concurrent substance addiction and mental disorders [9][10][11]. However, they face multiple difficulties in accessing primary health care and receive less preventive health care than the general population [12,13]. ...
Background:
Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant.
Methods:
We performed a literature review that included articles which described and evaluated primary care programs for homeless people.
Results:
Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community's health.
Conclusions:
Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model.
... As it can be seen, findings revealed that one of the key problems afflicting homeless girls is the presence of anxiety and depression symptoms. This coincides with previous studies in other countries [49,61,62] that show that such groups suffer from these because of growing up among vulnerable conditions that constitute one of the predominant reasons for abandoning their homes and entering an organization. Also, it was observed that they tend to be unassertive because they exhibit greater difficulty in defending their rights and interests; they cannot express their ideas and feelings without being aggressive, and are hostile and unable to establish healthy relationships. ...
... Homelessness has become one of the most pressing and complex social, health and political issues in many countries. Studies have consistently demonstrated particularly high prevalence rates of substance use and mental disorders among homeless populations in many Western countries including Canada (1,2), the US (3)(4)(5), Australia (6), and Europe (7)(8)(9). ...
Background: Homeless individuals with mental illness are challenging to recruit and retain in longitudinal research studies. The present study uses information from the Vancouver site of a Canadian multi-city longitudinal randomized controlled trial on housing first interventions for homeless individuals. We were able to recruit 500 participants and retain large number of homeless individuals with mental illness; 92% of the participants completed the 6-month follow up interview, 84% the 24-month follow up, while 80% completed all follow-up visits of the study.
Purpose: In this article, we describe the strategies and practices that we considered as critical for successful recruitment and retention or participants in the study.
Methods: We discuss issues pertaining to research staff hiring and training, involvement of peers, relationship building with research participants, and the use of technology and social media, and managing challenging situations in the context of recruitment and retention of marginalized individuals.
Conclusions: Recruitment and retention of homeless participant with mental illness in longitudinal studies is feasible. It requires flexible, unconventional and culturally competent strategies. Longitudinal research projects with vulnerable and hidden populations may benefit from extensive outreach work and collaborative approaches that are based on attitudes of mutual respect, contextual knowledge and trust.
... However, since studies often measure related but not identical aspects of women's mental health 1 in divergent samples using various measuring instruments, drawing clear-cut 1 Constructs used to measure general mental health vary from the prevalence of lifetime mental health problems (Edens, Mares and Rosenheck, 2011), to the occurrence of mental illness (Zugazaga, 2004) or the presence of mental disorders (Strehlau, Torchalla, Li, Schuetz and Kraus, 2012). conclusions about the prevalence of mental health problems among homeless women (or comparing homeless women with other groups or the general population) is difficult. ...
Chapter 7 examines the health of homeless women, which is an under-researched topic in most European countries. It presents an overview of the available European research evidence on the health of homeless women and the factors that influence homeless women’s access to health services in different national health care and welfare systems. Although the knowledge base is patchy, thus limiting the extent to which comparisons can be made between countries, there is considerable evidence of relatively poor health among homeless women. Furthermore, the effectiveness with which the health care needs of homeless women are met depends, to a large degree, on enabling factors such as the nature and accessibility of national health care services. The chapter concludes that there is considerable scope for further research within and across European countries in order to better establish how women’s homelessness affects their health and how homeless women experience health care services across Europe.
... Past literature demonstrates that homeless adults have high rates of chronic physical (Beijer et al., 2012;Bernstein, Meurer, Plumb, & Jackson, 2015;Notaro et al., 2013) and mental (Fazel et al., 2008;Folsom et al., 2005;Lippert & Lee, 2015;Martens, 2001;Stergiopoulos, Dewa, Durbin, Chau, & Svoboda, 2010;Strehlau, Torchalla, Li, Schuetz, & Krausz, 2012) health conditions, and that there are disparities in homeless men's and women's health. In studies from the 1980s, homeless women were more likely than men to report a mental health condition (Breakey et al., 1989;Crystal & Ladner, 1985); however, there are discrepancies in the literature regarding gender differences in mental health symptoms, with one relatively recent study reporting no significant differences (Edens, Mares, & Rosenheck, 2011) and another study finding that women were significantly more likely to report mental health symptoms (Hwang et al., 2009). ...
Background:
Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.
Methods:
This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area participated.
Results:
Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.
Conclusions:
There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.
... Hwang et al., 2011;S. W. Hwang, 2001;Kilbourne, Herndon, Andersen, Wenzel, & Gelberg, 2002;Levy & O'Connell, 2004;O'Campo et al., 2009;Rabiner & Weiner, 2012;Strehlau, Torchalla, Li, Schuetz, & Krausz, 2012;Teruya et al., 2010). ...
Physical Health, Abuse, Mental Illness, Loss, Instability, and Substance Use; the lives of homeless women are shaped by multiple interwoven domains. They confront extreme loss and destructive relationships throughout their lives. This dissertation addresses this syndemic (PHAMILIS) through an ethnography of homeless women staying at a rural emergency shelter in Northeastern Connecticut. My aim was to understand, through narratives, the life trajectories of homeless women, the experiences leading to their current state, and their perceptions of homelessness. My research involved interviewing 30 homeless women staying at the emergency shelter and 13 housing service providers throughout Connecticut. The purpose of the interviews was to hear and share the women’s stories and to gain insight into their conceptualization of homelessness. The provider interviews further contextualized the perception of homeless women. My research illuminated predisposing, exacerbating, and intervening factors that the women shared. They led complex, unstable lives growing up in various levels of poverty with dysfunctional families often rife with abuse and frequent relocation. Multiple, complex issues such as physical health problems, mental illness, substance use disorders, and abuse (sexual, physical, or emotional) exacerbated their homeless situation. Other factors intervened to interrupt their lives, including early parenthood, lack of education, Department of Children and Families involvement, custody battles, incarceration, and disability. The PHAMILIS syndemic elucidates the interrelatedness of factors that create the homeless experience and will help to inform how we strive to address the complex issues that affect the health and well-being of homeless women and the issue of homelessness itself.
... These investigators found that this rate was approximately ten times higher than the annual percentage of the housed population. When Strehlau, Torchalla, Kathy, Schuetz and Krausz (2012) investigated suicide in a sample of 193 homeless women, they found 50% (97) of the women reported at least one suicide attempt in their lives and 26% (50) reported suicidal thoughts within the past 12 months. Additionally, Goldstein et al. ...
SUICIDE RISK IN HOMELESS VETERANS WITH
TRAUMATIC BRAIN INJURY
Dr. Briana Lafferty
Dr. Marilynn Sommers
Every sixty-five minutes a veteran takes his or her own life. Suicide is now the second leading cause of death among United States (US) military service members, with rates almost three times that of the general population. An association may exist between suicide and traumatic brain injury (TBI). One in six military service members involved in the wars in Iraq and Afghanistan are said to have been subjected to at least one TBI. With the growing number of service members exposed to blast injuries, the consequences of TBI, such as changes in mood, personality, cognition, and behavior, expose them to the risk of suicide. Veterans are also 50% more likely than other Americans to become homeless, and homelessness is another problem contributing to a greater risk for suicide in this population. Rates of suicide among individuals experiencing homelessness are reported to be approximately ten times higher than the annual percentage of suicides within the housed population. Currently, there is no existing literature that examines suicide risk in veterans affected by both TBI and homelessness. The aim of my study was to examine the associations among suicide risk and specific physical, psychological, social, and military factors, as well as to describe the association of suicide risk and utilization of Veterans Affairs (VA) healthcare services, in a sample of homeless US Veterans who have experienced at least one TBI. I conducted a cross-sectional study using secondary data from the National Center for Homelessness Among Veterans, in addition to performing retrospective chart reviews. My findings demonstrated strong associations between high risk for suicide and marital status, PTSD, issues with memory/problem solving, seizures, and inpatient admissions for mental health treatment. My findings have implications for health care and policy change related to decreasing stigmatization of mental health issues, overcoming barriers and increasing eligibility to VA healthcare benefits, and mandating more aggressive screening and prevention efforts. These changes are needed particularly during the transition to civilian life.
... H omeless people's substance use has been characterized as the main mental health problem for homeless people. 1 A review among homeless populations in Western countries reported that alcohol dependence ranges from 8% to 59% and drug dependence from 5 to 54%. 1 A large cohort study among Swedish homeless people found a prevalence of alcohol and drug diagnoses of 42% for men and 41% for women. 2 Substance use among homeless populations has consistently been associated with a number of adverse outcomes, such as premature mortality, 3 symptoms of mental illness 4 and longer durations of homelessness. [5][6][7][8][9][10] However, it is important to note that most recent studies of substance use among homeless people were carried out outside Europe, mostly in the USA 10,[11][12][13] and Canada, 4,14,15 including most studies evaluating the relationship between substance use and longer durations of homelessness. [5][6][7][8][9][10] Because of factors such as the wide variation in prevalence rates of substance use among homeless populations and differences in drug markets and drug policy, these studies have limited generalizability to European countries. ...
Previous studies have shown that substance use among homeless people is a prevalent problem that is associated with longer durations of homelessness. Most studies of substance use among the homeless were carried out outside Europe and have limited generalizability to European countries. This study therefore aimed to address the prevalence of substance use among homeless people in the Netherlands, the pattern of their use and the relationship with housing status at follow-up.
This study included 344 participants (67.1% of the initial cohort) who were followed from baseline to 18 months after the baseline interview. Multinomial logistic regression analyses examined the relationship between substance use and housing status.
The most reported substances which were used among these homeless people were cannabis (43.9%) and alcohol (≥5 units on one occasion) (30.7%). Other substances were used by around 5% or less of the participants. Twenty-seven percent were classified as substance misuser and 20.9% as substance dependent. The odds to be marginally housed (4.14) or institutionalized (2.12) at follow-up compared to being housed of participants who were substance users were significantly higher than those of participants who did not use substances. The odds to be homeless were more than twice as high (2.80) for participants who were substance dependent compared with those who were not.
Homeless people who use substances have a more disadvantageous housing situation at follow-up than homeless people who do not use substances. Attention is needed to prevent and reduce long-term homelessness among substance-using homeless people.
© The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
... 32,[49][50][51] The reasons for this are multifactorial and include risk factors that increase individuals' risk for homelessness and are associated with poor health outcomes, such as early life poverty 52 and mental health and substance misuse disorders. 49,53 Mental health and substance misuse disorders both increase the risk of and are exacerbated by homelessness. Other risk factors are secondary to the conditions of homelessness itself, such as poor nutrition, 54,55 exposure to communicable diseases, 56 harsh living environments, 57,58 high rates of victimisation 59 and unintentional injuries, 57,60 and increased rates of tobacco use. ...
In the European Union, more than 400,000 individuals are homeless on any one night and more than 600,000 are homeless in the USA. The causes of homelessness are an interaction between individual and structural factors. Individual factors include poverty, family problems, and mental health and substance misuse problems. The availability of low-cost housing is thought to be the most important structural determinant for homelessness. Homeless people have higher rates of premature mortality than the rest of the population, especially from suicide and unintentional injuries, and an increased prevalence of a range of infectious diseases, mental disorders, and substance misuse. High rates of non-communicable diseases have also been described with evidence of accelerated ageing. Although engagement with health services and adherence to treatments is often compromised, homeless people typically attend the emergency department more often than non-homeless people. We discuss several recommendations to improve the surveillance of morbidity and mortality in homeless people. Programmes focused on high-risk groups, such as individuals leaving prisons, psychiatric hospitals, and the child welfare system, and the introduction of national and state-wide plans that target homeless people are likely to improve outcomes.
... Based on the findings of this study, policymakers and planners should develop integrated services that are easily accessible and appropriate for homeless and vulnerably housed individuals to close the gap between need and treatment. Such programs would help address their physical, mental and addiction disorders while at the same time assist them to reestablish residential stability, which may decrease the possibility of relapse and improve access to other important resources [49]. ...
We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study.
In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment.
Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43-2.64) and unmet mental (AOR 3.06; 95% CI 2.17-4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18-4.54).
Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.
... Individuals with concurrent mental and substance use disorders tend to present with multiple physical health problems and substantial social and behavioural problems [1]. Individuals with concurrent disorders (CD) are overrepresented in forensic settings, regularly inhabit substandard housing [2,3] and constitute a significant percentage of the homeless population [4,5]. Individuals suffering from CD typically have difficulty engaging with traditional health care services and tend to rely heavily upon emergency care as their access point to the health care system [6]. ...
Patients with addictions and concurrent disorders constitute the most underserved population in the system of care. There are numerous reasons why this population has so much difficulty accessing services, including behavioural issues, criminal engagement, and non-compliance with outpatient services. To improve services to this population which is marked by multiple morbidities, high mortality and insufficient access to health care, the government of British Columbia, Canada developed a program for people with both substance use disorder and one or more mental disorders who have not benefited from previous therapies.
In July 2008, the Burnaby Treatment Centre for Mental Health and Addiction (BCMHA), a specialized and integrated tertiary care facility, was opened. The current article provides a description of the treatment program and a clinical profile of the population.
The target population is being served, at intake clients present with high rates of psychopathology, childhood and adult trauma, and substance use.
While preliminary, these results indicate, that the novel approach of the Burnaby Centre may constitute a new path towards providing effective recovery for this population.
Objective
There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period.Methods
The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data.ResultsAt the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%-77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%-41.3%), p
Objectives
To assess the global prevalence estimates of depressive symptoms, dysthymia and major depressive disorders (MDDs) among homeless people.
Design
Systematic review and meta-analysis.
Data sources
Databases including PubMed, Scopus and Web of Science were systematically searched up to February 2020 to identify relevant studies that have reported data on the prevalence of depressive symptoms, dysthymia and MDDs among homeless people.
Eligibility criteria
Original epidemiological studies written in English that addressed the prevalence of depressive problems among homeless people.
Data extraction and synthesis
A random-effect meta-analysis was performed to pool the prevalence estimated from individual studies. Subgroup and sensitivity analyses were employed to compare the prevalence across the groups as well as to identify the source of heterogeneities. The Joanna Briggs Institute’s quality assessment checklist was used to measure the study quality. Cochran’s Q and the I ² test were used to assess heterogeneity between the studies.
Results
Forty publications, including 17 215 participants, were included in the final analysis. This meta-analysis demonstrated considerably higher prevalence rates of depressive symptoms 46.72% (95% CI 37.77% to 55.90%), dysthymia 8.25% (95% CI 4.79% to 11.86%), as well as MDDs 26.24% (95% CI 21.02% to 32.22%) among homeless people. Our subgroup analysis showed that the prevalence of depressive symptoms was high among younger homeless people (<25 years of age), whereas the prevalence of MDD was high among older homeless people (>50 years of age) when compared with adults (25–50 years).
Conclusion
This review showed that nearly half, one-fourth and one-tenth of homeless people are suffering from depressive symptoms, dysthymia and MDDs, respectively, which are notably higher than the reported prevalence rates in the general population. The findings suggest the need for appropriate mental health prevention and treatment strategies for this population group.
Objective:
The recognition of concurrent disorders (combined mental health and substance use disorders) has increased substantially over the last three decades, leading to greater numbers of people with these diagnoses and a subsequent greater financial burden on the health care system, yet establishing effective modes of management remains a challenge. Further, there is little evidence on which to base recommendations for a particular mode of health service delivery. This paper will further summarize the existing treatment models for a comprehensive overview. The objectives of this study are to determine whether existing service models are effective in treating combined mental health and substance use disorders and to examine whether an integrated model of service delivery should be recommended to policy makers. The following two research questions are the focus of this paper: (1) Are the existing service models effective at treating mental health and substance use disorders? (2) How are existing service models effective at treating mental health and substance use disorders?
Methods:
We used various databases to systematically review the effectiveness of service delivery models to treat concurrent disorders. Models were considered effective if they are found to be cost-effective and significantly improve clinical and social outcomes.
Results:
This systematic review revealed that integrated models of care are more effective than conventional, nonintegrated models. Integrated models demonstrated superiority to standard care models through reductions in substance use disorders and improvement of mental health in patients who had diagnoses of concurrent disorders. Our meta-analysis revealed similar findings, indicating that the integrated model is more cost-effective than standard care.
Conclusions:
Given the limited number of studies in relation to service delivery for concurrent disorders, it is too early to make a strong evidence-based recommendation to policy makers and service providers as to the superiority of one approach over the others. However, the available evidence suggests that integrated care models for concurrent disorders are the most effective models for patient care. More research is needed, especially around the translation of research findings to policy development and, vice versa, around the translation from the policy level to the patients' level.
Treatment readiness is a key predictor of drug treatment completion, rearrest, and recidivism during community reentry; however, limited data exist among homeless female offenders (HFOs). The purpose of this study was to present baseline data from a randomized controlled trial of 130 HFOs who had been released from jail or prison. Over half (60.8%) of HFOs had a treatment readiness score of ≥40 (n = 79, mean [μ] = 40.2, SD = 8.72). Bivariate analyses revealed that methamphetamine use, psychological well-being, and high emotional support were positively associated with treatment readiness. On the contrary, depressive symptomatology and depression/anxiety scores were negatively associated with the treatment readiness score. Multiple linear regression revealed that depressive symptomatology was negatively associated with treatment readiness (β = −0.377, p = .001). Further analyses revealed that the effect of emotional support on treatment readiness was mediated by depressive symptomatology.
Le présent article fait l’exercice de repenser la question de l’itinérance, en proposant l’adoption d’un regard neuf, parce que féminin, sur le phénomène. Incarnée dans une recherche participative en cours – notamment son Comité de reconnaissance –, cette nouvelle perspective s’appuie simultanément sur la parole et les savoirs de femmes en situation d’itinérance, sur une épistémologie de la marge, des théories de la reconnaissance et d’autres féministes, critiques et intersectorielles. À l’inverse d’une logique individualiste centrée sur la gestion du risque, sont abordés les enjeux structurels et systémiques que vivent ces femmes, qui les invisibilisent socialement, les fragilisent, et qui se posent donc en obstacle à une vie décente. Par conséquent, l’avènement d’une réponse adaptée et adéquate, ancrée dans les droits de la personne, ne peut faire l’économie d’un renouvellement de la perspective à la fois du phénomène de l’itinérance et des personnes qui vivent de telles situations.
Women living in vulnerable neighborhoods experience higher rates of poverty, homelessness, psychiatric issues, illicit substance use, rates of HIV, and a lowered life expectancy. The aim of the study was to further explore the history of mental illness and trauma in a sample of women (N = 31) who had recently given birth and had a substance use problem while pregnant. We investigated sociodemographic characteristics, history of trauma and post-traumatic stress disorder (PTSD), rates of substance use and dependence, and psychiatric symptoms. Childhood and adult traumatic experiences were found in the majority of the sample, and one-third presented with suspected PTSD diagnosis at the time of the interview. Women-centered services are in great demand, as well as trauma informed care, and further research on appropriate treatment for substance using, traumatized, women with a mental illness.
Introduction:
Individuals living in single-room occupancy (SRO) hotels constitute a socially marginalized group with exposure to multiple factors with adverse effects on neurocognition, including substance use, viral infection, psychiatric illness, and brain injury. Consequently, marked heterogeneity in neurocognitive functioning is observed. This study aimed to identify and describe distinct neurocognitive profiles within a marginally housed sample.
Method:
Two hundred and forty-nine (N = 249) SRO hotel residents (mean age = 43.5 years) were recruited. A battery of tests assessed neurocognition across six domains: premorbid IQ, verbal memory, attention, inhibition, mental flexibility, and decision making. Clinical examinations collected information pertaining to substance use and psychiatric diagnoses, viral infection, psychiatric symptoms, risk behaviors, and everyday functioning. Cluster analysis was used to identify subgroups of individuals with similar neurocognitive profiles and was supplemented with a discriminant function analysis. Analyses of variance and chi-square tests were used to validate the derived clusters on key clinical and functional variables.
Results:
A three-cluster solution was found to be optimal. Cluster 1 (n = 59) presented as overall higher functioning, whereas Cluster 3 (n = 87) exhibited overall lower functioning with a relative strength in decision-making skills. Cluster 2 (n = 103) was characterized by neurocognitive abilities that generally bisected the performance of the other groups, but with a relative weakness in decision-making skills. Discriminant function analysis indicated the six neurocognitive variables comprised two underlying dimensions that accounted for between-group variance. Clusters meaningfully differed on demographics, substance use, viral exposure, psychiatric symptoms, neurological soft signs, and risk behavior.
Conclusion:
Neurocognitive functioning provides the basis for identifying meaningful subgroups of marginally housed individuals, which can be reliably differentiated on key variables. This approach facilitates an understanding of the neurocognitive dysfunction and associated vulnerabilities of marginalized persons and ultimately may elucidate intervention targets.
This study examines the prevalence and characteristics of homelessness episodes in Australian substance misuse treatment. A dataset containing all closed substance treatment episodes in NSW, Australia from July 2006 to June 2011 was used. Statistical analysis was used to determine any relationships between demographic and treatment variables and homelessness. Of the 213, 129 treatment episodes in the dataset 12.8% have some form of homelessness. Non-government and residential services have the highest prevalence of homelessness. Sex, age, and drug type have weak relationships with homelessness. Leaving against the advice of the treatment provider is more common in episodes where homelessness is a factor. Homelessness is a problem experienced by a significant proportion of the substance treatment population and treatment providers have an opportunity and an obligation to address it in their treatment delivery.
Homeless individuals experience significant physical, mental health and substance abuse issues. This study describes the prevalence of health issues and perceptions of access to care among 300 homeless individuals who use a day shelter. Approximately 43% described a serious/chronic physical health problem, 53% a serious mental health problem, and 49% a substance use disorder. Those reporting a serious problem were more likely to have insurance and to report greater perceived access to care but perceived access to care was less than expected. Having insurance was also related to longer duration of homelessness. Targeting interventions to better match services to homeless individuals is the next challenge for advanced practice psychiatric and other nursing groups. Implications for doctoral level nurses in ways of evaluating models of care for this marginalized group are discussed.
Substance use disorder (SUD) and co-morbid mental health
conditions are a serious and growing issue associated with 14%
of the global health burden, and affecting family social wellness
and the future potential of children (World Health Organization
[WHO], 2008). Women with co-occurring substance
use and mental health disorders are at particular risk as they
may have dependent children and are vulnerable to poverty,
family dysfunction, violence, and homelessness. In 2001, the
World Health Report called for interconnected primary health
and community-based interventions and human resource development
to address mental health and SUD (WHO, 2001).
Gender-based approaches have been highlighted as essential
in order to engage women in treatment tailored to their needs
(United Nations Office on Drugs and Crime [UNODC], 2004).
In this column, we provide an epidemiological overview of this
vulnerable group of mothers and examine current progress and
opportunities for improving health and social outcomes for these
women.
The Working Alliance Inventory (WAI) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI.
This document was prepared under a grant from the National Institute on Alcohol Abuse and Alcoholism (R01 AA10368) and Center for Substance Abuse Treatment (TI 11320). It draws heavily on earlier versions developed for the National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, and the Interventions Foundation and builds heavily on earlier works of many others, as well as clinical input from many more people than can be directly acknowledged. All instructions, questions, and scales in this version are provisional and currently being tested in a field trial. In the interim, interpretation should only be made by a professional trained in using standardized or open-ended questions in behavioral health care. This document and the GAIN materials herein are the copyrighted property of Chestnut Health Systems. Please contact Dr. Dennis for permission prior to duplication or use.
Using data collected from people who are homeless and have a mental disability, this study assessed which person-related characteristics predicted the formation and the strength (therapeutic alliance) of a relationship with a clinical case manager. Although all persons were assigned a case manager, those people who reported forming a relationship with a case manager were more likely to be men and African-American, had more social support, received more public support and education, and subjectively reported more psychological problems. People who were less likely to report forming a relationship with a case manager spent more days intoxicated in the past 30 and more days homeless in the past 60, and were more overtly psychotic. Among clients who reported forming a relationship with a case manager, the alliance was strongest for women, Whites, those who had spent more days homeless in the past 60, and those who reported subjective psychological problems. The results are organized into a framework for understanding the development of a clinical case manager relationship. Implications for outreach to clients who are homeless and have a mental illness are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Hope is widely embraced as an important factor in the recovery process. The role of housing in inspiring hope and facilitating recovery has been explored with homeless populations but is not well understood. This study explores perspectives on hopes for recovery and the role of housing on these hopes from the perspective of homeless adults experiencing mental illness participating in a multisite Housing First randomised controlled trial in Canada. The study draws on data from in-depth qualitative interviews with participants from the Toronto, Ontario site of the 'At Home/Chez Soi' Project.
In-depth interviews were conducted with a subsample of participants from a larger Housing First randomised controlled trial.
The research took place in Toronto, Canada.
60 participants in the larger trial (36 from the Housing First group and 24 from the Treatment as Usual group) took part in in-depth interviews.
Participants for the in-depth interviews were purposively selected from the larger trial sample in Toronto and participated in an interview at the beginning of the study (baseline). Data from the baseline interviews were analysed using the constant comparative method derived from grounded theory methods.
Participants' narratives show clear visualisation of goals for recovery, and emphasise that housing is an integral factor that can facilitate hope and support dimensions of recovery. However, some participants had difficulty adjusting to housing, and were concerned about feeling socially isolated, which could have negative implications for hopefulness and recovery.
Housing First interventions should explicitly incorporate hope-inspiring, recovery-oriented approaches and support participants while adjusting to housing in order to sustain hopefulness.
Individuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented.
Eligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data.
Participants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.
The study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.Trial registration: Current Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).
SUMMARY This paper presents three exploratory studies of life skills interventions (employment, money management or food/nutrition) with 73 homeless individuals from four shelters and supportive housing programs located in the urban Midwest for youth, victims of domestic violence and adults with mental illness. The Ansell Casey Life Skills Assessment was administered prior to the eight group and individual sessions. Quizzes and posttests indicated clinical change in all groups, with statistical significance in the domestic violence group. The intervention implementation, challenges encountered, and strategies developed for implementing shelter-based interventions are discussed. Recommendations for successfully providing collaborative university-shelter clinical interventions are provided.
Background
Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required.
Aims
To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care.
Method
Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods.
Results
Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory – European Version (CSSRI–EU). This was subsequently administered to 404 people with schizophrenia across five countries.
Conclusion
The CSSRI – EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.
A new test of verbal learning and memory, the Hopkins Verbal Learning Test, was developed. The test consists of three trials of free-recall of a 12-item, semantically categorized list, followed by yes/no recognition. Six parallel forms yielded equivalent results in normals. The performance of patients with Alzheimer's disease and chronic amnesia is described. The test is likely to be useful in patients too impaired for more comprehensive memory assessments and where repeated testing is necessary.
The Hopkins Verbal Learning Test (HVLT) is a brief verbal learning and memory test with six alternate forms. The HVLT is ideal in situations calling for repeated neuropsychological examinations, but it lacks a delayed recall trial which is essential for the assessment of abnormal forgetting. We present a revised version of the HVLT which includes a delayed recall trial, and therefore delays the yes/no recognition trial. The equivalence of test forms was examined in two separate studies using between-groups and within-subjects research designs. In both studies, the six forms of the revised HVLT (HVLT-R) were found to be equivalent with respect to the recall trials, but there were some modest differences in recognition. Recommendations for the use of the HVLT-R in serial neuropsychological examinations are provided, as well as normative data tables from a sample of 541 subjects, spanning ages 17 to 88 years.
This article describes a revised Conflict Tactics Scales (the CTS2) to measure psychological and physical attacks on a partner in a marital, cohabiting, or dating relationship; and also use of negotiation. The CTS2 has (a) additional items to enhance content validity and reliability; (b) revised wording to increase clarity and specificity; (c) better differentiation between minor and severe levels of each scale; (d) new scales to measure sexual coercion and physical injury; and (e) a new format to simplify administration and reduce response sets. Reliability ranges from .79 to .95. There is preliminary evidence of construct validity.
Purpose:
This study used an experimental design to examine longitudinal changes in subjective quality of life (QoL) among homeless adults with mental illness after assignment to different types of supported housing or to treatment as usual (TAU, no housing or supports through the study). We hypothesized that subjective QoL would improve over time among participants assigned to supported housing as compared to TAU, regardless of the type of supported housing received or participants' level of need.
Methods:
Participants (n = 497) were stratified by level of need ("high" or "moderate") and randomly assigned to Housing First (HF) in scattered-site apartments, HF in a congregate setting (high needs only), or TAU. Linear mixed-effects regression was used to model the association between study arm and self-reported QoL at baseline and at 6 and 12 months post-baseline by need level.
Results:
Based on the adjusted overall score on the QoL measure, participants randomized to HF reported significantly greater overall QoL as compared to TAU, regardless of need level or type of supported housing at both 6 and 12 months post-baseline. Scores on the safety and living situation subscales were significantly greater for both high and moderate need participants assigned to supported housing regardless of type at both 6 and 12 months post-baseline as compared to TAU.
Conclusions:
Despite multiple health and social challenges faced by homeless individuals with mental illness, HF in both scattered-site and congregate models results in significantly greater perceived QoL as compared to individuals who do not receive HF even after a relatively short period of time.
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
Background
The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.
Methods
Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.
Results
The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.
Conclusions
Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.
The stereotype of the bag lady sheltering in a bus station is an anachronism because older homeless women are largely invisible. Economic and social factors contribute to the growing number of older homeless women and the risk of their displacement. This article presents a study that developed a profile that reframes the stereotype to allow fruitful analyses of these women's plight and need for services. The study found that mental health problems, low income, family disputes, and abuse or neglect by family members are the primary factors in homelessness.
Objective
Population health surveys around the world have studied the epidemiology of comorbid substance use disorders (SUDs) and other mental disorders as part of larger efforts to assess needs and direct integrated planning and delivery of services. This study presents the first national assessment in Canada of the prevalence of co-occurring SUDs and other mental disorders, with attention to differences by substance problem severity, sex, age, and region.
Methods
This work is a secondary analysis of data from the 2002 Canadian Community Health Survey: Mental Health and Well-Being. The sample was obtained using a multistage stratified cluster design ( n = 36 984, response rate = 77%).
Results
The 12-month population prevalence of co-occurring disorders was 1.7%. The 12-month prevalence of other mental disorders was higher among those with illicit drug, relative to alcohol, problems and among those with dependence, compared with those with less severe problems. Sex and age differences mirrored population differences in pure disorders. Salient regional differences included the higher rate of co-occurring disorders in British Columbia and the lower rates in Quebec.
Conclusions
Cross-study comparisons are hampered by methodological differences; however, these Canadian rates are at the lower end of the range reported internationally. This might have resulted from the exclusion of several disorders known to be highly comorbid with SUDs. Nonetheless, prevalence is high in certain subgroups, and efforts under way to improve Canada's substance abuse and mental health services should continue to ensure that adequate attention is directed to the needs of people with co-occurring disorders.
Objectives: This paper will present the findings from a qualitative study exploring the narratives of Indigenous counsellors in Native community. Design: The study employed a qualitative design. Semi-structured narrative interviews were used and analyzed through a narrative methodology. Methods: One Native community health agency participated and five individuals, who worked as counsellors with the agency's clients, were interviewed. Results: Four metathemes: community, cultural identity, holistic approach, and interdependence were identified as the main results. Further, a model for mental health and healing was created by the overlapping nature of these metathemes in practice. Conclusions: A health promoting counselling model for Indigenous clients could be based on cultural values and perspectives. However, employing these values and perspectives entails an understanding that a contemporary conception of Indigenous mental health contains two components: mental health as wellness, and mental health as a process of healing.
This article presents descriptive data for homeless single women and women with children, and contrasts it to parallel data for single homeless men. It explores demographic characteristics (race, age, marital status, household composition and education), length of current spells of homelessness and joblessness, income and income sources, history of personal problems (mental illness, chemical dependency, criminal justice involvement), patterns of utilization of soup kitchens and shelters, and diet adequacy. The data base for these comparisons is 1,704 in-person interviews from the first national study of homeless individuals that uses probability sampling, and therefore has the capacity to develop generalizations about a known universe of the homeless that transcends unique conditions in single cities. The study's population is homeless adults who use soup kitchens and shelters in U.S. cities of 100,000 or more. The results indicate that homeless single women, homeless women with children, and homeless men differ significantly on many variables, with implications for both the probable causes of their homelessness and preventive and ameliorative efforts.
This study explores factors contributing to delays and relocations during the implementation of the Housing First model in Toronto, Ontario. While interruptions in housing tenure are expected en route to recovery and housing stability, consumer and service provider views on finding and keeping housing remain largely unknown. In-person interviews and focus groups were conducted with 48 study participants, including 23 case managers or housing workers and 25 consumers. The following three factors contributed to housing delays and transfers: (1) the effectiveness of communication and collaboration among consumers and service providers, (2) consumer-driven preferences and ambivalence, and (3) provider prioritization of consumer choice over immediate housing access. Two strategies-targeted communications and consumer engagement in housing searches-supported the housing process. Several factors affect the timing and stability of housing. Communication between and among providers and consumers, and a shared understanding of consumer choice, can further support choice and recovery.
The Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview (DSI) developed in France and the United States to explore 17 disorders according to Diagnostic and Statistical Manual (DSM)-III-R diagnostic criteria. It is fully structured to allow administration by non-specialized interviewers. In order to keep it short it focuses on the existence of current disorders. For each disorder, one or two screening questions rule out the diagnosis when answered negatively. Probes for severity, disability or medically explained symptoms are not explored symptom-by-symptom. Two joint papers present the inter-rater and test-retest reliability of the Mini the validity versus the Composite International Diagnostic Interview (CIDI) (this paper) and the Structured Clinical Interview for DSM-IH-R patients (SCID) (joint paper). Three-hundred and forty-six patients (296 psychiatric and 50 non-psychiatric) were administered the MINI and the CIDI ‘gold standard’. Forty two were interviewed by two investigators and 42 interviewed subsequently within two days. Interviewers were trained to use both instruments. The mean duration of the interview was 21 min with the MINI and 92 for corresponding sections of the CIDI. Kappa coefficient, sensitivity and specificity were good or very good for all diagnoses with the exception of generalized anxietydisorder (GAD) (kappa = 0.36), agoraphobia (sensitivity = 0.59) and bulimia (kappa = 0.53). Inter-rater and test-retest reliability were good. The main reasons for discrepancies were identified. The MINI provided reliable DSM-HI-R diagnoses within a short time frame, The study permitted improvements in the formulations for GAD and agoraphobia in the current DSM-IV version of the MINI.
SUMMARY This article describes a successfully designed and implemented program created for mentally ill homeless men by Level II occupational therapy students from Eastern Kentucky University. Outcomes for the clients, the staff and the students were extremely positive and have contributed to the appreciation and acceptance of occupational therapy as a discipline that can contribute to the health of this underserved population. This model demonstrates the effectiveness of University sponsored fieldwork in introducing occupational therapy to the community, creating awareness of what occupational therapy has to offer and developing a climate to bring needed services to clients and provide community-based employment for occupational therapists.
The stereotype of the bag lady sheltering in a bus station is an anachronism because older homeless women are largely invisible. Economic and social factors contribute to the growing number of older homeless women and the risk of their displacement. This article presents a study that developed a profile that reframes the stereotype to allow fruitful analyses of these women’s plight and need for services. The study found that mental health problems, low income, family disputes, and abuse or neglect by family members are the primary factors in homelessness.
ABSTRACT This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencilversion of the inter- view. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection. Key words: Composite International Diagnostic Interview, epidemiologic research design, psychiatric
IntroductionSingle room occupancy (SRO) hotel units represent the most basic shelter provided for low-income individuals living in Vancouver's Downtown Eastside (DTES). While homelessness and marginalized housing in general, have been identified as environments that facilitate HIV risk behaviours, less attention has been paid to the specific context of living in SRO hotels. This analysis was therefore undertaken to describe the characteristics of individuals living in SRO hotels and to explore the association between living in SRO hotels and health status.
Prior research indicates that homeless consumers of mental health services have a marked preference for independent living, while clinicians tend to recommend staffed, group housing. In order to understand this divergence and identify its consequences for mental health policy, we test influences on housing preferences suggested by rational choice and social structural perspectives. We use a randomized field trial of independent and group housing to identify the consequences for subsequent housing loss and consumer functioning of consumer- and clinician-determined housing placements. We find that consumer preference at baseline for independent living indicates greater vulnerability to housing loss, but the bases of preferences change after consumers gained experience with stable housing. We interpret the results as indicating the contingent rationality of preferences and the susceptibility of preferences to change with experience.
Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Describes a paradigm shift, beginning in the 1950s and reaching its zenith in the 1970s, toward supported housing models and deinstitutionalization of the mentally ill. The linear residential continuum model formed the basis for residential treatment and the provision of specialized environments that prepared patients/clients for life in the community. A supported housing paradigm shifts the primary role of the service recipient from patient to community and shifts the locus of control from staff to client. Other elements of the shift include an emphasis on (1) social integration rather than homogeneous grouping by disability and (2) the most facilitative environment and best functioning rather than the least restrictive environment and independence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Compared 6 measures of working alliance: the California Psychotherapy Alliance Scales (CALPAS), the Penn Helping Alliance Scales (PHAS), the Vanderbilt Therapeutic Alliance Scale (VTAS), Working Alliance Inventory—Observer Form (WAI—O), Working Alliance Inventory—Client Form, and Working Alliance Inventory—Therapist Form. All measures had high internal consistency. Observers were able to reach high levels of interrater reliability on all the observer-rated measures (CALPAS, PHAS, VTAS, WAI—O). Evidence of construct validity was found for the CALPAS, VTAS, and WAI—O, given that they were all highly correlated with each other. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
"The Trail Making Test was administered to 200 patients with clear evidence of brain damage and to 84 Ss without anamnestic or clinical evidence of brain damage. The groups were comparable with respect to sex, CA, and… education. The results showed… significant differences in the performances of the two groups for Parts A and B of the test individually as well as for their total. Frequency distributions were given that may serve as preliminary norms for use in evaluating results obtained with individual Ss. Some comments were offered regarding possible reasons why the Trail Making Test differentiated the groups so well, relating known aspects of brain function to the structure and requirements of the test." (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Latent variable multiple-group confirmatory factor analyses assessed gender differences in relationships among drug and alcohol use, measures indicating severity of homelessness, criminal history, prior institutionalization, and mental illness (
N = 531 homeless persons; 386 men and 145 women). Severity was indicated by length of time homeless, housing quality, and victimization. Men reported more substance use, a longer time homeless, poorer housing quality, greater criminal involvement, and less likelihood of living with a child. Constrained multiple-group models surfaced 5 significantly different relationships between latent constructs. Men had stronger relationships between mental illness and prior institutionalization, drug use and mental illness, and drug use and victimization, whereas women had stronger relationships between drug use and alcohol use, and criminal involvement and drug use. Service delivery implications and suggestions for future research are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
New initiatives to house chronically street homeless (CSH) adults have led to increasing proportions of this population living in congregate supportive housing, but little is known about the impact of this shift on supportive housing programs. The present multisite, mixed-methods study examined service utilization and lease compliance among 52 chronically street homeless and 46 long-term shelter stayer (LTSS) adults during their first 12 months in congregate supportive housing. Quantitative analysis of administrative data revealed that CSH tenants used significantly more service resources than LTSS tenants, including more advocacy, escorting, and psychiatric treatment and more assistance with financial, housing, and mental and physical health issues. The 2 groups did not differ significantly on measures of lease compliance. Qualitative focus groups with CSH tenants, service provider staff, and property management staff all indicated that existing supportive housing services are suitable for this population, although some adjustments, additional resources, or both, may be indicated.
This study investigated the main effects of social support measures and their stress-buffering effects in two samples of homeless adults (Ns=249 and 219) obtained in the same large county (surrounding Detroit) at different points in time over an 8-year period (1992–1994 and 2000–2002). The findings suggest that the construct of social support, commonly applied to broad community and student samples, can also be usefully applied to at-risk groups such as the homeless. Although the study's main effects and stress-buffering effects were generally consistent with existing research on social support, the findings point out that expected results do not consistently emerge even when similar sampling and measurement techniques are employed. For example, a measure of perceived support showed consistent main and stress-buffering effects on psychological symptoms (but not other outcomes) and social network measures showed less consistent effects on outcomes (e.g., alcohol and drug abuse symptoms). © 2008 Wiley Periodicals, Inc.
Although sense of community was heralded by Sarason (1974) as the “overarching value” of community psychology, no theory or definition of the phenomenon has been operationalized or empirically tested. The difficulty in the scientific exploration of sense of community is in the value-laden and phenomenological nature of the experience. Following McMillan and Chavis (this issue), it is theorized that sense of community is represented by four elements: membership, influence, integration and fulfillment of needs, and shared emotional connection. Brunswik's lens model offers an appropriate method for determining the shared domain of the experience within a diverse population. The goal of this study was to develop a Sense of Community Index (SCI) that would allow the determination of the relative influence of various factors on the judgment of sense of community. Twenty-one judges, representing four professional groupings selected from three urban centers, where employed in the rating of 100 sense of community profiles of randomly selected individuals. There was a high degree of consensus among the diverse groups of judges, and a regression equation with 23 predictors derived from the sense of community profile accounted for 96% of the variance of mean judges, ratings of overall sense of community. The results were interpreted as supporting the theory of McMillan and Chavis, which appears suitable both for scientific investigation and as a framework for intervention. The relationships of specific profile items (e.g., neighboring behavior, length of residence, home ownership, involvement in voluntary associations) are related to the four elements and to the prediction of overall sense of community.
The provision of adequate housing for the severely mentally ill homeless has been considered a prerequisite for successful treatment. Whether or not providing access to independent housing environments without on-site support is an effective means for stabilizing this population in the community is far less studied. Preference studies indicate a strong desire for access to independent housing, but little is known about the ability of mentally ill homeless persons to remain in independent housing when such access is provided. The McKinney Homeless Research Demonstration Project in San Diego, CA evaluated the effectiveness of using Section 8 certificates as a means of providing independent housing to the severely mentally ill homeless. Three hundred sixty-two clients took part in a long-term experimental study employing a randomized factorial design. Clients were assigned to one of two types of supportive case management (comprehensive vs. traditional) and to one of two levels of access to independent housing (using Section 8 certificates). Innovative longitudinal summaries of housing outcomes were developed based on clients' patterns of living over time. Nine different patterns of living arrangements were identified, ranging from continuous occupation of independent housing to consistently unstable housing. Access to Section 8 housing markedly increased the probability of achieving stable independent living arrangements and of continued contact with case management services. A subset of clients in all experimental conditions followed less successful housing patterns, indicating the need to develop different service programs for individuals with different needs. Overall, however, access to independent housing had very positive effects on residential stability. © 1996 John Wiley & Sons, Inc.
Two commonly employed measures of social support were assessed in a sample of 144 homeless and poor adults. Both the Interpersonal Support Evaluation List (ISEL) and Social Network Interview (SNI) demonstrated acceptable psychometric properties. Reliability coefficients over a one-week interval ranged from 0.62 to 0.85 for ISEL variables and 0.74 to 0.82 for several key SNI variables. A number of significant predictors of variables derived from one or both measures were identified which supported the construct validity of the measures and which were generally consistent with prior research on homeless and similar samples. These predictors included gender, current psychological distress, a diagnosis of severe mental illness, and amount of time spent homeless. Social support was found to have a significant stress-buffering effect in one of four analyses done: Stress was positively related to physical health symptoms for those with small SNI family networks (but not for those with larger networks). © 1999 John Wiley & Sons, Inc.
This article describes a supported housing program that provides immediate access to permanent independent housing to individuals who are homeless and have psychiatric disabilities. Following housing placement, Assertive Community Treatment (ACT) teams provide treatment, support, and other needed services. The residential stability of tenants in this supported housing program was compared to that of tenants in a linear residential treatment program that serves the same population, but uses a step-by-step sequence of placements moving to supervised independent living. The 139 tenants of the supported housing program achieved a housing-retention rate of 84.2% over a 3-year period while the rate for 2,864 residents of the comparison program was only 59.6% over a shorter 2-year period. Additional data from direct interviews with the supported housing tenants were used to identify factors that predicted client participation in, and satisfaction with, particular services received. © 1999 John Wiley & Sons, Inc.
Missing data have long plagued those conducting applied research in the social, behavioral, and health sciences. Good missing data analysis solutions are available, but practical information about implementation of these solutions has been lacking. The objective of Missing Data: Analysis and Design is to enable investigators who are non-statisticians to implement modern missing data procedures properly in their research, and reap the benefits in terms of improved accuracy and statistical power. Missing Data: Analysis and Design contains essential information for both beginners and advanced readers. For researchers with limited missing data analysis experience, this book offers an easy-to-read introduction to the theoretical underpinnings of analysis of missing data; provides clear, step-by-step instructions for performing state-of-the-art multiple imputation analyses; and offers practical advice, based on over 20 years' experience, for avoiding and troubleshooting problems. For more advanced readers, unique discussions of attrition, non-Monte-Carlo techniques for simulations involving missing data, evaluation of the benefits of auxiliary variables, and highly cost-effective planned missing data designs are provided. The author lays out missing data theory in a plain English style that is accessible and precise. Most analysis described in the book are conducted using the well-known statistical software packages SAS and SPSS, supplemented by Norm 2.03 and associated Java-based automation utilities. A related web site contains free downloads of the supplementary software, as well as sample empirical data sets and a variety of practical exercises described in the book to enhance and reinforce the reader's learning experience. Missing Data: Analysis and Design and its web site work together to enable beginners to gain confidence in their ability to conduct missing data analysis, and more advanced readers to expand their skill set. © Springer Science+Business Media New York 2012. All rights reserved.
General psychotherapy research has underscored the importance of the therapeutic alliance in client outcomes. This study examined the association between therapeutic alliance and client outcomes specifically between chronically homeless clients in a supported housing program and their case managers. Using data from a federal supported housing initiative, participants were categorized into those who rated their therapeutic alliance with case managers at 3 months as relatively high (top 75th percentile; n = 123), relatively low (bottom 25th percentile; n = 128), or did not identify any primary mental health provider at 3 months (n = 205). Controlling for baseline differences, there were no group differences on any outcomes, except that participants who rated high therapeutic alliance at 3 months reported the highest subjective quality of life and perceived social support. Client outcomes in supported housing may rely more on practical assistance and access to other services than the quality of the therapeutic relationship with their primary mental health provider.
Emergency shelters, transitional housing, and permanent supportive housing are distinct programmatic responses to address the housing and service needs of the homeless population under the Continuum of Care (CoC) model for homeless service delivery. Using organizational-level data collected from a multi-site survey of 300 homeless residential programs in 14 communities, this study examines the extent to which operationalization of these programs is in accordance with the CoC model. Findings suggest consistency with as well as deviation from the CoC model in the operationalization of homeless residential programs. Recommendations are provided for local community service planning and development that can assure effective delivery of services for meeting the needs of homeless people.
Based on a broad sample of 228 homeless adults from throughout Buffalo, New York, single homeless women (n = 56), homeless women with children (n = 41), and single homeless men (n = 131) were compared on a wide range of measures with established reliability and validity. Based on total lifetime income from all sources, the poorest of the three groups was the women with children. The two groups of women reported greater psychological distress than the men, had more contact with family members, were more likely to have been recently assaulted, and were less likely to have a history of substance abuse or criminal behavior. Although the single men and women reported more stressful life events commonly associated with homelessness than the women with children, the measure used contained few items pertaining to child-rearing. The findings suggest that the three groups examined have different needs and require different interventions. © 1999 John Wiley & Sons, Inc.
Despite the fact that needle exchange was introduced in Vancouver as early as 1988, needle sharing remains common. An analysis was conducted to identify determinants of borrowing used needles among subjects participating in a case-control study. IDUs had a documented HIV seroconversion after 1 January, 1994 (h = 89), or repeatedly tested HIV-seronegative after this date (h = 192). Interviewer-administered questionnaires focused on drug use, sexual behaviours, source of needles and depression. Subjects were asked if they had “ever been forced to have sex” as a child, youth or adult. Logistic regression identified determinants of borrowing needles. After controlling for HIV serostatus, factors independently associated with borrowing were injecting > 4 times/day, poly drug use, and ever experiencing non-consensual sex (AOR = 3.4, 95% CI: 1.8, 6.5). Depression was associated with borrowing, although not independently so. Homosexual activity was independently associated with borrowing among males, whereas living with a sexual partner was an independent predictor for females. Access or barriers to clean needle use were not associated with borrowing. Social determinants, particularly a history of sexual abuse, are among the most significant predictors of needle borrowing among Vancouver's IDUs. Early identification of these factors should be a component of HIV prevention programmes.
Random samples of 250–435 adults were interviewed by telephone in five different nations (N= 1,546): Belgium, Germany, Italy, the UK, and the United States. The interview included questions on respondent attitudes, knowledge, and opinions regarding homelessness; respondents' own personal experiences with homelessness and homeless people; and demographic characteristics of the respondents. The highest rates for lifetime literal homelessness were found in the UK (7.7%) and United States (6.2%), with the lowest rate in Germany (2.4%), and intermediate rates in Italy (4.0%) and Belgium (3.4%). Less compassionate attitudes toward the homeless were also found on many dimensions in the United States and the UK. Possible explanations of these findings, drawn from various theoretical perspectives, and policy implications are provided.