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Improving outcomes for homeless people with alcohol disorders: a multi-program community-based approach
Journal of Mental Health
Abstract
Background: Relatively few community-based programs have been found to be helpful for homeless people with alcohol disorders, even though this group represents a high-risk, vulnerable population prone to poor outcomes.
Aims: This study sought to implement and evaluate intensive community-based programs for homeless people with alcohol disorders.
Method: The project worked closely with a homeless outreach team for referrals, and then provided two different, intensive substance abuse treatment approaches matched to the needs of two subgroups: homeless individuals with alcohol disorders without severe mental illness received community reinforcement approach (CRA) and case management services, while those with alcohol and severe mental illness were assigned to assertive community treatment and integrated dual disorders (ACT/IDDT) services. The study enrolled 322 homeless people with alcohol disorders and outcomes were assessed at six months and program discharge.
Results: Participants improved significantly over the first six months in a number of outcome areas, including substance abuse, mental health, housing, employment and health; progress generally remained stable between six months and discharge.
Conclusions: Community-based programs that coordinate with mobile outreach teams and then provide CRA and ACT/IDDT appear to be promising approaches for helping individuals with alcohol disorders out of homelessness and into recovery.
Background
Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self‐esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.
Objectives
To understand the effectiveness of different substance use interventions for adults experiencing homelessness.
Search Methods
The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand‐searching key journals, and unpacking relevant systematic reviews.
Selection Criteria
Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.
Data Collection and Analysis
Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random‐effects meta‐analysis and robust‐variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non‐randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta‐analysis, we have provided a narrative synthesis of the study and its findings.
Main Results
We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of –0.11 SD (95% confidence interval [CI], −0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (−0.21 SD, 95% CI [−0.59, 0.17] − 6 studies, 17 effect sizes), the removal of quasi‐experimental studies (−0.14 SD, 95% CI [−0.30, 0.02] − 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (−0.08 SD, 95% CI [−0.31, 0.15] − 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence‐based interventions compared to treatment‐as‐usual (TAU) service provision was –0.28 SD (95% CI, −0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, −0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence‐based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [−0.07, 0.13] and –0.47 SD, 95% CI [−0.72, −0.21] 0.05 SD, 95% CI [−0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of –0.47 SD, 95% CI (−0.72, −0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.
Authors' Conclusions
Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.
Background
Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.
Objectives
To summarise the best available evidence relating to the components of case‐management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.
Search Methods
We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.
Selection Criteria
We included all randomised and non‐randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.
Data Collection and Analysis
We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta‐analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most ‘rich’ and ‘thick’ data.
Main Results
We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.
Case Management and Housing Outcomes
Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = −0.51 [95% confidence interval [CI]: −0.71, −0.30]; p < 0.01). For studies included in the meta‐analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = −0.6 [–1.1, −0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta‐analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.
Case Management and Mental Health Outcomes
The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [−0.15, 0.18]; p = 0.817).
Case Management and Other Outcomes
Based on meta‐analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one‐third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.
Case Management Components
For homelessness outcomes, there was a non‐significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = −0.64 [−1.04, −0.24] vs. −0.27 [−0.53, 0]; p = 0.16) and for in‐person meetings in comparison to mixed (in‐person and remote) approaches (SMD = −0.73 [−1.25,−0.21]) versus −0.26 [−0.5,−0.02]; p = 0.13). There was no evidence from meta‐analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = −0.36 [−0.55, −0.18] vs. −1.00 [−2.00, 0.00]; p = 0.02). There was not enough evidence from meta‐analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.
Characteristics of Persons Experiencing Homelessness
No conclusions could be drawn from meta‐analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = −0.61 [−0.91, −0.31] versus −0.36 [−0.68, −0.05]; p = 0.3.
The Broader Context of Delivery of Case Management Programmes
Other major themes from the implementation studies included the importance of interagency partnership; provision for non‐housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.
Cost Effectiveness
The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off‐set by reductions in the use of other services. Cost estimates from three North American studies were $45–52 for each additional day housed.
Authors' Conclusions
Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in‐person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost‐effectiveness.
This report details the findings of the fourth update of the evidence and gap map on effectiveness of interventions for homeless or at the risk of homelessness. It also discusses the evidence base on homelessness for effectiveness research in the UK.
Homelessness is persistent as a major social problem, and addressing behavioral health challenges for people experiencing homelessness has become a classic domain of modern community psychiatry. This chapter discusses the current epidemiology and causes of homelessness as they relate to behavioral health and outlines the resultant overall landscape of services and interventions for affected adult populations. It details challenges in care and covers clinical technique, both psychosocial and biological, while also describing a comprehensive and systematic model to guide the use of all interventions to support transition from the street to home.KeywordHomelessnessModels of carePovertyHousingEvidence-based practicesClinical engagementOutreachPromising practicesRecoveryStages of changeCritical time interventionCo-occurring mental illnesses and chemical dependencyVocational rehabilitationAssertive community treatmentHousing firstPeer workersTraumaPrimary carePsychopharmacologyCultural competence
Issue addressed:
Problematic alcohol consumption (PAC) affects one-third of homeless Australians, and it is expected that the rates will increase as the population ages. However current policy does not recognise the importance of this problem. The aim of this narrative review is to examine the social determinants and other risk factors contributing to PAC in homeless Australians, the barriers to receiving help, and possible solutions for the Australian context.
Methods:
PubMed and PsycINFO databases and Australian government websites were examined for the keywords "alcohol" and "homeless", and pertinent articles were selected for inclusion and for citation tracking of further relevant articles.
Results:
The causes of PAC in homeless Australians are multifactorial, and multi-directional, and include risk factors such as low socioeconomic status, mental illness, and having experienced trauma. There is significant stigma associated with both homelessness and PAC, which further isolates this group. Current policies to address PAC in the homeless are inadequate; however there are a range of possible programs to reduce PAC in this group, and international harm reduction strategies have also shown success in improving outcomes for this group.
Conclusion:
there are numerous social risk factors that influence the development of PAC in the homeless. The introduction of harm reduction strategies, programs to enhance motivation and personal skills, as well as better mental health treatment, would all fill important gaps in services for homeless Australians with PAC. SO WHAT?: Health professionals can be advised that there are many social determinants that influence PAC in homeless Australians. There are important structural barriers to providing this marginalised group with the services they require, however there is scope for the introduction of new programs, including harm reduction strategies, to meet the fundamental needs of this group.
Background:
Adults experiencing homelessness and serious mental illnesses (SMI) are at an increased risk for poor mental health and treatment outcomes compared to stably housed adults with SMI. The additional problem of alcohol misuse further complicates the difficulties of those living with homelessness and SMI. In this secondary data analysis, we investigated the impact of homelessness on attrition and alcohol use in a contingency management (CM) intervention that rewarded alcohol abstinence in outpatients with SMI.
Methods:
The associations between housing status and attrition and alcohol abstinence during treatment, as assessed by ethyl glucuronide (EtG) urine tests, were evaluated in 79 adults diagnosed with alcohol dependence and SMI.
Results:
Thirty-nine percent (n=31) of participants reported being homeless at baseline. Individuals who were homeless were more likely to drop out of CM (n=10, 62.5%), than those who were housed (n=4, 16.7%), X(2) = (1) 8.86, p< 0.05. Homelessness was not associated with attrition in the non-contingent control group. Accounting for treatment group and pre-randomization EtG levels, neither the effect of housing status nor the interaction of housing status and group were associated with EtG-assessed alcohol abstinence during treatment.
Conclusions:
Individuals experiencing homelessness and co-occurring alcohol dependence and SMI receiving CM had higher rates of attrition, relative to those who were housed. Homelessness was not associated with differences in biologically assessed alcohol abstinence.
The Simple Screening Instrument for Substance Abuse (SSI-SA) is gaining widespread use as a self-report measure of substance abuse; yet, little information exists regarding the instrument's psychometric properties. This study examined the SSI's psychometric properties within a population of 6,664 adult Medicaid enrollees in Florida, who responded to a survey conducted as part of a statewide evaluation of Medicaid services. The SSI-SA had excellent internal consistency (.85). Evidence of the SSI's validity was strong; SSI-SA scores distinguished among individuals with and without substance abuse needs and were significantly correlated with a measure of functioning in daily living. Using the recommended SSI-SA cutoff score of 4 or higher to indicate the presence of a substance abuse problem, the SSI-SA had respectable sensitivity (.82) and specificity (.90).
This study examined the reliability and construct validity of a modified version of the Colorado Symptom Index (MCSI), a brief, self-report measure of psychological symptomatology, in a study of interventions to prevent homelessness. Eight projects in a national, cooperative study collected new data at baseline, 6, and 12 months using a set of common measures as well as site-specific instruments. The pooled sample consisted of 1,381 persons in treatment for mental illness or substance abuse (or both), of which 84% had a history of homelessness. The analyses employed classical and Rasch methods to examine the MCSI's content validity, internal consistency and item quality, test/retest reliability, dimensionality, appropriateness for the sample, construct validity, and responsiveness to change. This 14-item scale was found to be a reliable and valid measure of psychological symptoms in this sample. Its content was consistent with other symptom measures, its high internal consistency and test-retest coefficients supported its reliability, its relationships to other measures indicated that it had good construct validity, and it was responsive to change. We conclude that the MCSI performed similarly to longer, more widely used measures of psychological symptomatology and could be useful in other studies targeting homeless adults with severe mental illness, substance use disorders, or both.
Little empirically-based information is available regarding how best to intervene with substance-abusing homeless mothers. This study pilot-tested a comprehensive intervention with 15 homeless women and their 2- to 6-year-old children, recruited from a local family shelter. All participants were offered integrated intervention with three major components. The first component was housing which included 3 months of rental and utility assistance, and these services were not contingent upon women's abstinence from drugs or alcohol. The second and third components included 6 months of case management services and an evidence-based substance abuse treatment (Community Reinforcement Approach; CRA). Analysis revealed that women showed reductions in substance use (F(2,22) = 3.63; p < .05), homelessness (F(2,24) = 25.31; p < .001), and mental health problems (F(2,20) = 8.5; p < .01). Further, women reported reduced internalizing (F(2,22) = 4.08; p < .05) and externalizing problems (F(2,24) = 7.7; p = .01) among their children. The findings suggest that the intervention is a promising approach to meet the multiple needs of this vulnerable population. These positive outcomes support the need for future research to replicate the findings with a larger sample using a randomized design.
This article describes the critical ingredients of the assertive community treatment (ACT) model for people with severe mental illness and then reviews the evidence regarding its effectiveness and cost effectiveness. ACT is an intensive mental health program model in which a multidisciplinary team of professionals serves patients who do not readily use clinic-based services, but who are often at high risk for psychiatric hospitalization. Most ACT contacts occur in community settings. ACT teams have a holistic approach to services, helping with medications, housing, finances and everyday problems in living. ACT differs conceptually and empirically from traditional case management approaches.
ACT is one of the best-researched mental health treatment models, with 25 randomized controlled trials evaluating its effectiveness. ACT substantially reduces psychiatric hospital use, increases housing stability, and moderately improves symptoms and subjective quality of life. In addition, ACT is highly successful in engaging patients in treatment. Research also suggests that the more closely case management programs follow ACT principles, the better the outcomes.
ACT services are costly. However, studies have shown the costs of ACT services to be offset by a reduction in hospital use in patients with a history of extensive hospital use.
The ACT model has been hugely influential in the mental health services field. ACT is significant because it offers a clearly defined model, and is clinically appealing to practitioners, financially appealing to administrators and scientifically appealing to researchers.
A longitudinal experimental design was used to compare the effectiveness of three community-based treatment programs serving homeless mentally ill people: traditional outpatient treatment offered by a mental health clinic, a daytime drop-in center, and a continuous treatment team program that included assertive outreach, a high staff-to-client ratio, and intensive case management. At 12-month follow-up, clients in all three treatment programs spent fewer days per month homeless, showed fewer psychiatric symptoms, and had increased income, interpersonal adjustment, and self-esteem. Clients in the continuous treatment program had more contact with their treatment program, were more satisfied with their program, spent fewer days homeless, and used more community services and resources than clients in the other two programs.
In Great Britain 1-2 million people may be homeless. Most homeless people are men, but about 10-25% are women, of whom about half are accompanied by children. Significant mental illness is present in 30-50% of the homeless: functional psychoses predominate; acute distress and personality dysfunction are also prevalent. Co-morbidity of mental illness and substance abuse occurs in 20%, and physical morbidity rates exceed those of domiciled populations. The homeless mentally ill also have many social needs. Pathways to homelessness are complex; deinstitutionalization may be only one possible cause of the increase in the number of homeless people. There is much recent research estimating the extent of mental illness and the characteristics of selected subgroups of accessible homeless people. The evaluation of potential service solutions has received less attention. This review outlines the research, highlights current views on the definition and classification of homeless populations, and offers some guidelines on avenues which need to be explored.
This study estimates the extent and distribution of specific drug problems among homeless adults.
A countywide probability sample of 564 homeless adults received structured interviews that included a standardized assessment of substance use disorders.
Two thirds of the sample (69.1%) had a lifetime history of a substance use disorder (including abuse of or dependence on alcohol [52.6%] or drugs [52.2%]); half had a current (52.4%) substance use disorder (including alcohol [38.8%] or drugs [31.3%]). Current drug disorders were higher among respondents who were younger, homeless longer, or sampled from the city of Oakland, Calif. Alcohol use disorders were higher among men than among women; surprisingly, drug use disorders were not.
Rates of current drug use disorders for homeless adults were more than eight times higher than general population estimates. However, estimates of drug problems among homeless adults vary as a function of case ascertainment and sampling strategy. Estimates based only on samples from urban areas may overestimate drug problems among the area's larger homeless populations.
This study examined the effects of integrating mental health, substance abuse, and housing interventions for homeless persons with co-occurring severe mental illness and substance use disorder. With the use of a quasi-experimental design, integrated treatment was compared with standard treatment for 217 homeless, dually diagnosed adults over an 18-month period. The integrated treatment group had fewer institutional days and more days in stable housing, made more progress toward recovery from substance abuse, and showed greater improvement of alcohol use disorders than the standard treatment group. Abuse of drugs other than alcohol (primarily cocaine) improved similarly for both groups. Secondary outcomes, such as psychiatric symptoms, functional status, and quality of life, also improved for both groups, with minimal group differences favoring integrated treatment.
Homeless alcohol-dependent individuals were randomly assigned to receive either a behavioral intervention (i.e., the Community Reinforcement Approach [CRA]) or the standard treatment (STD) at a large day shelter. Ninety-one men and 15 women participated. The majority of participants were White (64%), but both Hispanic (19%) and Native American (13%) individuals were represented as well. Overall, the decline in drinking levels from intake through follow-ups was significant. As predicted, CRA participants significantly outperformed STD group members on drinking measures across the 5 follow-ups, which ranged from 2 months to 1 year after intake. Both conditions showed marked improvement in employment and housing stability.
After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.
Background Homelessness affects many people in contemporary society with consequences for individuals and the wider community. Homeless people experience poorer levels of general physical and mental health than the general population and there is a substantial international evidence base which documents multiple morbidity. Despite this, they often have problems in obtaining suitable health care. Aim To critically examine the international literature pertaining to the health care of homeless people and discuss the effectiveness of treatment interventions. Design of study Review and synthesis of current evidence. Method Medline (1966-2003), EMBASE (1980-2003), PsycINFO (1985-2003), CINAHL (1982-2003), Web of Science (1981-2003) and the Cochrane Library (Evidence Based Health) databases were reviewed using key terms relating to homelessness, intervention studies, drug misuse, alcohol misuse and mental health. The review was not limited to publications in English. It included searching the internet using key terms, and grey literature was also accessed through discussion with experts. Results Internationally, there are differing models and services aimed at providing health care for homeless people. Effective interventions for drug dependence include adequate oral opiate maintenance therapy, hepatitis A, B and tetanus immunisation, safer injecting advice and access to needle exchange programmes. There is emerging evidence for the effectiveness of supervised injecting rooms for homeless injecting drug users and for the peer distribution of take home naloxone in reducing drug-related deaths. There is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain. Conclusions As multiple morbidity is common among homeless people, accessible and available primary health care is a pre-requisite for effective health interventions. This requires addressing barriers to provision and multi-agency working so that homeless people can access the full range of health and social care services. There are examples of best practice in the treatment and retention of homeless people in health and social care and such models can inform future provision.
The purpose of this study was to determine whether mental health status and being homeless were significant predicators of substance abuse severity among adults and to determine whether mental health status was a significant predictor of substance abuse severity among adults over and above homeless status. Data were collected from 60 individuals from the Baltimore metropolitan area. Thirty individuals were homeless and attended a breakfast program; 30 individuals were residents of a community in close proximity to the program. Modes of measurement consisted of the Addiction Severity Index Self Report Form and the Kessler Psychological Distress Scale. Data for this study were coded numerically and analyzed using multiple regression analysis. Results revealed that housing status was a significant predictor of alcohol abuse and that mental health status was not a significant predicator of substance abuse severity over and above homeless status.
At least 50 percent of America's homeless people have significant current problems with alcohol and other drugs. These problems are important risk factors in the selection of the undomiciled from the larger population of extremely poor people. This paper reviews what is known about homeless people with alcohol and other drug problems; assesses the relationship between such individual problems and the larger phenomenon of homelessness; and describes selected aspects of projects funded through the National Institute on Alcohol Abuse and Alcoholism/National Institute on Drug Abuse Demonstration Program for Homeless Persons with Alcohol and Other Drug Problems. It concludes with observations about future directions for research and practice.
A clinician-randomized trial was conducted using the chronic care model for disease management for alcohol use problems among n=82 women served in a health care for the homeless clinic. Women with problem alcohol use received either usual care or an intervention consisting of a primary care provider (PCP) brief intervention, referral to addiction services, and on-going support from a care manager (CM) for 6months. Both groups significantly reduced their alcohol consumption, with a small effect size favoring intervention at 3months, but there were no significant differences between groups in reductions in drinking or in housing stability, or mental or physical health. However, intervention women had significantly more frequent participation in substance use treatment services. Baseline differences and small sample size limit generalizability, although substantial reductions in drinking for both groups suggest that screening and PCP brief treatment are promising interventions for homeless women with alcohol use problems.
Copyright © 2014 Elsevier Inc. All rights reserved.
Substance abuse is a frequent and complicating feature of homelessness. Barriers to service access have prevented homeless individuals from receiving substance abuse care. Outreach to homeless persons is a mechanism for identifying homeless substance abusers and engaging them in treatment. This study describes a program of substance abuse treatment conducted by a medical care provider for homeless persons in Baltimore, Maryland and compares characteristics of outreach recipients to those of walk-in clients. The study also examines the differences in drug abuse pathology and selected treatment outcomes among homeless and non-homeless clients and the extent to which homeless persons are unidentified in the drug abuse treatment reporting system of the state. Homelessness is about 5.5 times more prevalent in the clientele of drug abuse treatment programs than is reflected in the statewide substance abuse management information system of Maryland. Composite scores on the Addiction Severity Index for homeless individuals are significantly higher (reflecting more serious problems) on every measure in the interview, compared to non-homeless individuals. Except for residential treatment settings, homeless persons demonstrate a shorter length-of-stay in substance abuse treatment than housed clients. Our outreach effort successfully located its targets. Outreach clients reported significantly higher levels of substance abuse than walk-in clients. In addition 42.3% of outreach contacts became service recipients. These findings indicate that outreach can be a successful method of targeting and engaging a segment of homeless substance abusers who are otherwise difficult to engage in treatment.
The present study used cluster analysis to empirically derive and cross-validate a system for classifying homeless persons on the basis of their service needs. Variables used in the subgroup identification phase of the study included psychopathology, alcoholism, social support, socioeconomic status, and health status. Four subgroups were identified: (1) an economically disadvantaged group, (2) an alcoholic group, (3) a mentally ill group, and (4) a relatively advantaged group. Subsequent analysis revealed few differences between the four groups in background characteristics. Moreover, subgroups were similar in service willingness and utilization, with the exception of utilization and willingness to receive treatment for alcohol and mental health problems. The results suggest the need for policies and services that address the core socioeconomic needs that cut across all subgroups, as well as for additional, specialized services for those with psychiatric or alcohol problems.
The author played a key role in the creation of the Mental Health Screening Form III (MHSF-III). It is noted that one must
understand who will be using a given tool, the setting it will be used, and how the information obtained from it will be used
by staff. To meet the needs of clinicians, MHSF-III was required to be short, understandable, inexpensive, and easy to use.
The tool is not meant to be diagnostic but rather one which can better screen for possible mental health problems and to effectively
refer identified cases.
This study examined whether an adapted Assertive Community Treatment (ACT) intervention improved substance use, mental health,
physical health, legal, employment, and housing outcomes for a U.S. sample of homeless men with a substance use disorder or
a dual-diagnosis of substance use and mental health disorders and whether this intervention was equally effective for a subgroup
of minority men. Data were collected from 103 participants who received treatment services for up to 12 months. The intervention
significantly reduced recent substance use, the severity of problems and the number of hospitalizations related to substance
use. The intervention also improved mental health problem severity and legal outcomes. The proportion of men living in stable
housing increased at 12-month follow-up, whereas the severity of employment problems increased over time yet decreased for
those who more fully utilized the services provided by the program. In general, the intervention was equally effective for
minority and non-minority men.
The purpose of this study was to compare the effectiveness of four interventions in providing services to homeless clients with dual disorders: standard care (SC), assertive community treatment only (ACTO), integrated assertive community treatment (IACT), and new integrated assertive community treatment (NIACT). Participants had to be homeless, have a substance use disorder, and have a severe mental illness to be eligible for the study. One hundred ninety-six individuals were randomly assigned to SC, ACTO, or IACT. Approximately two years later, 85 participants were assigned to NIACT. A quasi-experimental design was employed to analyze the data. Clients in the NIACT program had better outcomes on consumer satisfaction than clients in the other conditions. Clients in NIACT, IACT, and ACTO groups had better housing outcomes than clients in SC. Clients in NIACT reduced their use of drugs more than clients in the other programs, but there was no difference between conditions on the other substance abuse variables. There was no difference between conditions on psychiatric symptoms. IACT may need to be augmented with other services to reduce substance use and produce better psychiatric outcomes for dual-disorder homeless individuals.
Studied 122 female and 126 male homeless persons (mean age of 30.6 yrs) in St Louis, Missouri, and their service needs. 64.9% of the Ss were from racial minorities. Psychopathology was assessed with the Brief Symptom Inventory (BSI) of L. R. Derogatis and P. M. Spencer (1984). Alcoholism and drug abuse were assessed, and Ss were questioned about their use of social services and informal social supports used or desired. 25% of the Ss were hospitalized previously for mental disorders, 16% received outpatient treatment, and 15.3% currently received mental health care (MHC). About 50% scored above the cutoff of the BSI. Most indicated a willingness to receive MHC. About 35% seemed to have drinking problems, and about 21% had used drugs in the past month. Physical health needs, employment training, and legal and financial assistance joined housing and MHC as important needs of these homeless Ss. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Previously published research on interventions for persons who are homeless and mentally ill has exhibited marked limitations in attrition, sample sizes, generalizability and outcome measures. This report presents results from an outreach and linkage project wherein the research design has better addressed these limitations. Successful outcomes in terms of the number housed were documented. However, significant changes in participant functioning levels were not. Multinomial logistic regression indicated that three variables were significant predictors of 4 month residential setting: recruitment source (shelter, psychiatric hospital or community mental health agency), client functioning cluster type, and hours of service from the homeless project. The latter finding suggests that project interventions contributed to positive changes in clients' residences. Implications of the results for future service and research efforts are discussed.
The aim of this study was to describe a homeless population's lived experience with substance abuse. A retrospective descriptive design was used to collect data from a sample of 75 homeless adults participating in a community-based homeless recovery residential program. Each participant was interviewed concerning gender, age, marital status, race, religion, education, employment, substance abuse, family history, psychiatric history, and legal history. Characteristics that emerged from the data were grouped into categories using content analysis. Seventy-three of the 75 homeless participants reported a history of substance abuse and provided in-depth descriptions of issues concerning their substance abuse.
Multiple regression analysis was used to identify correlates of problem drinking among 165 homeless men in St. Louis, Missouri. Variables that were the strongest predictors of alcoholism included number of stressful events before becoming homeless, age, current life satisfaction, psychopathology, and prior mental hospitalization. The full-scale model predicting problem drinking produced a total explained variance (R2) of .38. In contrast with findings from previous research on the homeless, the length of time homeless and the degree of transience were not predictive of alcoholism. Similarly, social support had no impact on problem drinking.
This paper describes a model of outreach predicated on developing a trusting, meaningful relationship between the outreach worker and the homeless person with mental illness. We describe five common tasks inherent in this model of outreach (establishing contact and credibility, identifying people with mental illness, engaging clients, conducting assessments and treatment planning, and providing ongoing service). Other issues discussed include: (a) Responding to dependency needs and promoting autonomy; (b) setting limits while maintaining flexibility; (c) resistance to mental health treatment and follow-up service options.
This study examined data on case management clients who are homeless and have a severe mental illness to determine how those contacted through street outreach differ in their socio-demographic characteristics, service needs, and outcomes from those clients contacted in shelters and other health and social service agencies.
As part of the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, data were obtained from potential clients over the first 3 years of the program at the time of the first outreach contact (n = 11,857), at the time of enrollment in the case management program (n = 5,431), and 3 months after enrollment (n = 4,587).
Clients contacted at outreach on the street, as opposed to being contacted in shelters and service agencies, were generally worse off. They were more likely to be male, to be older, to spend more nights literally homeless before the contact, to have psychotic disorders, and took longer to engage in case management. They expressed less interest in treatment and were less likely to enroll in the case management phase of the project. Subjects contacted on the street who did enroll were more impaired than their street counterparts who did not enroll. Three month outcome data showed that enrolled clients contacted through street outreach showed improvement that was equivalent to those enrolled clients contacted in shelters and other service agencies on nearly all outcome measures.
Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings. Street outreach is further justified as it engages the most severely impaired among the street population. Street outreach also appears to be effective as the clients reached in this way showed improvement equal to that of other clients in most outcome domains when baseline differences were taken into account.
The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbach's alpha =.86), the IDS-SR(30) (Cronbach's alpha =.92), and the HAM-D(24) (Cronbach's alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.
We identified substance use patterns and factors associated with increased substance use after users become homeless.
We carried out a 2-city, community-based survey that used population-proportionate sampling of 91 sites with random selection at each site.
Five hundred thirty-one adults were interviewed; 78.3% of them met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for substance abuse or dependence. Most of those who met the criteria reported using drugs and alcohol less since they became homeless, commonly because they were in recovery. Factors independently associated with increased use were no health insurance (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.02, 2.58), alcohol abuse or dependence (OR = 3.5; 95% CI = 1.85, 6.78), and selling plasma (OR = 2.6; 95% CI = 1.32, 5.14) or panhandling (OR = 3.0; 95% CI = 1.65, 5.55) to acquire drugs.
Becoming homeless plays a role in self-reported substance use. Multiservice treatment programs and tailored interventions for homeless persons are needed.
This study compared the costs and outcomes associated with three treatment programs that served 149 individuals with dual disorders (i.e., individuals with co-occurring severe mental illness and substance use disorders) who were homeless at baseline. The three treatment programs were: Integrated Assertive Community Treatment (IACT), Assertive Community Treatment only (ACTO), and standard care (Control). Participants were randomly assigned to treatment and followed for a period of 24 months. Clients in the IACT and ACTO programs were more satisfied with their treatment program and reported more days in stable housing than clients in the Control condition. There were no significant differences between treatment groups on psychiatric symptoms and substance use. The average total costs associated with the IACT and Control conditions were significantly less than the average total costs for the ACTO condition.
U.S. Department of Housing and Urban Development. The 2016 Annual Homeless Assessment Report (AHAR) to Congress: Part 1: Point-In-Time Estimates of Homelessness
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Department of Housing and Urban Development. The 2016 Annual
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A manual for ACT start-up: Based on the PACT model of community treatment for persons with severe and persistent mental illnesses. USA: National Alliance for the Mentally Ill
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Assertive community treatment. Evidence based mental health practice: A textbook
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The 16 item quick inventory of depressive symptomalogy (QIDS), clinician rating (QIDS-C) and self report (QIDS-SR)
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of depressive symptomalogy (QIDS), clinician rating (QIDS-C) and
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Homelessness: Provision of mental health and substance abuse services
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(2003a). Homelessness: Provision of mental health and substance
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Blueprint for change: ending chronic homelessness for persons with serious mental illnesses and/or co-occurring substance use disorders
Substance Abuse Mental Health Services Administration (SAMHSA)
(2003b). Blueprint for change: ending chronic homelessness for
persons with serious mental illnesses and/or co-occurring substance
use disorders. Rockville (MD): Department of Health and Human
Services.