More Homeless Mentally Ill Than Expected According To UCSD Study: Interventions Urged

Published in the February 2005 issue of the American Journal of Psychiatry, the study noted that homelessness in this population might potentially be reduced or prevented with substance abuse treatment and help in obtaining public-funded health benefits (Medicaid, or MediCal in California). Because homeless mentally ill were more than twice as likely to be hospitalized as non-homeless patients, the investigators said improved care for homeless persons with serious mental illness may be cost effective or at least result in improved patient outcomes with only moderate increases in total costs.

The research was conducted among an ethnically diverse population of 10,340 San Diegans with serious mental illness (both homeless and those with housing) who were treated by San Diego County Adult Mental Health Services (AMHS). While one-fourth to one-third of homeless persons are estimated to have a serious mental illness, this is one of the first studies to document and describe the other side of the picture – the number of mentally ill who are homeless.

"Homelessness is more common in patients with serious mental illness than I would have guessed," said the study's first author, David Folsom, M.D., co-director of the UCSD Combined Family Medicine-Psychiatry Residency Program and the assistant medical director of St. Vincent de Paul Village's Family Health Center, a free medical clinic located in one of San Diego's largest homeless service agencies.

According to the UCSD researchers, homelessness was most frequently associated with people who were diagnosed with schizophrenia or bipolar disorder, who were substance abusers, and who had no public-funded health care. Men were also more likely to be homeless than women, as were African Americans. Latinos and Asian Americans were less likely to be homeless.*

"Homelessness is an increasingly important public health issue, with seriously mentally ill persons most at risk for homelessness," said the study's senior author, Dilip Jeste, M.D., UCSD Estelle and Edgar Levi Chair in Aging, professor of psychiatry and neurosciences, director of the UCSD Sam and Rose Stein Institute for Research on Aging, and a geriatric psychiatrist at the VA San Diego Healthcare System. "In addition to the trauma experienced by these individuals, there is also a cost to society. Homeless persons have a significantly more-frequent use of expensive emergency services** and are more likely to spend more time in jail."

The study noted that in San Diego, African Americans comprise 5 percent of the general population, 11 percent of the AMHS population with serious mental illness, and 16 percent of the homeless patients with serious mental illness treated in AMHS. Latinos contribute 23 percent of the general population, 19 percent of the AMHS patients, and 12 percent of the homeless.

"It is possible that the higher rate of homelessness among African Americans may be in part due to fewer community resources for this group of patients, whereas the larger Latino community may be able to provide more resources to protect against homelessness," the study said. "However, African Americans have been found to be at higher risk of homelessness in other cities with larger African American populations, such as New York and Philadelphia***."

The authors also said that an investigation of homeless persons in Los Angeles, only some of whom had mental illness, found lower rates of homelessness in Caucasians and Latinos than in African Americans.

Noting that treatment for substance abuse has been reported to improve outcomes, the researchers said "access to substance abuse treatment is more difficult for homeless persons with serious mental illness than for other homeless persons. Similarly, patients who did not have MediCal insurance were twice as likely to be homeless as patients with MediCal; homeless persons with psychotic disorders have been reported to have greater difficulty obtaining and maintaining entitlement benefits than non-psychotic homeless persons."

The authors concluded that "although it would be naïve to assume that treatment for substance use disorders and provision of MediCal insurance could solve the problem of homelessness among persons with serious mental illness, further research is warranted to test the effect of interventions designed to treat dually diagnosed patients and to assist homeless persons with SMI obtain and maintain entitlement benefits."

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The study was funded by the National Institute of Mental Health and by the Department of Veterans Affairs. Additional authors were William Hawthorne, Ph.D., Laurie Lindamer, Ph.D., Todd Gilmer, Ph.D., Anne Bailey, M.S., Shahrokh Golshan, Ph.D., Piedad Garcia, Ed.D., Jurgen Unutzer, M.D., and Richard Hough, Ph.D.

* Patients with schizophrenia were 2.4 times more likely, and those with bipolar disorder 1.6 times more likely to be homeless than those with major depression. Substance users were more than 4 times as likely to be homeless as non-users. Homelessness was twice as common among patients lacking MediCal insurance compared to MediCal beneficiaries.

** see http://health.ucsd.edu/news/2004/04_01_Jeste.html (previous study)The current study found that homeless patients were 10 times more likely to use crisis residential treatment and 4 times more likely to use inpatient psychiatric hospitalization than non-homeless persons.

*** American Journal of Public Health, 1995, 85:1153-1156; American Journal of Public Health 1994, 84:265-270; and Psychiatric Services 1997, 48:390-392