The Health of the Homeless - The Mental Health Of Homeless People

Before the 1960s people with chronic mental illness were often committed involuntarily to state psychiatric hospitals. The development of medications that could control the symptoms of mental illness coincided with a growing belief that involuntary hospitalization was warranted only when a mentally ill person posed a threat to him- or herself or to others. Gradually, large numbers of mentally ill people were discharged from hospitals and other treatment facilities. Because the community-based treatment centers that were supposed to take the place of state hospitals were often either inadequate or nonexistent, many of these people ended up living on the streets.

According to Folsom and his colleagues, 15% of patients treated for serious mental illness in California's mental health system were homeless at some point during a one-year period (American Journal of Psychiatry, vol. 162, February 2005). Twenty percent of patients with schizophrenia, 17% of patients with bipolar disorder, and 9% of patients with depression were homeless. The authors found that mentally ill people are at a much higher risk of homelessness than the general population.

Many homeless people do not realize how ill they are and how dependent they are on regular treatment. Others no longer believe the system can or will help them. This seems to have been borne out by a 1999 survey of 301 homeless adults in Buffalo, New York (O. Acosta and P. A. Toro, "Let's Ask the Homeless People Themselves: A Needs Assessment Based on a Probability Sample of Adults," American Journal of Community Psychology, vol. 28, 2000). When researchers asked homeless people what their greatest needs were, respondents listed affordable housing, safety, education, transportation, medical/dental treatment, and job training/placement. Formal mental health and substance abuse services were rated as unimportant by comparison, easy to obtain, and not very satisfactory to people who had used them.

In a 1998 study of 132 homeless adults (E. M. Reichenbach et al., "The Community Health Nursing Implications of the Self-Reported Health Status of a Local Homeless Population," Public Health Nurse, December 1998), researchers explored the personal characteristics and the health and health-related concerns of homeless health clinic clients. The study examined the significant differences in health and well being between homeless shelter residents and nonshelter residents. The homeless population studied featured a majority of males with an average age in the mid-thirties, a high rate of unemployment, and a low rate of health insurance. One-third of respondents reported their own health status as fair or poor. Joint problems and cardiovascular disease were the two most common physical ailments mentioned, while depression was the most common self-identified mental health problem. The most common fear mentioned by study participants was loneliness, but homeless people staying in shelters reported this fear much less often than those who did not stay in shelters.

Table 7.2 describes a study of 100 homeless women with schizophrenia and 100 non-homeless women with schizophrenia. The study, summarized by Silver and Pañares, found that homeless schizophrenic women had higher rates of co-occurring disorders, including alcohol and/or drug abuse and antisocial personality disorder.

Silver and Pañares noted that families with children comprise about 40% of the total homeless population, and the vast majority (about 90%) are female-headed. The authors reported on a study of 436 sheltered homeless and low-income housed mothers. The study found that 84% of all of these women had a history of having been severely assaulted at some point in their lives. Research has shown that mothers with a history of abuse are more likely to have children with mental health problems.

Perceptions of Mental Illness and the Homeless

Homeless people may be looked upon as mentally ill when their "abnormal" actions may actually be behavior caused by social and economic problems. For example, some homeless women act strangely and neglect personal hygiene as a way to protect themselves from attack. A 1988 report on homeless women in San Francisco (C. J. Cooper, "Brutal Lives of Homeless S.F. Women," San Francisco Examiner, December 18, 1988) revealed a high rate of rape and sexual assault—some of the women had been raped as many as seventeen times. The report stated that to protect themselves from attack, homeless women would wear ten pairs of panty hose at once and bundle up in layers of clothing.

Prevalence and Treatment

There is some debate over the rate of mental disorders among homeless populations, but there is general agreement that it is greater among the homeless than the general population. The 2004 U.S. Conference of Mayors study revealed that an average of 23% of the homeless in the twenty-seven surveyed cities were mentally ill. The National Resource and Training Center on Homelessness and Mental Illness reported in "Get the Facts: Why Are So Many People with Serious Mental Illnesses Homeless?" that a disproportionate percentage of the homeless population suffers from serious mental illnesses of the most "personally disruptive" kind, "including severe, chronic depression; bipolar disorder; schizophrenia; schizoaffective disorders; and severe personality disorders." An estimated 20% to 25% of the homeless population is afflicted, compared with only 4% of the general population.

Mentally ill homeless people present special problems for health care workers. They may not be as cooperative and motivated as other patients. Because of their limited resources, they may have difficulty getting transportation to treatment centers. They frequently forget to show up for appointments or take medications. They are often unkempt. The addition of drug abuse can make them unruly or unresponsive. Among people with severe mental disorders, those at greatest risk of homelessness are both the most severely ill and the most difficult to help.