literature review

Running head: MENTAL ILLNESS AND HOMELESSNESS 1

Mental Illness and Homelessness: A Review of the Literature

Bailey Cage, Samantha Lee, and Mitch Moody

Auburn University

November 18th, 2014

MENTAL ILLNESS AND HOMELESSNESS 2

Abstract

This literature review discusses the problem and impact of mental illness in homeless

populations, particularly in chronically homeless populations. Housing First and Full-Service

Partnership programs are specifically evaluated for their efficacy in combatting chronic

homelessness. There is plentiful information concerning the effects of co-morbid diagnoses and

substance abuse on mentally ill homeless populations. There is also significant information

regarding how Housing First and Full-Service Partnership programs affect the quality of life of

their participants. However, little research is available on homelessness and mental illness in

certain demographics, and existing studies also have certain methodological limitations. For

these reasons, suggestions for future research are discussed as well.

Keywords: mental illness, homelessness, chronic homelessness, Housing First, Full-

Service Partnership, quality of life


Table of Contents

Abstract ............................................................................................................................................2

Introduction ......................................................................................................................................4

Literature Review.............................................................................................................................5

Discussion ......................................................................................................................................16

References ......................................................................................................................................17


Introduction

On an average night in the United States 410,000 individuals find themselves with

nowhere to stay. Of these around 110,000 are chronically homeless (Substance Abuse and

Mental Health Services Administration, 2011). The chronically homeless often find themselves

in a cycle of shelters, couches, park benches, and alleyways. A large portion of the homeless and

chronically homeless populations are the mentally ill. Estimates put the amount of homeless

people who suffer from mental illness to be around a third of the entire homeless population

(SAMHSA, 2011). Of those who are homeless and suffer from serious mental illness, around

60% suffer from Schizophrenia, 25% from Bipolar Disorder, and 15% from Major Depressive

Disorder (Ettner, Gilmer, Manning, Stefancic, Tsemberis, 2010). These individuals face many

obstacles and adversities. They may reject treatment or have trouble gaining treatment due to the

adversities they face. They face stigmatization by others, including other individuals within

shelters and other people who are homeless. Those who are mentally ill also face some of the

toughest challenges in getting out of homelessness. There is often a bar between getting stable

housing that they must cross by first getting treatment. The problem with this is that a homeless

individual with serious mental illness will find it nigh impossible to obtain stability and make

progress within treatment. To address this issue, a new approach has been suggested for

treatment of the mentally ill homeless population, and the homeless population itself. Called the

Housing First approach or alternatively Full Service Partnerships, many are placing homeless

individuals into permanent individual housing immediately, instead of attempting to ease them

into housing itself or requiring treatments first. The following studies examine this approach and

its effectiveness in treating the population of homeless individuals who suffer from serious

mental illness specifically.


Literature Review

According to the United States Department of Housing and Urban Development, chronic

homelessness occurs when an individual or group has a disabling condition and is homeless for

either one full calendar year or for four separate homelessness episodes in a three year period

(“Resources for Chronic Homelessness,” 2014). Because the “disabling condition” observed in

chronically homeless populations can be some form of mental illness or substance abuse,

obtaining adequate psychiatric care and/or sobriety is often a prerequisite for seeking permanent

housing through assistance programs (Pearson, Montgomery, and Loche, 2009). However, some

programs that use a “Housing First” approach function by providing permanent, supportive

housing to the chronically homeless without first requiring them to become sober or seek

psychiatric treatment. Housing First programs operate under the assumption that if an individual

can have access to reliable housing, then problems like untreated mental illness or drug and

alcohol abuse become easier to manage (Pearson et al., 2009). One study’s findings offer support

to the theory that providing housing without requiring treatment for mental illness can yield

desirable outcomes. Specifically, 84% of participants in the study stayed in Housing First

programs for a year after enrollment. Of these participants, approximately 50% spent every night

in their specific unit. The remaining 50% spent time living in other environments during their

stay (Pearson et al., 2009).

The study began by selecting three programs in the United States that used the Housing

First approach. The programs were selected based on size, how long they had been in existence,

and shared similarities in program implementation. The three programs eventually chosen were

the Downtown Emergency Service Center (DESC) in Seattle, Reaching Out and Engaging to

Achieve Consumer Health (REACH) in San Diego, and Pathways to Housing in New York. A

total of 80 participants were then selected from the three programs based on the order in which


they entered the programs. 25 were from DESC, 26 were from Pathways to Housing, and 29

were from REACH. Qualitative data was collected via focus groups where participants were

asked about their quality of housing and quality of life. Participants also provided further insight

into how the programs were run, including information such as how participants enter the

program and the degree of control they had over the services they received. Quantitative data

collected included severity of mental illness and substance abuse, as well as frequency of

program departures. This data was then analyzed with chi-square tests (Pearson et al, 2009).

Participant demographics varied across each program. Most participants were in their

40’s, and 66%-73% of participants in each program had a disorder co-occurring with a

psychiatric diagnosis of a psychotic or mood disorder. Over two-thirds of participants in all three

programs had a history of substance abuse. However, there were many differences in

demographics observed across all three programs. REACH had significantly more female

participants (34%) than DESC and Pathways to Housing (16% and 15% respectively), and

REACH also had a notably higher percentage of participants with mood disorders (41%,

compared to 16% in DESC and 8% in Pathways to Housing). DESC had a sizable portion of

participants that were HIV positive (20%), while Pathways to Housing and REACH each had 4%

and 0% test HIV positive. Finally, all participants from Pathways to Housing had received

substance abuse treatment in the past, but only 48% of the participants from DESC and 15% of

participants from REACH had ever received such treatment (Pearson et al., 2009).

Despite some differences in demographics in each of the three programs, DESC,

Pathways to Housing, and REACH all had relatively high percentages of participants stay in

their programs. 79%-92% of participants in each of the three programs stayed for a year,

including all female participants. Participants with severe mental illness were more likely to

remain in the programs in order to keep access to their mental health resources. Other


participants that were more likely to stay were those that came directly from a psychiatric

hospital and those that came from a jail or prison. Participants that were less likely to stay were

ones with less than a high school education and ones that came in directly off the streets. Out of

all the participants that left the Housing First programs, only three individuals (3.75% of the total

number of participants) left on their own accord. The others that did not remain enrolled for the

entire year either passed away, left involuntarily to receive more intensive care, were

incarcerated, or lost housing due to assaulting other residents. Problem behavior, such as drug

and alcohol use, was also frequently observed amongst participants in Housing First programs.

The most problem behavior occurred in the DESC program and the least amount of problem

behavior occurred in the Pathways to Housing program. Participants who stayed in the Housing

First programs spent an average of 30 days in other living environments, while those that left the

programs spent approximately twice as many days in other living environments before

eventually leaving their programs. Overall, participants were significantly satisfied with their

experiences in the three programs, even if their housing options were limited upon enrollment.

However, severity of mental illness and substance abuse tended to remain constant for all

participants, even those that remained in the programs for the entire year (Pearson et al., 2009).

Pearson et al.’s (2009) study was the first to evaluate the effectiveness of multiple

Housing First programs in combating chronic homelessness. The data supported claims that

chronically homeless populations with mental illness will be able to access psychiatric resources

more easily if housing needs are met first. Participants with mental illness were more likely to

remain in the Housing First programs, despite traditionally being one of the most difficult

homeless populations to serve. The study also provided important information clarifying the

degree of success that can be expected from using Housing First programs. While Housing First

programs can provide many benefits to their residents, the data seems to indicate that it alone


cannot sufficiently treat mental illness and substance abuse in chronically homeless populations

(Pearson et al., 2009).

However, there is still much more that can be studied concerning homeless people with

mental illness in Housing First programs. Firstly, all three programs in the study were located in

large, urban areas. Results might have been different if programs from rural or suburban parts of

the United States were chosen instead. Therefore, future studies might benefit from evaluating

the success of programs in different types of developed environments. Additionally, Pearson et

al.’s (2009) study neglected to provide complete demographic data on participants, particularly

in reference to sexual orientation and gender identity. LGBT* people are a statistically

significant portion of homeless populations, including chronically homeless populations (“LGBT

Homeless,” 2009). Neglecting to evaluate the rate of their success in Housing First populations

means that claims of success in Housing First programs are only supported by research if

participants identify as heterosexual and cisgender. Furthermore, Pearson et al.’s (2009) study

noted a retention rate of 100% for women in the programs, despite an overall retention rate of

only 84%. Therefore, this study provided some data suggesting that Housing First programs may

vary in effectiveness based on gender. Providing additional information on the effectiveness of

Housing First programs for transgender individuals could potentially further support such claims.

Finally, while collecting data in focus groups was probably time efficient and practical,

this method of data collection can also lead to dishonesty from participants. Specifically,

participants with negative opinions about their housing arrangements may not report them in a

group due to social influence and societal expectations of gratitude (Baumeister & Bushman,

2014). Future studies may benefit from conducting one-on-one interviews with homeless

individuals, by conducting anonymous surveys, or by utilizing multiple methods of collecting

qualitative data in order to best ensure accuracy.


Homeless individuals with SMI (serious mental illness) are often arrested or injured, or

may find shelter or treatment with mental health services or inpatient treatment centers. All of

these have significant effects on the individual but also on the system itself, these services cost

money that the homeless will not be able to pay; these services are either given for free or taken

from government funds. Housing First Programs have already been shown to better treatment

and the quality of life of homeless with SMI, a study has been done to measure the effects of

Housing First programs on the affected institutions as well as the individuals enrolled in the

program (Ettner, Gilmer, Manning, Stefancic, and Tsemberis, 2010).

Data provided by San Diego County was used to identify participants who were placed

into FSP (Full Service Partnership), this information was then compared to data collected when

homeless individuals initiated services and were not participants in a FSP. By using data

provided by administrators in the services that were used, information on costs was able to found

and collected and then compared to the costs of FSP. Costs of FSP were estimated and pegged at

$680 per person per month and on average subjects provided 50% of this cost, usually through

supplemental security. Housing maintenance, upkeep, and utilities were averaged at $760 per

year. Housing status, employment, and disability benefits were analyzed before and after service

enrollment. Three sets of estimates were compared, before and after results for the FSP group,

before and after sets for the non-FSP group, and the differences between these estimates. Quality

of life was measured in a cross section of FSP and homeless clients seeking outpatient services

(Ettner et al., 2010).

209 individuals in FSP were compared to 154 individuals who were not enrolled in a FSP

program but were still homeless. All individuals in both groups suffered from SMI. In total, the

mean age for all participants in the study was 44, 37% were female, 61% were white, 25% were

African American, 10% were Hispanic, 60% were diagnosed with Schizophrenia, 25% with


Bipolar Disorder, and 15% with Major Depression. Data was collected on days spent in different

types of housing, the use of outpatient medical services, the probability of using inpatient or

emergency services, quality of life, and the difference in standardized costs for using FSP. For

the first section of this data, days spent in different housing environments, data was collected one

year prior to enrollment and then one year following enrollment. The other sets of data were

compared between those in FSP and those not enrolled (Ettner et al., 2010).

The amount of days a homeless individual spent living in independent or congregate

living per year increased on average by 147 days a year. Time spent homeless decreased by 67%

from 191 days a year to 62 days a year. There was a 32% increase in the number of participants

receiving Supplemental Security (53% to 70% of those participating). Employment did not

increase among those in FSP, but it should also be taken into account that all those involved

suffer from SMI which may make employment difficult to attain. The use of Outpatient services

increased greatly among the FSP group, an increase that was not found in the control group. The

FSP group had a mean of 36 visits for case management, 27 visits for medication management,

22 for therapy while the control group only averaged had a mean of 1 for case management and

three for both therapy and medication. Those in FSP were 11% less likely to use inpatient care

and 20% less likely to use emergency and justice system services. Those involved in FSP used a

mean of $2116 more in services than the control group, but this is also figuring in the costs of

housing and the large increase in outpatient care usage. Not counting housing, those in FSP used

a mean of $1064 less in services than the control group (even when including the very large

increase in outpatient service), greatly reducing the use of inpatient, emergency, and justice

system services. Those in FSP also showed a large increase in satisfaction in life (Ettner et al.,

2010).

In the future it would be beneficial to gather data from homeless populations in different


locales and climates. By limiting a study to the San Diego area, some of the data may have been

skewed. The climate in San Diego is much more ideal for outdoor living than most of the United

States, and this may have had an effect on the data collected on housing, as shelter seems to be

less necessary in a climate that remains fairly warm and moderate such as San Diego. A study

can also be limited by its locale as the amount of mental health services available may vary

largely between states and cities. A large, metropolitan city such as San Diego likely has a much

larger population of mental health professionals available. The effectiveness of FSP on

individual mental health could vary if outpatient services were not as readily available as they

are in San Diego (Ettner et al., 2010).

As has been discussed, there have been numerous studies done on the effectiveness of

housing first programs in combating homelessness. Another study done by Tsemberis et al.

(2004) and Pearson et al. (2009) has found housing first programs to be successful at ending

homelessness, and the United Nations (1976) has found the programs to be consistent with

human rights. Additionally two studies led by Culhane (2002, 2008) have found that these

programs are cost-effective when targeting people with complex health and social

needs. Unsurprisingly, housing first programs are those that focus first on housing a homeless

individual without requiring “adherence to treatment and abstinence from substances before

granting access to permanent housing options” (Tsemberis et al., 2004). These types of

programs generally offer treatment and support for substance abuse and other disorders, but do

not require perfect mental and physical health prior to granting an individual access to

housing. Studies previously done on housing first programs, such as the ones mentioned earlier,

focus on community integration as a primary outcome of interest.

With all this research done on housing first programs, few studies, if any, have been done

concerning the basic questions of life quality and satisfaction. Nearly all previous studies


operated under the assumption that “the degree of movement within one’s community [is] a

predictor of subjective quality of life” (Townley et al., 2009); however, there are multiple aspects

to and measures of one’s quality of life. Recognizing this lack of completeness, the researchers*

behind this particular article developed a study to address this gap.

The researchers Benjamin F. Henwood, Jason Matejkowski, Ana Stefancic, and Jonathan

M. Lukens; chose a housing first agency located in Philadelphia, Pennsylvania. This particular

program used scatter-style housing rented from private landlords--as opposed to community-

style housing that is centralized and owned by a housing first agency itself--that generally

consisted of a one-bedroom apartment subleased to the individual by the agency. Apartments

were chosen by availability and also by affordability, as tenants were expected to contribute one-

third of their income towards rent. The majority of participants were African-American males

whose average age was forty-six. The primary diagnoses were split evenly between mood and

psychotic disorders severe enough to cause clinically significant impairment.

Study data was collected through two in-person interviews using a variety of

measures. The first interview occurred when the participant initially joined the program and

moved in to his or her apartment unit. This interview is referred to as the T1 or as the baseline

interview. The baseline interview occurred an average of two months after the new tenant

moved in. The second interview, the T2 interview, occurred approximately a year after the

baseline interview. Both the T1 and the T2 interviews were structured based on the Lehman’s

Quality of Life Interview (Lehman, 1988), which included eight subjective scales and three

objective scales. Each subjective measure used a seven-point “terrible” to “delighted”

scale. Among the objective measures were frequency of contact with family and non-family

members, adequacy of finances, and frequency of community participation. The researchers

hypothesized that “participation in community activities will … be positively related to [the]


quality of life” of the tenants.

The researchers controlled for age, race, gender, time, psychiatric symptoms, substance

abuse, and percent of activities undertaken within one’s neighborhood in an attempt to purely

examine the relationship between housing first programs and quality of life. However, “given

the variation in adaptive functioning that exists within classes of psychiatric disorders,” the

researchers recognized symptom severity as a covariate, which is a secondary variable that can

affect the relationship between the dependent variable (quality of life) and other independent

variables (housing first programs) of primary interest. They measured symptom severity using

the Modified Colorado Symptom Index and attempted to control for this covariate.

The discussed study found that there were no significant differences between the T1

interview and the T2 interview in the individual scores of symptom severity, substance

involvement, and community participation. There were few differences between the T1

interview and the T2 interview in the level of community involvement, but there was a

statistically significant decrease in the number of days participants visited parks or

church. Participant-reported subjective satisfaction ratings statistically increased in the

following quality of life measures: living situation, family relations, and finances. Satisfaction

with living situations increased substantially while satisfaction with family relations and finances

increased only a modest amount.

After identifying these three statistically significantly increased areas of quality of life as

well as two others, the researchers examined the relationship each of them had with community

participation and general life satisfaction. They found that while certain domains of quality of

life improved with housing, overall quality of life and life satisfaction did not improve between

the T1 interview and the T2 interview. In fact, personality structure was more determinant than

external circumstances on life satisfaction. A change in these external circumstances, such as


those from a housing first program, caused a change in specific areas of satisfaction but not in

general life satisfaction. Additionally, the original hypothesis of the researchers was proved

false: the findings did not show any association between community activities and quality of

life. In regards to mental illness, the study found that “symptom severity was … negatively

related to quality of life in all six models, indicating that psychiatric symptom severity negatively

and broadly impacts quality of life.” This finding lead researchers to conclude that emphasizing

mental health treatment would be the most effective solution in increasing quality of life among

adults with serious mental illness who have experienced chronic homelessness. This is because

symptom severity has been found to affect such a large range of quality of life factors, but also

because a previous report (Matejkowski et al., 2013) suggested that simply “improving

perceptions of health or improving the ability to cope with symptoms could improve quality of

life,” and that is the ultimate goal of the researchers, anyway.

A key weakness for this study is that the researchers only conducted two interviews that

were spaced a year apart. There are numerous confounding variables that would cause an

individual to be more or less inclined to answer favorably that has no relationship to the actual

level of satisfaction. There is also the unanswered question regarding shorter- and longer-term

changes in life satisfaction. We are left wondering how the tenants’ satisfaction levels changed

from week to week and month to month. We are also left wondering how these changes affect

one’s quality of life in the long run. Considering permanent supplemental housing is permanent

rather than temporary, it is important to take an expansive view of the tenants’ lives. An

additional weakness is that the initial interview was not conducted until approximately two

months after the tenants moved in, which leaves the possibility that the majority of change in life

satisfaction occurs during the first two month period of permanent supplemental housing. A

final key weakness is the systematic sample bias. The sample is disproportionately African-


American male and therefore does not reflect the homeless population as a whole. This study

may not be generalizable to all homeless populations nor all housing first programs in all

locations. Follow-up studies are needed to provide a wider knowledge base and decrease the

systematic bias of this study. Suggestions for future studies include attempting to adequately

address the following questions: shorter-term and longer-term impacts, immediate effects, and

generalizability of housing first programs.


Discussion

Some differences between the previously mentioned articles on homelessness and mental

illness include the types of programs utilized by the homeless. Two studies used Housing-First

programs (Henwood et al., 2014; Pearson et al, 2009), while one of the studies used Full-Service

Partnerships (Gilmer et al., 2010). Specifically, Gilmer et al.’s (2010) study was also the only

study using a housing program with psychiatric treatment as a co-requisite. This study was also

the only study evaluating the financial cost of implementing these programs for the homeless

(Gilmer et al., 2010). The two remaining studies (Henwood et al., 2014; Pearson et al., 2009)

attempted to measure additional outcomes unique to Housing-First programs. One study was a

longitudinal study meant to measure how Housing-First programs can lead to changes in quality

of life (Henwood et al., 2014), while the other study primarily sought to measure program

retention rates amongst the chronically homeless (Pearson et al., 2009).

Most studies discussing homelessness and mental illness examine the positive effects

different supportive treatments can have on the individuals who use them (Gilmer et al., 2010;

Henwood et al., 2014; Pearson et al., 2009). These positive effects are determined through the

collection of both qualitative and quantitative data from participants. Some examples of

qualitative data collected include evaluations on quality of life and overall satisfaction with the

programs (Gilmer et al., 2010; Henwood et al., 2014; Pearson et al., 2009). Commonly collected

quantitative data include number of days spent homeless (Gilmer et al., 2010; Henwood et al.,

2014; Pearson et al., 2009). Overall, results for all three studies were relatively consistent. While

no program offered immediate improvement on overall quality of life or symptoms of mental

illness, some specific aspects of quality of life were improved, and access to psychiatric care was

much easier to obtain (Gilmer et al., 2010; Henwood et al., 2014; Pearson et al., 2009).


References

Baumeister, R. F., & Bushman, B. J. (2014). Social influence and persuasion. Social Psychology

and Human Nature, Brief Version (3rd ed., pp. 267-297). Belmont, CA: Cengage

Learning.

Ettner, S.L., Gilmer, T.P., Manning, W.G., Stefancic, A., Tsemberis, S., (2010). Effect of full-

service partnerships on homelessness, use and costs of mental health services, and quality

of life among adults with serious mental illness. Jama Network. Retrieved from

http://archpsyc.jamanetwork.com/article.aspx?articleid=210805

Henwood, B.F. (2014). Quality of life after housing first for adults with serious mental illness

who have experienced chronic homelessness. Psychiatry Research, Retrieved October 10,

2014, from http://dx.doi.org/10.1016/j.psychres.2014.07.072

Lehman, A.F., (1988). A quality of life interview for the chronically mentally ill. Evaluation and

Program Planning, 11(1), 51 - 60.

LGBT homeless. (2009). National Coalition for the Homeless. Retrieved October 7, 2014, from

http://www.nationalhomeless.org/factsheets/

Matejkowski, J., Lee, S., Henwood, B., Lukens, J., Weinstein, L.C., (2013). Perceptions of health

intervene in the relationship between psychiatric symptoms and quality of life for

individuals in supportive housing. The Journal of Behavioral Health Services &

Research, 40(4), 469 - 475.

Pearson, C., Montgomery, A. E., & Locke, G. (2009). Housing stability among homeless

individuals with serious mental illness participating in Housing First programs. Journal

of Community Psychology, 37(3), 404-417.

Resources for chronic homelessness. (2014). HUD Exchange. Retrieved October 7, 2014, from

https://www.hudexchange.info/homelessness-assistance/resources-for-chronic-


homelessness/

Substance Abuse and Mental Health Services Administration. (2011). Current Statistics on the

Prevalence and Characteristics of People Experiencing Homelessness in the United

States. Retrieved from http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf

United Nations, (1976). Office of the High Commissioner for Human Rights, International

Covenant on Economic, Social, and Cultural Rights. Geneva, Switzerland. Available at:

http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx.

http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx

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