Social Support and Psychopathologyin Homeless Patients Presenting forEmergency Psychiatric Treatment

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Tina WuNew York University School of Medicine

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Mark R. SerperHofstra University andNew York University School of Medicine

We compared homeless to domiciled psychiatric patients’ symptomatol-ogy and perceived level of social support (PSS) within hours of psychiatricemergency service (PES) arrival. Homeless patients experienced less PSSand more negative symptoms, but not more psychosis, than their domi-ciled counterparts. Domiciled patients’ PSS was highly related to theirclinical presentation: less support predicted increased psychopathology.Homeless patients’ clinical symptoms, although as common and severe,were unassociated with PSS. These findings suggest that homeless psy-chiatric patients may be less reactive to positive environmental influenceslike social support and manifest more severe and refractory symptomsthan domiciled patients presenting for emergency treatment. © 1999John Wiley & Sons, Inc. J Clin Psychol 55: 1127–1133, 1999.

There is no group of individuals more vulnerable to exhibiting impoverished social net-works than homeless psychiatric patients (Fischer & Breakey, 1986). Psychiatric patientshave been found to exhibit particular risk factors for homelessness (Caton, Shrout, Eagle,& Opler, 1994), including experiencing less adequate support from family, friends, and

The authors thank Eun Sun Chun and Maha Ghosn for their help in data collection. They also thank theBellevue CPEP staff for its cooperation in completing this study.This research was supported by a Young Investigator Award from the National Alliance for Research on Schizo-phrenia and Depression and by USPHS grant MH57793 from the NIMH.Correspondence concerning this article should be addressed to Dr. Mark R. Serper, Department of Psychology,41 Monroe Hall, 1000 Fulton Avenue, Hofstra University, Hempstead, NY 11549–1270.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 55(9), 1127–1133 (1999)© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/091127-07

significant others than domiciled psychiatric patients (Lehman, Kernan, DeForge, & Dixon,1995). Although past investigations have evaluated patients’ levels of social support,these studies typically focused on patients who were either weeks into an inpatient hos-pital stay and ready for discharge or remitted outpatients living in the community orattending day treatment programs (e.g., Leavy, 1983; Lehman et al., 1995; Opler, Caton,Shrout, & Dominguez, 1994; Susser, Lin, & Conover, 1991; Wenzel, Gelberg, Bakhtiar,& Caskey, 1994). As a result, the relationship between patients’ acute psychopathologyand social support remains unclear.

In addition, investigators have focused on the quantity of social networks whileoverlooking the quality of patients’ subjective appraisal of their existing social support(Porritt, 1979). An important finding that has emerged in recent years is that psychiatricpatients’ subjective appraisal of the quality of their social support network is a morerobust predictor of clinical outcome than the actual quantity of social support available(e.g., Cohen & Syme, 1985; George, Blazer, Hughes, & Fowler, 1989). Consequently theinterrelationship between patients’ acute manifestations of psychopathology and theirsubjective appraisal of the quality of their social support has not been well characterizedadequately. As a result, it is unknown what the impact of perceived level of support hason homeless patients’ acute clinical presentation.

In the present study, we examined homeless patients’ perceived level of social sup-port and its effects on psychiatric illness within hours of psychiatric emergency presen-tation. We hypothesized that homeless patients’ self-perception of their social networkswould be significantly less adequate than domiciled patients. We also predicted that home-less patients would present with significantly more psychosis, negative symptoms, anxiety/depression, and hostility than their domiciled counterparts. Lastly, we hypothesized thatboth patient groups’ severity of psychiatric symptoms would be inversely correlated withtheir perceived level of social support.

Method

Participants

Participants were 15 homeless and 22 domiciled psychiatric patients presenting for con-secutive admission to the Bellevue Hospital psychiatric emergency service (PES) whoconsented for participation and met study criteria.1 Demographic information for bothpatient groups is presented in Table 1. All participants included in the study were requiredto have had a past psychiatric history and a current and past DSM-III-R Axis I diagnosis.The participants were divided into domiciled and homeless groups determined by bothmedical chart record and by patient self-report. To be included in the homeless group,participants had to have a documented chart record of homelessness exceeding 6 monthsor more duration. Patients who were currently homeless, but for less than 6 months, werenot included in either group.

Clinical Assessment

Multidimensional Scale of Perceived Social Support (MSPSS).The MSPSS (Zimet,Dahlem, & Zimet, 1988) is a multifactorial self-report scale used to rate level of subjec-tive social support. The scale assesses the extent to which respondents perceive social

1One homeless and two domiciled, were unable/unwilling to complete the protocol and withdrew from thestudy.

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support from three sources: family, friends, and significant others. Higher scores reflecthigher levels of perceived social support. The scale has shown excellent construct valid-ity (Kazarian & McCabe, 1991), internal consistency, internal and test-retest reliability,and strong factorial validity (Zimet, Powell, Farley, & Werkman, 1990).

The Brief Psychiatric Rating Scale (BPRS).The BPRS (Overall & Gorham, 1962) isan 18-item rating scale used to assess a wide degree of psychopathology. The scale con-tains five factors including anergia (negative symptoms), thought disturbance (positivesymptoms), anxiety/depression, activation, and hostility subscales.

Procedure

Patients in the psychiatric emergency service were approached within 24 hours of arrivaland invited to participate in the study after giving informed consent. Consenting patientswere interviewed and their medical charts were reviewed to ascertain demographic infor-mation and residential status. Participants were then administered the BPRS and theMSPSS by one of two trained raters. Thirty percent of the BPRS interviews were over-lapped for reliability. Interrater agreement for the BPRS using intraclass correlations(Shrout & Fleiss, 1979) was high: .84.

Data Analysis

Patients’ substance abuse, diagnostic, sex, employment, and marital status were analyzedusing chi-squares. Comparisons of participants’ age, years of education, and MSPSS andBPRS factor scale ratings were analyzed using one-way analysis of variance (ANOVA).Pearson product moment correlations were then computed for each group to examine therelationship between homeless and domiciled patients’ symptom severity and perceivedsocial support. When significant correlations were found, Fisher’sZ transformations werethen computed to determine whether the correlational patterns were significantly differ-ent across participants’ residential status.

Table 1Demographic Data on Participants

Group

Domiciled Homeless

Variable M SD M SD

Age 37.22 11.19 36.93 8.30Years of Education 11.89 3.09 11.46 3.12% Men 64 — 80 —% Unmarried 95 — 93 —% Unemployed 90 — 93 —% of Patients w/Substance Abuse or Dependence Diagnoses 59 — 80 —% of Patients with Schizophrenia Diagnosis 45 — 47 —% of Patients with Major Depression Diagnosis 36 — 33 —

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Results

Analysis of demographic information revealed the groups were indistinguishable on alldemographic variables, including age, sex, years of education, substance abuse, employ-ment, and marital status (p . .05). Additionally, both groups had an equivalent numbersof patients with schizophrenia and major depression diagnoses.

The means and standard deviations for both groups’ BPRS and MSPSS scores arepresented in Tables 2 and 3. On the MSPSS, homeless patients were found to have sig-nificantly less total social support,F(1,36) 5 8.13, p , .01; perceived support fromsignificant others,F(1,36)5 6.10,p , .01; and from family,F(1,36)5 5.01,p , .03. Nogroup differences in social support were detected on the Friends subscale.

On the BPRS, homeless participants demonstrated significantly more anergia,F(1,36)5 5.66, p , .05; and hostility,F(1,36)5 4.65, p , .05, than the domiciledpatients. No other BPRS subscale differences were detected.

Correlational Analysis

Correlations between MSPSS and BPRS total and subscale scores for each group arepresented in Table 4. For domiciled patients, total BPRS score was significantly nega-tively correlated with their total MSPSS,r 5 2.49,p , .05; Friends,r 5 2.49,p , .05;

Table 2Perceived Support Total and Mean Subscale Scores for Domiciled and Homeless Patients

MSPSS Scale

Total* Family** FriendsSignificant

Others*

Group M SD M SD M SD M SD

Domiciled Patients 43.42 19.47 15.14 7.68 13.14 9.30 15.14 10.05Homeless Patients 25.93 16.07 9.33 7.66 8.80 6.93 7.80 6.43

Note. *p , .01; **p , .03.

Table 3Mean Symptom Severity Subscale Scores for Domiciled and Homeless Patients

BPRS Scale

Total Anergia*Thought

DisturbanceAnxiety/

Depression Hostility* Activation

Group M SD M SD M SD M SD M SD M SD

Domiciled Patients 35.45 8.59 3.90 1.38 9.00 4.14 11.09 5.26 3.09 1.48 2.90 .86Homeless Patients 40.68 12.14 5.60 3.29 9.09 4.59 10.07 3.75 4.53 2.59 3.33 1.67

Note. *p , .05.

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and Significant Other subscale scores,r 5 2.53,p , .05. Additionally, domiciled patients’BPRS Thought Disturbance subscale was correlated with their MSPSS total score,r 52.73, p , .01, as well as Friends,r 5 2.62, p , .05; Family,r 5 2.60, p , .05; andSignificant Others,r 5 2.76,p , .01, subscale scores.

No significant correlations between any BPRS and MSPSS social support measureswere obtained for the homeless patients. Fisher’sZ transformation analyses of significantcorrelations revealed that domiciled psychiatric patients, in comparison to their homelesscounterparts, displayed a pattern of significant associations between measures of psycho-pathology and levels of perceived social support. Significant group correlational differ-ences were found between homeless and domiciled patients’ positive thought disorderand MSPSS Friends (Fisher’sZ 5 3.09,p , .05), Family (Fisher’sZ 5 3.85,p 5 .05),Significant Others (Fisher’sZ 5 4.14,p , .05), and MSPSS total score (Fisher’sZ 53.56,p , .05), and between total BPRS score and MSPSS Significant Other subscalescore (Fisher’sZ 5 2.20,p , .05). No group difference was detected for the associationbetween BPRS and total MSPSS score (Fisher’sZ 5 1.75,p . .05) or Friends (Fisher’sZ 5 1.52,p . .05) subscale.

Discussion

As predicted, homeless psychiatric patients, compared to domiciled patients, appraisedtheir social support networks as less supportive, reliable, and available. These results areconsistent with previous reports that found homelessness predisposes an individual towardhaving impoverished social relations (e.g., Caton et al., 1994; Leavy, 1983; Surtees &Ingham, 1980). Contrary to our expectations, however, domiciled and homeless patientspresent for emergency psychiatric treatment with equivalent levels of psychosis. Addi-tionally, both homeless and domiciled patients had almost identical demographic back-grounds such as number of past psychiatric admissions, types of diagnoses received, ratesof substance abuse comorbidity, and marital and employment status. This overlap sug-gests that the two groups cannot be distinguished easily by psychiatric diagnosis, severityof psychosis, or social-occupational functioning. The groups differed, however, by the

Table 4Correlations of Social Support and Psychopathology Measures for Homeless and DomiciledPatients

MSPSS

BPRS Friends FamilySignificant

Other Total

Thought Disturbance 2.20 (2.62**) 2.03 (2.60**) 2.27 (2.76**) 2.12 (2.73**)Anergia 2.33 (2.41) 2.17 (2.20) 2.27 (.20) 2.36 (2.10)Anxiety/Depression .11 (2.21) 2.31 (.01) .01 (2.61*) .10 (2.40)Hostility 2.38 (2.29) 2.28 (.04) 2.19 (2.15) 2.23 (2.12)Activation 2.22 (2.38) .00 (2.39) 2.23 (2.20) 2.36 (2.25)Total 2.27 (2.49*) 2.23 (2.30) 2.21 (2.53**) 2.24 (2.49*)

Note. Correlations for domiciled patients are presented in parentheses.* 5 significant at .05 level.** 5 Fisher’sZ significant at .05 level.

Social Support, Psychopathology, and Homelessness 1131

differential association between their psychopathology and social support and by theseverity of hostility and negative symptoms.

Specifically, for domiciled patients, appraisal of existing social networks was highlyrelated to their clinical presentation. In general, less social support predicted increasedpsychopathology, particularly psychotic symptoms. Homeless patients’ clinical symp-toms, although as common and severe, were unassociated with their perceived level ofsocial support. The differential correlational pattern between the two groups suggests thatperceived levels of social support may, in part, mediate domiciled patients’ psychiatricsymptomatology, but not homeless patients’ symptomatology. It appears that domiciledpatients’ symptoms may be more reactive to fluctuations in perceived social support,wherein observed lapses in social networks lead to increased expression of psychopathol-ogy. This association is consistent with past reports that found domiciled psychiatricpatients with low levels of social support exhibited increased severity of illness, poorerillness course, and poorer treatment outcome than patients with adequate social networks(Lehman et al., 1995; Surtees & Ingham, 1980). It may be the case for domiciled psy-chiatric patients who frequently relapse that social support serves as a protective factorfrom the adverse effects of stressful events rather than toward maintaining a state ofwell-being or a symptom-free mental state (Cohen & Wills, 1985).

Homeless patients’ psychiatric symptomatology, in contrast, appears to be indepen-dent from their perceived level of social support. This finding suggests homeless patients’clinical symptomatology may not be as reactive to psychological factors as their domi-ciled counterparts. This suggestion is further supported by the differential symptom pre-sentation exhibited by the two groups. As noted previously, the homeless patients showedsignificantly more negative symptoms than domiciled patients. Negative symptoms havelong been hypothesized to be stable over time, associated with earlier onset, and to bebiologically mediated (for a review see Andreasen, Paradiso, & O’Leary, 1998). It maybe the case that patients who exhibit elevated negative symptoms and are less reactive toprotective environmental influences, like social support, represent a distinct subgroup ofpatients who are at increased risk for homelessness.

This discussion, however, must be regarded cautiously because of the limitations ofthe correlational research design. It may be the case, for example, that homeless patientsexhibit less social support and more negative symptoms as a consequence of being home-less. Another limitation of the present report is that the small sample size may havereduced power to detect other differences between groups. Longitudinal reports examin-ing factors that predict homelessness in a large cohort of psychiatric patients are neededto further identify symptom dimensions that predict patients most vulnerable to becom-ing homeless. If the present findings are confirmed by future studies, it suggests that acertain subgroup of patients that are less reactive to positive environmental influencesand presents with more severe and refractory symptoms are at increased risk for becom-ing homeless.

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