Homelessness is a significant social problem in Toronto, Canada’s largest and most ethnically diverse urban center, where approximately 29,000 individuals use shelters each year and roughly 5,000 people are homeless on any given night.
So opens this week’s Reading. The sentence is simple and direct; the facts conveyed are haunting. But this week’s Reading is ultimately a good news story. Actually, it’s a very good news story.
The Reading: “Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial” by Vicky Stergiopoulos et al., which has just been published in PLOS ONE.
Here’s a quick summary: offer the homeless housing, and they not only gain housing stability but end up drinking less and are hospitalized less.
The full paper can be found here:
This is the second Reading in 2015 about Housing First – and no wonder. It’s exciting to watch this important public-policy experiment evolve. It’s also nice to see that so much important work is being done right here in Canada.
Just to recap points I’ve made in a past Reading: for decades, the approach for helping the homeless was that they should be housing ready. That is, they need to address their mental illness and/or addiction issues and then – and only then – they can gain public housing. In recent years, though, policymakers have begun experimenting with housing first. The main idea? Many problems of the homeless actually stem from the instability of their housing. Get a person with an addiction or mental health issue into a home, and he’ll do better.
At Home/Chez Soi is a Canadian initiative. Funded by the federal government and overseen by the Mental Health Commission of Canada, the project has studied Housing First efforts in five Canadian cities. The original budget was roughly $110 million (more funding than STAR-D, CATIE, and STEP BD – three huge psychiatry projects – put together).
In this paper, Stergiopoulos et al. describe their Housing First initiative in a major Canadian city. They evaluate everything from alcohol use to ED visits.
Here’s what they did:
· Study participants met three inclusion criteria: they were 18 and over; they were “absolutely homeless” (no home for 7 days) or “precariously housed” (essentially housed in places like motels with two or more past episodes of absolute homelessness in the past year); they met criteria for a serious mental disorder.
· Recruitment ran from October 2009 to June 2011 in Toronto.
· Participants were randomized to a treatment as usual group and an intervention group (Intensive Case Management with scattered-site supportive housing; the ICM used “a recovery oriented, trauma informed approach and harm reduction principles”). In the paper, the study group is referred to as HF-ICM (Housing First-Intensive Case Management).
· The ethnicity of participants was part of the study. They were considered “racialized” if they self-identified with one of several groups (outside of Caucasians and Aboriginals or mixed).
· Follow up interviews took place up over a study period of 24 months.
· A variety of measures were used to measure physical and mental health, but also social functioning and quality of life, and health service use.
Here’s what they found:
· Study participants were primarily in their 40s (32%), male (68%), native English speakers (60%), single never-married (68%), and had no children (70%).
· Half of the participants had been born outside of Canada (50%). The majority of participants had been absolutely homeless at study start (92%), with a mean total length of homelessness of 4.7 ± 5.7 years.
· Most common diagnoses: substance dependence or abuse (46%), major depression (45%), post-traumatic stress disorder (29%) and psychotic disorder (26%). Amazingly: almost 70% reported suicidal ideation. (!)
· The study group did vastly better in terms of housing compared to the TAU group (75.1 vs. 44.2 mean percentage of days stability housed).
· And in terms of substance use: there was a significant decrease in substance problems (a 28% reduction on GAIN-SS); for alcohol, there was a significant reduction in the number of days spent experiencing alcohol problems among the HF-ICM compared to the TAU group at both 12 months and 24 months (see the graph below). (!)
· People in the HF-ICM group were less likely to be hospitalized over the study period (70.4% vs. 81.1%); ED visits, though, were similar between the groups.
· With regard to racialization, improvements in areas like physical health and number of days experiencing alcohol improvement tended to be higher among those who self-identified as a minority (though an analysis considering the intervention, time and ethnicity didn’t yield a clear result).
The authors note:
HF-ICM resulted in significant improvements in housing stability, probability of hospitalization, community functioning, and a reduction in number of days experiencing problems due to and money spent on alcohol use in an ethnically diverse sample of homeless individuals with mental illness living in a large urban metropolis.
The literature on the effectiveness of HF interventions in reducing emergency department use and hospitalizations is scarce… In our study, HF-ICM did not lead to reductions in self-reported emergency department use or number of hospitalizations, however, the proportion of participants who had 1 or more hospitalizations during the study period was significantly lower among the HF-ICM participants compared to their TAU counterparts.
A few thoughts.
1. Wow. Wow. Wow.
2. This study adds nicely to the growing Housing First literature. This is a big sample in a big city with a nicely designed study.
3. It’s difficult not to feel enthusiastic. It seems that Housing First doesn’t just achieve stable housing for people – which is obviously great – but also helps address core issues, like alcohol misuse. (!)
At Home/Chez Soi is a major project. This summary barely scratches the surface of this important work.
The Mental Health Commission of Canada has many reports from At Home/Chez Soi.
Find them here:
The JAMA paper by Stergiopoulos et al. (featured in a March Reading) can be found here:
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.