From the Editor

For much of her admission, she was disorganized and, at times, agitated. But when the medications started to work, Tanya talked about her years of homelessness and the stresses of finding a warm place to stay on a cold night, which often involved sleeping on buses – and “that’s not easy, I’m almost elderly.” 

This week, we take a closer look at homelessness and mental illness.

In the first selection, Richard Barry (of the University of Calgary) and his co-authors describe a systematic review and meta-analysis of mental disorders and homelessness for JAMA Psychiatry. They included 85 studies involving more than 48 000 people globally. “The findings demonstrate that most people experiencing homelessness have mental health disorders.” We explore the paper and its implications.

Street art in Quebec City

In the second selection, Nick Kerman and Dr. Vicky Stergiopoulos (both of the University of Toronto) examine different aspects of homelessness. In a comprehensive review for Nature Mental Health, they analyze the origins of the problem in high-income nations: focusing on deinstitutionalization. They also point to a way forward, noting the successes of Housing First and other interventions. “Homelessness among people with mental illness is a prevalent and persisting problem.”

And in the third selection, Shannon Jones writes about her son, who was homeless, in a deeply personal essay for The Washington Post. She discusses his childhood and the trips they took as a family. Also, she describes his illness and his death. “There are an estimated 600,000 homeless people in America, 75,000 of them in Los Angeles County. The number who die each year is increasing, with drug overdoses the leading cause. And every one of them has a story.”


Selection 1: “Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness: A Systematic Review and Meta-Analysis

Richard Barry, Jennifer Anderson, Lan Tran, et al.

JAMA Psychiatry, 17 April 2024  Online First

One population with particularly high rates of mental health disorders is people experiencing homelessness… Individual factors, such as substance use, relationship conflicts, and traumatic experiences, may contribute to homelessness among people with mental health disorders. Poverty, lack of affordable housing, transitions from foster care or institutional settings, stigma, racism, and discrimination may further perpetuate homelessness for these individuals. The relationship between mental health disorders and homelessness is complex and bidirectional. Mental health disorders may lead to situations that result in homelessness, or homelessness may be a stressor contributing to the development or worsening of mental health disorder symptoms… 

While mental health disorders are common among people experiencing homelessness, to our knowledge, there are currently no meta-analyses examining the prevalence of or factors associated with mental health disorders among people experiencing homelessness globally.

So begins a paper by Barry et al.

Here’s what they did:

  • They conducted a systematic review and meta-analysis, drawing on several databases, included PubMed. 
  • Studies were included that investigated the prevalence of mental health disorders among people experiencing homelessness aged 18 years and older. 
  • They excluded studies on suicide, self-harm, cognitive impairment (except dementia), neurological disorders, and smoking.
  • The main outcome: “current prevalence of any diagnosed mental health disorder.” 
  • “Subgroup analyses were performed by sex, study year, age group, region, risk of bias, and measurement method. Meta-regression was conducted to examine the association between mental health disorders and age, risk of bias, and study year.”

Here’s what they found:

  • Among 7 729 citations, 291 underwent a full review with 85 studies included in the analysis.
  • The studies. The studies included 48 414 participants; the majority (77%) were male. Most studies were conducted in the US (36 in total), followed by Canada (8), and Germany (7).
  • Prevalence. 67% of those experiencing homelessness had mental health disorders, and the lifetime prevalence was 77%. Males experienced a significantly higher lifetime prevalence compared to females (86% vs. 69%).
  • Specific disorders. Participants had different disorders, including substance use disorder (44%), antisocial personality disorders (26%), major depression (19%), anxiety disorders (14%), posttraumatic stress disorder (11%) schizophrenia (7%), and bipolar disorder (8%).
  • Regional differences. North America had the highest prevalence of mental health disorders at 77%.
  • Time periods. Studies published after 2010 had a higher prevalence of mental health disorders compared to those published during and before that year.

A few thoughts:

1. This is an important study – the largest to report on the prevalence of mental health disorders among the homeless globally. 

2. The main finding in nine words: the majority of the homeless had mental health disorders. 

3. That finding is similar to past studies and, frankly, not at all surprising. 

4. Another finding shows a higher prevalence of mental health disorders among people experiencing homelessness more pronounced in recent studies. The authors suggest that this may be due to better access to mental health services, leading to more diagnoses.

5. The clinical implications? “Integrated interventions for mental health disorders in homeless populations are vital, focusing specifically on substance use disorder, antisocial personality disorder, major depression, and psychotic disorder.” They also consider approaches that focus on males. 

6. Like all studies, there are limitations. The authors note several including: “many studies potentially miss the so-called hidden homeless who do not access homeless services and may be living in cars or staying with friends or family.”

The full JAMA Psychiatry paper can be found here:

Selection 2: “Addressing health needs in people with mental illness experiencing homelessness”

Nick Kerman and Vicky Stergiopoulos 

Nature Mental Health, 5 April 2024

Homelessness is an extreme form of material deprivation that occurs when people do not have permanent, safe and adequate accommodations. Although there is no consensus on the types of living situation that constitute homelessness, definitions often include temporarily residing in emergency accommodations (such as shelters), living on the streets, in cars or in buildings not intended for human habitation or staying temporarily with family and friends (that is, hidden homelessness). People experiencing homelessness are also overrepresented in hospitals and jails, making these institutions central to some experiences of homelessness.

Homelessness in its various forms is an enduring social problem that is widespread in high-income countries. An estimated 2.1 million people experience homelessness every year across 36 member countries of the Organisation for Economic Co-operation and Development (OECD).

So begins a paper by Kerman and Stergiopoulos. Their review focuses on eight areas; here, we summarize four.

Mental illness and homelessness: emergence of an intractable problem

“Beginning in the 1960s, many psychiatric hospitals were closed in response to growing concerns about the poor quality of care in those facilities, emerging evidence on recovery in mental illness and advancements in psychotropic medications… Of the 559,000 state psychiatric hospital beds that existed in the USA in 1955, over 400,000 had been closed by the early 1980s. Similar reductions in psychiatric inpatient beds occurred in Canada (a 70.6% decline from 1965 to 1981) and in the UK (a 60.0% decrease from 1954 to 1990). As a result, many long-stay hospital patients with serious mental illness were discharged to community settings. This transformational shift corresponded with rising rates of homelessness among people with mental illness during these decades.”

Premature mortality among homeless people with mental illness

“Mortality rates among people experiencing homelessness are many times higher than in the general population – a finding that has been replicated in multiple high-income countries. Unsheltered homelessness further exacerbates this mortality disparity. Life-expectancy estimates differ between studies, as well as by age and gender, but people experiencing homelessness generally live 16–28 fewer years than same-aged peers in the general population.”

Living at the margins

“In all of its forms, homelessness is a period of instability and social exclusion that can precipitate and exacerbate mental illness, yielding a bidirectional relationship between the two experiences. There are several factors that impel deteriorations in mental health. First, people experiencing homelessness have ‘competing priorities’ among multiple unmet needs. This can lead to needs that are less immediate than shelter, food and safety to go unaddressed, such as healthcare. One US study found than approximately 20% of people experiencing homelessness reported a past-year unmet need for mental health services. Poor care quality, inadequate continuity, and stigma and discrimination are additional barriers to addressing mental health and addiction needs.”

They note violence. “Estimates of recent violent victimization among homeless adults with serious mental illness found prevalence rates of 45.0 and 76.7% for the past month and two months, respectively.”

Interventions for improving housing and health outcomes

They focus on four:

  • Housing First. “The intervention involves the provision of permanent housing in the form of a rental subsidy or an affordable housing unit, with accompanying community-based support such as ACT or ICM” but “no requirements for sobriety or medication adherence…” They cite evidence from Canada and France and add: “Studies have increasingly involved longer follow-up periods, demonstrating that most people continue to experience housing stability after six years.”
  • ACT. This standalone intervention is “used with homeless adults that experience serious mental illness. ACT, using multidisciplinary teams with small caseloads that offer intensive contact and 24-hour coverage, has been found to yield greater reductions in homelessness and improvements in psychiatric symptom severity compared with standard case management in randomized controlled trials.”
  • ICM. This standalone community intervention is “commonly used with homeless people who experience mental illness. ICM involves the provision of community-based supports via a case manager who has small caseloads to facilitate weekly contact and coordinate care with other service providers.” They note that on its own there are “small reductions in the number of days spent homeless compared with usual care…” 
  • CTI. This case management intervention attempts to “reduce the risk of homelessness and enhance the continuity of care during service transitions (for example, following hospital discharge or entry into housing programs from homelessness). As with ICM, CTI workers are responsible for service provision and coordination.” The evidence: “Randomized trials have found that CTI cam improve housing and service use outcomes among homeless people with serious mental illness during transition periods.”

A few thoughts:

1. This paper is comprehensive, thoughtful, and important.

2. The above summary doesn’t quite capture the nuance and detail of their review.

3. How to move forward? Ultimately, they suggest we think upstream:

“Childhood adversity, pre-existing poverty, lower educational achievement and other forms of social exclusion are prevalent among homeless people with mental illness, making upstream prevention a critical policy and intervention target. Investments to strengthen social safety nets, including more affordable housing, livable wages and income supports tied to the cost of living, will create a strong foundation for homelessness prevention among people with mental illness.”

The full Nat Ment Health paper can be found here:

Selection 3: “In 2022, I wrote about seeking my homeless son. This is the rest of his story.”

Shannon Jones

The Washington Post, 8 February 2024

It’s been three months since my son Andrey died. The grief still hits me in waves so strong I can’t breathe. But I have been grieving his loss since long before he died.

In April of 2022, I wrote in The Post about searching with my husband for Andrey on the streets of Los Angeles County. I wondered: When people saw him sleeping on the sidewalk, unkempt and disoriented, did they understand that he had a story? There was a brief period of hope when we finally found him. But then we lost him again.

Here is the tragic coda: On a chilly Monday morning in October, a passerby found Andrey’s body on a bench less than a mile from our home, a pipe in his hand.

So begins an article by Jones.

She talks about the early years. “When we adopted Andrey, we never dreamed he’d end up homeless. He had therapy and Scouts and sports and tutors and family vacations. And love. So very much love.”

She discusses his struggle with mental illness. “Andrey was 31. He battled mental illness since being diagnosed with bipolar disorder, PTSD and suspected fetal alcohol syndrome at 8, shortly after we adopted him. For more than a decade, he also battled addiction. The past few years were a hopscotch trail from group home to treatment facility to rehab to cheap motel to the streets to jail, then back through the cycle again.”

He entered into a period of sobriety. “He was in a group home with therapy and medication management and meals… We visited Andrey regularly, and we had hope. But there was no drug testing and little oversight, and Andrey began using again.” She notes an altercation with a security guard. “The police were called. I wish they had put him safely behind bars. Instead, he spent a week in L.A.’s Union Station.”

Things become worse. “In the months before he died, Andrey was extremely delusional. He told us his ‘real parents’ would be coming to get him in a spaceship.”

She looks back on happier times. “One summer, when Andrey was 10 or 11, we went snorkeling in Maui’s Honolua Bay. The brightly colored fish, beautiful coral and sea turtles drew us farther and farther into the bay. I kept asking, ‘Are you still okay?’ Andrey kept giving me a thumbs-up… We stayed there for what felt like forever. Finally, as we were swimming back, Andrey tired. So I held out my arm and let him hang on, and my buoyancy was enough to bring him safely back to shore. I wish buoyancy and love had been enough.”

“I hope where Andrey is now, he is at peace. But here on Earth, there are many others in his situation, needing help that isn’t there.”

A couple of thoughts:

1. This is a moving and raw essay.

2. It was tough to read – despite the beautiful writing, it’s so raw.

The full Wash Post article can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.