Can we end chronic homelessness?

Just a few years ago, that question would have seemed absurd. Chronic homelessness was, well, chronic. Today, a re-think of an old problem is yielding incredible results. And here’s the best part: Canadian researchers and the Mental Health Commission of Canada are playing crucial roles.

Let’s take a step back and consider the background.

Homelessness is a major issue. Tonight, roughly one hundred and fifty thousand people will be without a home in Canada. Many are chronically homeless. In this population, serious mental illness and/or addiction is all too common. Homelessness is tied to frequent use of health care and impacts life expectancy.

And, of course, there is the human tragedy of homelessness. A JAMA editorial describes this well:

Few sights are as distressing as a person living on the streets, under a freeway or in a bus shelter, in a cardboard box or a makeshift tent, pushing a wagon of possessions or draped in newspapers as protection against oncoming rain.

For years, policy makers have struggled with the issue. In the 1980s, New York Mayor Ed Koch tried to push the homeless into treatment and famously and publicly debated Joyce Patricia Brown, a mentally ill woman who slept on a subway vent. In court, her lawyers argued she had the right to defecate in public; they won the battle and she was released to the streets (though she lost the war, dying a few years later, long before her 50th birthday). In Los Angeles, a former Secretary of State was tasked with re-thinking the problem but his long report was short on ideas. North of the 49th parallel, many government and not-for-profit reports have discussed this issue; in cities like Vancouver, homelessness is much debated in municipal politics. Speeches, reports, debates. Yet nothing seemed to change.

Ed Koch

Then everything changed, and it started with a re-think.

Policymakers abandoned the old approach: that people needed to be housing ready, leaving behind their addiction, seeking treatment for their mental illness, and thus preparing themselves for housing. Instead, policymakers began experimenting with Housing First. The core idea? Put people in stable homes first, with the reasoning that stable housing will make sobriety and better mental health more realistic. From New York City to Salt Lake City, homeless have been housed, with good results. These experiments have been innovative, important – and relatively small.

At Home/Chez Soi is a Canadian effort to study this issue, part of the work of the Mental Health Commission of Canada. And their effort is huge. Think of big research studies in psychiatry – STAR-D, CATIE, and STEP BD – and consider that the initial funding of At Home/Chez Soi was larger than all of them put together at $110 million. (!!)

The Reading of the Week is the first of two papers to come out of this important project: “Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness: A Randomized Trial” by Stergiopoulos et al. (The second is in press.)

It’s a big study in a big journal – and it’s all very Canadian, from the co-authors to the funding source.

In this JAMA paper, Stergiopoulos et al. tested the effectiveness of Intensive Case Management with scattered-site supportive housing, as opposed to the more expensive Assertive Community Treatment (ACT) management and single-site supportive housing. (Note that for higher demand clients, At Home/Chez Soi also considered ACT management, the topic of their next paper.) In other words, this is a large-scale study of Housing First but with a model that is lower cost and more flexible.

Here’s what they did:

· In a randomized controlled trial involving 5 Canadian cities (Vancouver, Winnipeg, Toronto, Montreal, and Moncton), participants were assigned to the intervention or the usual care.

· Participants were recruited from shelters, drop-in centers, criminal justice program, hospitals, and other agencies/institutions serving the homeless.

· Participants had a mental illness (based on a Mini International Neuropsychiatric Interview).

· High-needs participants were assigned to an ACT team (and not part of this paper but part of the larger study). Note that the Moncton participants were followed by ACT (meaning that the JAMA paper includes data from 4, not 5, cities).

· The non-high-needs participants had weekly contact with a case manager.

Here’s what they found:

· “The primary study outcome was housing stability…”

· Over 24 months, participants in the intervention group had stable housing for a majority of the time; across all 4 sites, people in the usual care didn’t. In fact, the intervention group participants did far better than the usual care group (ranging from an adjusted mean difference of 33% to 49.5% depending on the city).

· A comment on the homeless: “depressive episode” was the most common diagnosis in almost 60% of participants; alcohol and other substance were common.

· In this population, there was no reduction in ED visits with more stable housing – but, again, the ACT population is considered in another paper. One measure of quality of life didn’t change with the intervention (though a secondary measure did).

Scattered-site supportive housing using rent supplements and ICM services led to significantly greater housing stability for homeless adults with mental illness…

This is a big result for a few reasons. First, it adds to the growing evidence that Housing First works. (!) Second, it offers a way of delivering Housing First that isn’t as expensive as the older, ACT-based model (call it Housing First on the cheap) – yet it is effective. (!) Third, with regard to health care utilization, it suggests that Housing First is important but that the model will need to evolve over time, to better address the needs of participants. For the record, this is a great problem to have, considering where we have been. (!)

Back then to the original question – can we end chronic homelessness? The results of At Home/Chez Soi suggest we can take a big step in that direction.


Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.