8-10 pages See attachment and Instructions

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2117722

An increased risk of homeless- ness among persons with mental illness has been noted

for many years (1). However, the rea- sons for this increase—and appropri- ate solutions to the problem—are still being debated (2–4). Some argue that vulnerability to homelessness in this group is the result of the symptoms of mental illness (3,5). Symptoms such as persecutory delusions, auditory hallucinations, bizarre behavior, and neglect of personal hygiene interfere

with normal interpersonal relation- ships and cause conflicts with house- mates and landlords. According to this view, mental illness represents a specific vulnerability factor for home- lessness, and the reasons for home- lessness among persons with mental illness are different from those in oth- er groups.

Yet homeless persons with mental illness often attribute their housing problems to economic and social fac- tors rather than to their psychiatric

problems (6,7), a view that is also shared by some investigators (4,8). From this point of view, poverty, stig- ma, and limited job opportunities are at the root of homelessness among persons with mental illness, as they are in other vulnerable social groups. According to this view, mental illness represents a general vulnerability fac- tor for homelessness, and the reasons for homelessness among persons with mental illness are mostly the same as in other groups (4).

These contrasting views have dif- ferent implications for policy and service planning. The specific vulner- ability hypothesis calls for more in- vestment in psychiatric treatment of homeless persons who have mental illness (9) and for a linear or step-by- step housing program that requires treatment of psychiatric and sub- stance use problems before inde- pendent housing is provided (10,11). The general vulnerability hypothesis, on the other hand, calls for the same structural solutions to the problem of homelessness for persons with mental illness as for other vulnerable groups (8,12), such as increasing the avail- ability and accessibility of low-cost housing (13,14).

Better understanding of the rea- sons for loss of housing among per- sons with mental illness could in- form this debate. If these individu- als lose their housing because of a distinct set of factors related to symptoms of mental illness, such as disturbed behavior and interperson- al conflict, then the specific vulnera- bility hypothesis would be support- ed. However, if the immediate rea- sons for homelessness among per- sons with mental illness are mostly

Perceived Reasons for Loss of Housing and Continued Homelessness Among Homeless Persons With Mental Illness RRaammiinn MMoojjttaabbaaii,, MM..DD..,, PPhh..DD..

Dr. Mojtabai is affiliated with the department of psychiatry of Beth Israel Medical Cen- ter in New York City. Send correspondence to him at 10 Waterside Plaza, Apartment 5J, New York, New York 10010 (e-mail, [email protected]).

Objective: The objective of this study was to examine the reasons for the most recent loss of housing and for continued homelessness as perceived by homeless persons with mental illness. Methods: A total of 2,974 cur- rently homeless participants in the 1996 National Survey of Homeless Assistance Providers and Clients (NSHAPC) were asked about the rea- sons for their most recent loss of housing and continued homelessness. The responses of participants who had mental illness, defined both broadly and narrowly, were compared with responses of those who were not mentally ill. The broad definition of mental illness was based on a set of criteria proposed by NSHAPC investigators. The narrow definition in- cluded past psychiatric hospitalization in addition to the NSHAPC crite- ria. Results: A total of 1,620 participants (56 percent) met the broad def- inition of mental illness, and 639 (22 percent) met the narrow definition; 1,345 participants (44 percent) did not meet any of these criteria and were categorized as not having a mental illness. Few differences in rea- sons for the most recent loss of housing were noted between the partic- ipants with and without mental illness. Both groups attributed their con- tinued homelessness mostly to insufficient income, unemployment, and lack of suitable housing. Conclusions: Homeless persons with mental ill- ness mostly report the same reasons for loss of housing and continued homelessness as those who do not have a mental illness. This finding sup- ports the view that structural solutions, such as wider availability of low- cost housing and income support, would reduce the risk of homelessness among persons with mental illness, as among other vulnerable social groups. (Psychiatric Services 56:172–178, 2005)

moj2.qxd 1/19/2005 11:06 AM Page 172

similar to those among non–mental- ly ill homeless persons, then the general vulnerability hypothesis would be supported.

The study reported here used data from the National Survey of Home- less Assistance Providers and Clients (NSHAPC) (15) to test these con- trasting hypotheses. Two specific questions were addressed. First, how do the perceived reasons for the most recent loss of housing differ between persons who are mentally ill and those who are not? Second, how do the perceived reasons for continued homelessness differ between these two groups?

Methods The NSHAPC methods have been described in detail elsewhere (15– 18). Briefly, a nationally representa- tive sample of more than 4,200 per- sons who used homeless services in 52 metropolitan and 24 nonmetropol- itan areas in the United States be- tween October 18 and November 14, 1996, was randomly selected and sur- veyed; the response rate was 96 per- cent. Services included emergency shelters, transitional housing pro- grams, permanent housing programs for homeless persons, migrant work- ers’ camps, centers for distribution of vouchers for shelter, soup kitchens, food pantries, drop-in centers, mobile food programs, and street outreach programs. Six to eight clients were in- terviewed in person during each of approximately 700 program visits. Semistructured interviews were con- ducted by trained Census Bureau field-workers. Each interview lasted about 45 minutes, and participants were paid $10 for their participation. NSHAPC was funded by the U.S. Census Bureau.

Participants This article focuses on 2,974 current- ly homeless NSHAPC participants. Participants were rated as currently homeless if they reported staying in an emergency shelter, a transitional housing program, a hotel or motel paid for by a shelter voucher, an aban- doned building, a place of business, a car or another vehicle, or any other nonresidential space on the day of the survey or during the seven-day period

before being interviewed; reported that the last time they had a place of their own for at least 30 days in the same place was more than seven days ago; said that their last period of homelessness ended within the previ- ous seven days; were identified for in- clusion in the NSHAPC client survey at an emergency shelter or a transi- tional housing program, or at a vouch- er distribution program, but only if there was at least one other indicator of current homelessness; reported getting food from the shelter where they lived within the previous seven days; or reported staying in their own

or someone else’s place on the day of the interview but said they “could not sleep there for the next month with- out being asked to leave.”

Assessments Mental illness. Accurate diagnosis of mental illness in surveys of home- less populations is difficult (19–21). Following the suggestion of Susser and colleagues (20), two methods for defining mental illness were used in this study: a broad definition based on meeting the NSHAPC criteria for lifetime mental illness, used in previ-

ous NSHAPC reports (16,18), and a narrow definition that requires meet- ing the NSHAPC criteria for lifetime mental illness and a history of psychi- atric hospitalization. NSHAPC crite- ria include scoring at least .25 on the psychiatric problems domain of the Addiction Severity Index (ASI) (22), ever having been treated for psychi- atric problems, ever having taken prescribed medications for psychi- atric problems, having any history of treatment and at least one ASI psy- chiatric problem, and having stayed in a psychiatric hospital or a group home for persons with mental illness. Meeting any of these criteria qualifies for the designation of mentally ill in the NSHAPC.

The NSHAPC criteria also include self-report of “a mental health condi- tion” as the most important factor contributing to the individual’s contin- ued homelessness. However, because this study examined perceived reasons for continued homelessness among mentally ill persons, this criterion was not used for defining mental illness.

The ASI is a semistructured inter- view for assessing problems in seven domains—psychiatric, medical, legal, employment, family and social, illicit drug abuse, and alcohol abuse. Rat- ings on psychiatric problems, drug abuse, and alcohol abuse were used in this study. The psychometric proper- ties of ASI ratings in various popula- tions have been extensively studied and were generally found to be in the acceptable range (22–29). For exam- ple, in a sample of homeless persons, the alpha coefficients of internal con- sistency for ratings of psychiatric problems, alcohol abuse, and drug abuse were .89, .87, and .70, respec- tively (28). Also, ratings on these do- mains correlated strongly and specifi- cally with other measures of each do- main. For example, for psychiatric problems, the correlation coefficients with the Beck Depression Inventory (30) exceeded .50 and with the 90- Item Symptom Checklist (SCL-90) (31) exceeded .60.

Alcohol and drug abuse. Alcohol and drug abuse were rated on the ba- sis of the NSHAPC criteria. Past- month alcohol abuse is ascertained by the NSHAPC when any of the follow- ing criteria are met: a score of at least

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2 117733

According

to one view,

mental illness represents

a specific vulnerability

factor for homelessness, and

the reasons for homelessness

among persons with

mental illness are

different from those

in other

groups.

moj2.qxd 1/19/2005 11:06 AM Page 173

.17 on the ASI alcohol abuse domain, treatment for alcohol abuse during the previous month, getting drunk at least three times a week during the previous month, and having any his- tory of treatment and drinking at least

three times a week during the previ- ous month. Past-year and lifetime al- cohol abuse were defined similarly by extending the time qualifiers. Persons who reported at least three alcohol- related difficulties during their life-

time from a list of eight difficulties adopted from the Michigan Alco- holism Screening Test (MAST) (32) were also categorized as having a life- time alcohol problem.

Past-month drug abuse is ascer- tained by the NSHAPC when any of the following criteria are met: a score of at least .10 on the ASI drug abuse domain, treatment for drug abuse in the previous month, current intra- venous drug use, and use of drugs at least three times a week during the previous month. Past-year and life- time drug abuse were defined simi- larly by extending the time qualifiers. Individuals who reported having at least three drug-related difficulties during their lifetime from a list of eight that were adopted from the Drug Abuse Screening Test (DAST) (33) were also rated as having a life- time drug problem.

Medical conditions. Ratings of medical conditions were based on self-reports of diabetes, anemia, hy- pertension, heart disease or stroke, liver disease, arthritis, cancer, and HIV infection or AIDS.

Perceived reasons for loss of housing and homelessness. The study participants were asked about 32 reasons for leaving the last place of their own, such as a house, apart- ment, room, or other housing where they stayed for at least 30 days. They were then asked to identify which was the main reason. For this study, the responses were categorized by the au- thor into five broad categories, de- scribed in the box on this page: finan- cial problems, interpersonal prob- lems, health-related reasons, drug and alcohol abuse, and miscellaneous reasons. Categorization of these items by a second mental health researcher who was blinded to the aims of the study and the author’s original catego- rization produced very similar results (88 percent agreement, kappa=.83, p<.001). Respondents were also asked to select the most important reason for their continued homeless- ness from a list of ten reasons.

Statistical analysis Two sets of analyses were conducted. First, sociodemographic and clinical characteristics of the study partici- pants with mental illness and those

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2117744

RReeaassoonnss ffoorr lloossss ooff hhoouussiinngg aanndd ccoonnttiinnuueedd hhoommeelleessssnneessss aammoonngg ccuurrrreennttllyy hhoommeelleessss ppaarrttiicciippaannttss iinn tthhee NNaattiioonnaall SSuurrvveeyy ooff HHoommeelleessss AAssssiissttaannccee PPrroovviiddeerrss aanndd CClliieennttss

Reason for most recent loss of housing Financial problems

Couldn’t pay the rent Lost your job or the job ended Rent increased and you couldn’t afford to pay it Someone who paid the rent or mortgage stopped paying it Lost welfare or other cash assistance benefit Not enough money for habitation

Interpersonal problems You or your children were abused or beaten; violence in the household Pushed out or kicked out Didn’t get along with people there The people you were staying with asked you to leave The landlord made you leave Moved out because of a problematic relationship or the end of a

relationship with a partner or relative Had roommate or landlord problems

Health-related reasons Went into a hospital or a treatment program HIV, AIDS, or AIDS-related complex (ARC) Was pregnant or had just had a baby Became sick or disabled (other than ARC or AIDS related)

Drug or alcohol abuse Was drinking Was taking drugs

Miscellaneous reasons Had a problem with the residence or the area in which the residence

is located Was displaced because the building was condemned, destroyed, or

subject to urban renewal The lease expired or the building was sold Was looking for work or was forced to relocate to keep your current job Had problems abiding by the rules of the current residence or program

time ran out Was released, dismissed, or discharged Moved in with a significant other, a friend, or a relative Death or illness in the family Went to jail or prison Went into the military Left town Needed a change of scenery or climate Other reasons

Reason for continued homelessness Insufficient income Lack of employment Lack of suitable housing Drug or alcohol addiction Insufficient education, skills, or training Physical condition or disability Mental health condition Family or domestic instability Insufficient services or lack of information about available services Other reasons

moj2.qxd 1/19/2005 11:06 AM Page 174

without mental illness were com- pared. Second, the perceived reasons for the most recent loss of housing and continued homelessness were compared among these two groups by using a series of binary logistic regres- sions in which mental illness was the dependent variable and the reasons for loss of housing and continued homelessness were the independent variables. Each category of reasons for loss of housing was rated dichoto- mously: 1 if a reason in that category was reported by the participant and 0 if not. Analyses adjusted for sociode- mographic and clinical characteristics that had been found to be significant- ly different between groups in the first set of analyses.

Statistically significant logistic re- gression coefficients associated with any of the reasons for the most recent loss of housing or for continued homelessness would indicate signifi- cant differences between the study participants who were mentally ill and those who were not mentally ill on that reason or category of reasons. If individuals with mental illness lose their housing or remain homeless for a distinct set of reasons related to symptoms of mental illness, such as disturbed behavior and interpersonal conflict, the regression coefficients associated with these reasons would be statistically significant. In contrast, if the reasons for loss of housing and continued homelessness are similar between persons who are mentally ill and those who are not, few or none of the regression coefficients would be statistically significant.

Analyses were conducted once by using the broad definition of mental illness and another time by using the narrow definition. The comparison group of persons without mental ill- ness for both analyses comprised the study participants who did not meet the broad criteria for mental illness.

Probability weights provided by the Census Bureau were used in all analy- ses to make percentages nationally representative. The complex sampling design of the NSHAPC requires ad- justment using design elements (stra- ta and primary sampling units). How- ever, because of confidentiality con- cerns, these data are not made avail- able. Instead, the Census Bureau rec-

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2 117755

TTaabbllee 11

Characteristics of currently homeless persons with and without a lifetime history of mental illness in the National Survey of Homeless Assistance Providers and Clients

Mental illness No mental illness Broadly defined Narrowly defined (N=1,354) (N=1,620) (N=639)

Variable N %a N %a Zb N %a Zb

Age (years) 17 to 29 250 21 383 22 136 20 30 to 49 842 63 995 65 395 66 50 or older 228 16 206 12 .54 94 14 .09

Gender Male 985 71 1,028 65 405 58 Female 367 30 591 35 .69 234 42 1.28

Race or ethnicity Non-Latino white 447 33 732 47 1.78 317 56 2.33∗

Non-Latino black 679 45 596 35 1.32 220 29 1.85 Latino 156 10 184 11 .33 62 12 .31 Native American 52 11 82 6 .89 35 4 1.47 Other 17 1 22 1 .58 5 1 .54

Locale Urban 1,029 64 1,266 74 1.28 501 64 .06 Suburban or urban fringe 192 21 218 19 .24 92 29 .78 Rural 133 15 136 7 1.51 46 7 1.14

Education Did not finish high school 491 40 585 37 .39 220 34 .56 High school or equivalent 481 38 531 32 .83 210 34 .4 Any college 380 23 496 32 1.37 206 32 1.15

Veteran status 302 23 361 22 .16 163 22 .18 Any incarceration of more

than five days’ duration 675 51 942 56 .7 382 52 .16 Number of lifetime homeless episodes of at least 30 days

One 711 55 641 46 217 38 Two or three 324 26 426 30 180 32 Four to ten 192 17 346 19 147 24 Ten or more 36 2 70 5 1.21 30 6 1.93

Duration of current episode of homelessness

Less than a week 29 6 40 5 17 4 A week to a month 88 9 93 7 30 6 One to three months 259 17 265 14 99 12 Four to six months 166 11 185 11 74 14 Seven to 12 months 243 14 280 16 102 18 13 to 24 months 156 18 212 14 78 9 25 to 60 months 110 7 165 13 60 8 Five years or more 178 19 242 21 .87 110 28 .97

Number of medical conditions

None 831 66 695 45 266 48 One 325 22 441 27 173 23 Two or more 198 11 484 28 3.09∗∗ 200 29 2.44∗

Alcohol or drug abuse history Lifetime 819 66 828 82 2.19∗ 309 79 .89 One year 929 51 1,340 65 1.83 410 59 .79 One month 700 42 1,054 55 1.66 532 50 1.16

a Weighted percentages. The percentages may not add up to 100 percent because of rounding error.

b Z test for comparison of participants with and without mental illness. For categorical (nonordinal) variables, each category was compared with all other categories combined.

∗p<.05 for comparison with participants with no mental illness ∗∗p<.01 for comparison with participants with no mental illness

moj2.qxd 1/19/2005 11:06 AM Page 175

ommended adjusting standard errors by using an approximation of the de- sign effect (square root of 3) (18). All statistical tests reported in this article are thus adjusted. Analyses were con- ducted by using the logit routine of Stata 8.0 software (34) using probabil- ity weights provided by the NSHAPC.

Results Overall, 1,620 (56 percent) of the 2,974 participants met the broad def- inition of mental illness, and 639 (22 percent) met the narrow definition. Few differences were noted between the group with mental illness and the comparison group of participants without mental illness (Table 1). Compared with those who were not mentally ill, participants who met the broad definition were more likely to have multiple medical conditions and lifetime alcohol or drug abuse; whereas participants who met the narrow definition were more likely to be non-Latino white and to have mul- tiple medical conditions.

Few differences were noted be- tween participants who were mental- ly ill, however defined, and those who were not mentally ill on the perceived reasons for loss of housing or contin- ued homelessness (Tables 2 and 3). Financial and interpersonal problems were the most commonly perceived reasons for the most recent loss of housing and insufficient income, fol- lowed by unemployment and lack of suitable housing, the most common perceived reasons for continued homelessness. Although persons with mental illness were more likely than those without mental illness to give “a mental health condition” as the rea- son for continued homelessness, only 7 percent of those who met the nar- row criteria and 4 percent of those who met the broad criteria for mental illness stated that reason.

Discussion The findings of this study are con- strained by a number of limitations. First, the data are based on self-re-

port. Errors and biases in causal attri- bution are common with self-report- ed data, especially among individuals with severe mental disorders, who may lack insight into their illness and its social impact (35). To further ex- plore this possibility, the perceived reasons for the most recent loss of housing were examined among partic- ipants who stated that mental illness was the main reason for their contin- ued homelessness. Presumably, these individuals have more insight into the relationship between their illness and homelessness. However, even in this group, 28 percent reported financial problems as the major reason for the most recent loss of housing, 19 per- cent reported interpersonal prob- lems, 12 percent reported health problems, and 17 percent reported al- cohol and drug abuse. Nevertheless, reliance on self-report and lack of ob- jective measures remain the major limitation of this study.

Second, the use of the same correc- tion method for standard errors ob- tained in the different analyses might have inordinately reduced the power of some of the statistical tests. Thus the results of the statistical analyses should be viewed with caution. Third, the sampling frame of the NSHAPC included institutions that typically serve chronically homeless individuals. Furthermore, the NSHAPC was a prevalence survey. Persons with longer episodes of homelessness are overrep- resented in prevalence samples. Thus the findings may not apply to the larg- er group of persons who experience only transient homelessness (36).

Despite these limitations, the NSHAPC data provide useful infor- mation about the chronically homeless persons who are the most vulnerable group in the homeless population. The perceived reasons for loss of housing and continued homelessness among persons with mental illness were most- ly similar to the reasons reported by those without mental illness. Only a small fraction of the mentally ill indi- viduals reported mental illness as the main reason for their continued home- lessness. These findings support the general vulnerability hypothesis.

The findings are consistent with consumer surveys of homeless indi- viduals with mental illness (7,37) in

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2117766

TTaabbllee 22

Perceived reasons for loss of housing and continued homelessness among cur- rently homeless persons with and without a lifetime history of mental illness in the National Survey of Homeless Assistance Providers and Clients

Mental illness

No mental Broadly Narrowly illness defined defined (N=1,354) (N=1,620) (N=639)

Reasons N %a N %a N %a

Main reason for the most recent loss of housing

Financial problems 497 38 470 33 162 20 Interpersonal problems 304 22 469 29 189 34 Health-related reasons 39 4 91 7 53 15 Drug or alcohol abuse 92 10 136 11 50 13 Miscellaneous reasons 324 26 367 19 144 18

Most important reason for continued homelessness

Insufficient income 409 31 446 28 168 28 Lack of employment 365 28 307 22 94 15 Lack of suitable housing 137 13 141 10 58 9 Drug or alcohol addiction 117 7 153 10 60 11 Insufficient education, skill, or training 22 2 50 4 16 6 Physical condition or disability 20 2 61 4 24 3 Mental health condition 2 <1 93 4 67 7 Family or domestic instability 13 1 32 2 13 3 Insufficient services or lack of

information about services 12 1 30 1 13 2 Other 160 14 210 15 80 18

a Weighted percentages. The percentages may not add up to 100 percent because of rounding error.

moj2.qxd 1/19/2005 11:06 AM Page 176

which the participants attribute their success or failure in obtaining and maintaining housing more to financial factors and housing availability than to mental illness and its treatment. The findings are also consistent with results of recent studies of risk factors of homelessness among persons with mental illness (12,38). Comparing homeless and nonhomeless individu- als who had mental illness and those who did not, Sullivan and colleagues (12) concluded that mental illness does not represent a “distinctive path- way to homelessness,” but rather an added disadvantage.

However, the findings are at odds with the results of a number of other studies (5,39) that showed a specific association between symptoms of mental illness and homelessness. These studies may have focused on individuals who had more severe ill- nesses, for whom mental health prob- lems may be more significant deter- minants of housing instability (40). The divergent results of the studies

may also be due to differences in raters’ perspectives (41). Studies based on providers’ assessment (5,39) often indicate a larger role for psychi- atric factors than studies based on self-report (4,7,37).

Conclusions Findings from this study support the general vulnerability hypothesis for loss of housing and continued home- lessness among the homeless mental- ly ill. Treatment of mental illness and substance use disorders is only one of the needs of these individuals. To achieve housing stability, some men- tally ill individuals may need assis- tance in obtaining public benefits. Others may need third-party money management (42), vocational assis- tance (43), and, on occasion, media- tion to resolve emerging conflicts with housemates or landlords. These elements have been successfully im- plemented in case management pro- grams designed specifically for home- less individuals with severe and per-

sistent mental disorders (44). While anticipating implementation of such comprehensive case management programs in various health care and social agencies that serve the home- less mentally ill, these individuals could benefit from wider availability of low-cost housing, improved job op- portunities, and income support pro- grams (45)—the same structural ini- tiatives that have been proposed to prevent homelessness in other vul- nerable social groups.

The predominant service delivery models in many large urban areas make mental health and substance abuse treatment a prerequisite for housing placement. These service de- livery models imply that mental ill- ness is a specific vulnerability factor for homelessness. However, the re- sults of this study support alternative service delivery models that do not distinguish between the housing needs of persons with and without mental illness and in which access to housing is not contingent on receipt

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2 117777

TTaabbllee 33

Results of logistic regression analysis of perceived reasons for loss of housing and continued homelessness among currently homeless persons with and without a lifetime history of mental illness in the National Survey of Homeless Assistance Providers and Clients

Broadly defined mental illness ver- Narrowly defined mental illness ver- sus no mental illness (N=2,967) sus no mental illness (N=1,990)

Adjusted Adjusted Reasonsa βb Z OR βb Z OR

Main reason for most recent loss of housing Financial problems –.103 .29 .90 –.755 1.58 .47 Interpersonal problems .554 1.67 1.74 .670 1.61 1.95 Health-related reasons .711 .64 2.04 1.408 1.21 4.09 Drug and alcohol abuse .119 .23 1.13 .270 .51 1.31 Miscellaneous reasons –.241 .72 .79 –.298 .70 .74

Most important reason for continued homelessness

Insufficient income –.104 .29 .9 –.270 .62 .76 Lack of employment –.294 .74 .75 –.691 1.02 .50 Lack of suitable housing –.372 .77 .69 .419 .70 .66 Drug or alcohol addiction .201 .42 1.22 .192 .36 1.21 Insufficient education, skills, or training .954 1.13 2.59 1.465 1.44 4.33 Physical condition or disability –.128 .15 .88 –.649 .58 .52 Mental health condition 4.33 2.88∗∗ 76 5.125 3.3∗∗ 168.2 Family or domestic instability .450 .42 1.57 .892 .84 2.44 Insufficient services or lack of information

about services .219 .17 1.24 .788 .62 2.2 Other .207 .42 1.23 .438 .87 1.55

a Each entry represents the results of a separate regression model. b Unstandardized regression coefficient obtained in multiple logistic regressions adjusting for race or ethnicity, number of medical

conditions, and lifetime history of alcohol or drug abuse ∗∗p<.01

moj2.qxd 1/19/2005 11:06 AM Page 177

of mental health or substance abuse treatment. The results of recent stud- ies that compared these models fur- ther support the benefits of direct-ac- cess service models (46,14). ♦

References

1. Susser E, Moore R, Link B: Risk factors for homelessness. Epidemiological Review 15:546–556, 1993

2. Draine J, Salzer MS, Culhane DP, et al: Role of social disadvantage in crime, job- lessness, and homelessness among persons with serious mental illness. Psychiatric Ser- vices 53:565–573, 2002

3. Nelson SH: A second opinion. Psychiatric Services 53:573, 2002

4. Cohen CI, Thompson KS: Homeless men- tally ill or mentally ill homeless? American Journal of Psychiatry 149:816–823, 1992

5. Lamb HR, Lamb DM: Factors contribut- ing to homelessness among the chronically and severely mentally ill. Hospital and Community Psychiatry 41:301–305, 1990

6. Roth D, Bean GJ Jr: New perspectives on homelessness: findings from a statewide epidemiological study. Hospital and Com- munity Psychiatry 37:712–719, 1986

7. Tanzman B: An overview of surveys of men- tal health consumers’ preferences for hous- ing and support services. Hospital and Community Psychiatry 44:450–455, 1993

8. Mossman D, Perlin ML: Psychiatry and the homeless mentally ill: a reply to Dr Lamb. American Journal of Psychiatry 149:951– 957, 1992

9. Lamb HR: Will we save the homeless men- tally ill? American Journal of Psychiatry 147:649–651, 1990

10. Outcasts on Main Street: Report of the Federal Task Force on Homelessness and Severe Mental Illness. DHHS pub ADM 92-1904. Washington, DC, Interagency Council on the Homeless, 1992

11. Korman H, Engster D, Milstein B: Hous- ing as a tool of coercion, in Coercion and Aggressive Community Treatment. Edited by Dennis D, Monahan J. New York, Plen- um, 1996

12. Sullivan G, Burnam A, Koegel P: Pathways to homelessness among the mentally ill. So- cial Psychiatry and Psychiatric Epidemiolo- gy 35:444–450, 2000

13. Tsemberis S, Eisenberg RF: Pathways to housing: supported housing for street- dwelling homeless individuals with psychi- atric disabilities. Psychiatric Services 51: 487–493, 2000

14. Metraux S, Marcus SC, Culhane DP: The New York–New York housing initiative and use of public shelters by persons with se- vere mental illness. Psychiatric Services 54:67–71, 2003

15. US Department of Housing and Urban Development: Homelessness: Programs and the People They Serve: Summary. Dec

1999. Available at www.huduser.org/public ations/homeless/homelessness/contents.html

16. US Department of Housing and Urban De- velopment: Homelessness: Programs and the People They Serve: Technical Report. Dec 1999. Available at www.huduser.org/ publications/homeless/homeless_tech.html

17. US Census Bureau: National Survey of Homeless Assistance Providers and Clients (NSHAPC). Technical Documentation. March 2000. Available at www.census. gov/prod/www/nshapc/nshapc4b.html

18. Kushel MB, Vittinghoff E, Haas JS: Factors associated with the health care utilization of homeless persons. JAMA 285:200–206, 2001

19. Robertson MJ: The prevalence of mental disorders among the homeless, in Home- lessness: A Prevention-Oriented Approach. Edited by Jahiel RI. Baltimore, Johns Hop- kins University Press, 1992

20. Susser E, Conover S, Struening EL: Prob- lems of epidemiological method in assess- ing the type and extent of mental illness among homeless adults. Hospital and Com- munity Psychiatry 40:261–265, 1989

21. Bellavia CW, Toro PA: Mental disorder among homeless and poor people: a com- parison of assessment methods. Communi- ty Mental Health Journal 35:57–67, 1999

22. McLellan AT, Luborsky L, Woody GE, et al: An improved diagnostic evaluation in- strument for substance abuse patients: the Addiction Severity Index. Journal of Ner- vous and Mental Disease 168:26–33, 1980

23. McLellan AT, Kushner H, Metzger D, et al: The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treat- ment 9:199–213, 1992

24. McLellan AT, Luborsky L, Cacciola J, et al: New data from the Addiction Severity In- dex: reliability and validity in three centers. Journal of Nervous and Mental Disease 173:412–423, 1985

25. Alterman AI, Brown LS, Zaballero A, et al: Interviewer severity ratings and composite scores of the ASI: a further look. Drug and Alcohol Dependence 34:201–209, 1994

26. Hodgins DC, El-Guebaly N: More data on the Addiction Severity Index: reliability and validity with the mentally ill substance abuser. Journal of Nervous and Mental Dis- ease 180:197–201, 1992

27. Cary KB, Cocco KM, Correia CJ: Reliabili- ty and validity of the Addiction Severity In- dex among outpatients with severe mental illness. Psychological Assessment 9:422– 428, 1997

28. Zanis DA, McLellan AT, Canaan RA, et al: Reliability and validity of the Addiction Severity Index with a homeless sample. Journal of Substance Abuse Treatment 11:541–548, 1994

29. Argeriou M, McCarty D, Mulvey K, et al: Use of the Addiction Severity Index with homeless substance abusers. Journal of Substance Abuse Treatment 11:359–365, 1994

30. Beck AT, Ward CH, Mendelson M, et al:

An inventory for measuring depression. Archives of General Psychiatry 4:53–63, 1961

31. Derogatis LR, Lipman RS, Covi L: The SCL-90: an outpatient psychiatric rating scale. Psychopharmacology Bulletin 9:13– 28, 1973

32. Moore R: The diagnosis of alcoholism in a psychiatric hospital: a trial of the Michigan Alcoholism Screening Test (MAST). Amer- ican Journal of Psychiatry 128:1565–1569, 1972

33. Skinner HA: The Drug Abuse Screening Test. Addictive Behavior 7:363–371, 1982

34. StataCorp: Stata Release 8.0 User’s Guide. College Station, Tex, 2003

35. Amador XF, Flaum M, Andreasen NC, et al: Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives of General Psychiatry 51:826–836, 1994

36. Link BG, Susser E, Stueve A, et al: Life- time and five-year prevalence of homeless- ness in the United States. American Journal of Public Health 84:1907–1912, 1994

37. Crowded Out: Homelessness and the El- derly Poor. New York, Coalition for the Homeless, 1984

38. Odell SM, Commander MJ: Risk factors for homelessness among people with psychotic disorders. Social Psychiatry and Psychiatric Epidemiology 35:396–401, 2000

39. Gelberg L, Linn LS, Leake BD: Mental health, alcohol and drug use, and criminal history among homeless adults. American Journal of Psychiatry 145:191–196, 1988

40. Clark C, Rich AR: Outcomes of homeless adults with mental illness in a housing pro- gram and in case management only. Psychi- atric Services 54:78–83, 2003

41. Rosenheck R, Lam JL: Homeless mentally ill clients’ and providers’ perceptions of service needs and clients’ use of services. Psychiatric Services 48:381–386, 1997

42. Elbogen EB, Swanson JW, Swartz MS, et al: Characteristics of third-party money management for persons with psychiatric disabilities. Psychiatric Services 54:1136– 1141, 2003

43. Min S-Y, Wong YLI, Rothbard AB: Out- comes of shelter use among homeless per- sons with serious mental illness. Psychiatric Services 55:284–289, 2004

44. Susser E, Valencia E, Conover S, et al: Pre- venting recurrent homelessness among mentally ill men: a ‘critical time’ interven- tion after discharge from a shelter. Ameri- can Journal of Public Health 87:256–262, 1997

45. Meyer IH, Schwartz S: Social issues as pub- lic health: promise and peril. American Journal of Public Health 90:1189–1191, 2000

46. Tsemberis S, Gulcur L, Nakae M: Housing first: consumer choice and harm reduction for homeless individuals with a dual diag- nosis. American Journal of Public Health 94:651–656, 2004

PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ February 2005 Vol. 56 No. 2117788

moj2.qxd 1/19/2005 11:06 AM Page 178

<< /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Gray Gamma 1.8) /CalRGBProfile () /CalCMYKProfile (U.S. Sheetfed Uncoated v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel 1.3 /CompressObjects /Off /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket true /DefaultRenderingIntent /Default /DetectBlends true /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedJobOptions true /DSCReportingLevel 0 /SyntheticBoldness 1.00 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams true /MaxSubsetPct 100 /Optimize false /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage false /PreserveEPSInfo true /PreserveHalftoneInfo true /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Preserve /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile (Color Management Off) /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /DownsampleColorImages false /ColorImageDownsampleType /Average /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /DownsampleGrayImages false /GrayImageDownsampleType /Average /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /DownsampleMonoImages false /MonoImageDownsampleType /Average /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError false /PDFXTrimBoxToMediaBoxOffset [ 0.50000 0.50000 0.50000 0.50000 ] /PDFXSetBleedBoxToMediaBox false /PDFXBleedBoxToTrimBoxOffset [ 0.12500 0.12500 0.12500 0.12500 ] /PDFXOutputIntentProfile (None) /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /Unknown /Description << /DEU <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> /FRA <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> /JPN <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> /PTB <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> /DAN <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> /NLD <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> /ESP <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> /SUO <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> /ITA <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> /NOR <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> /SVE <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> /ENU <FEFF004300610064006d007500730020004d00650064006900610057006f0072006b0073002000730065007400740069006e00670073002000760065007200730069006f006e00200043004d0057005f0041006300720036005f00560032002e002000200041006c006c002000730065007400740069006e0067007300200070006f00730074006500640020006f006e0020007700770077002e006300610064006d00750073006d00650064006900610077006f0072006b0073002e0063006f006d002e00200020> >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice