Term Paper, Due 2/20/15, Mental illness in relation to Homelessness.

RESEARCH AND PRACTICE

Homelessness, Health Status, and Health Care Use I Bella Schanzer, MD, MPH, Boanerges Dominguez, MS, Patrick E. Shrout, PhD, Carol L.M. Caton, PhD

Health problems associated with homeless- ness are documented throughout the litera- ture. Increased rates of infectious diseases as well as chronic medical conditions have been reported, ranging from community-acquired pneumonia, tuberculosis, and HIV to cardio- vascular disease and chronic obstructive limg disease.'"^ For some cancer risk factors, prev- alence rates are higher in the homeless than in the general population, including sun expo- sure, cigarette smoking, and alcoholism.* Nearly 40% of homeless individuals are re- ported to have some type of chronic health problem.^ Psychotic and affective disorders are common, with prevalence rates ranging for the former between 10% and 13% and for the latter between 20% and 40%.'°" In- dividuals lacking stable housing are more likely to use the emergency department as their regular source of care.'^ In one study, homeless individuals made 20% to 30% of all adult emergency department visits.''' Homeless patients are admitted to inpatient units 5 times more often and have average lengths of stay that are longer than those of nonhomeless persons.''''^ Homelessness is also associated with a foreshortened

A similar literature exists relating poor health status to lower socioeconomic level'*"^' as well as racial and ethnic cate- gories.^^ The relation hcis been reported for dental care,^^ cancer screening,^'' life ex- pectancy,^^ the effect of smoking on

h,̂ ^ mortality rates after elective sur- y,̂ ^ and many other aspects of physical

health and health outcomes. A similar rela- tion has been documented between lower socioeconomic status and poorer mental

The literature highlights the effect that sodoeconomic status has on health status, regardless of housing status. Given the additional stress of homelessness, we ques- tioned whether homelessness would further negatively affect health status and use of the hecdth care system.

Objectives. Little is known about the health status of those who are newly honneless. We sought to describe the health status and health care use of new clients of homeless shelters and observe changes in these health indicators over the study period.

Methods. We conducted a longitudinal study of 445 individuals from their entry into the homeless shelter system through the subsequent 18 months.

Results. Disease was prevalent in the newly homeless. This population ac- cessed health care services at high rates in the year before becoming homeless. Significant improvements in health status were seen over the study period as well as a significant increase in the number who were insured.

Conclusion. Newly homeless persons struggle under the combined burdens of residential instability and significant levels of physical disease and mental illness, but many experience some improvements in their health status and access to care during their time in the homeless shelter system. (Am J Public Health. 2007;97: 464-469. doi:10.2105/AJPH.2005.076190)

A few studies have followed homeless in- dividuals longitudinally. These studies con- firmed the potentially negative effect home- lessness can have on mortality, physical health, mental well-being, and substance use.^'"''^ However, these studies focused on either chronically homeless persons or those living on the street, with the studies begin- ning after the participants were already homeless. We investigated the effect of being homeless on individuals who were new to homelessness and whether their course—find- ing housing or remaining homeless—made a difference. In addition, we focused on home- less shelter residents, whose experience of homelessness was most likely different from that of homeless persons living on the street.

We chose to study newly homeless indi- viduals from their entry into the New York City homeless shelter system until 18 months later to examine the effect of the longitudinal course of homelessness on health status and health care use. Our data describe health changes that occur over the course of early homelessness experienced in shelters.

METHODS

Participants The study was carried out in cooperation

with the Department of Homeless Services,

the municipal agency responsible for the pro- vision of shelter care in New York City. The participants were men and women aged 18 to 65 years who were homeless for the first time, had entered the shelter system within 2 weeks of losing their housing, and intended to re- main in New York for at least 1 year. There were no medical or psychiatric exclusion crite- ria. The participants were recruited fi-om the 3 men's and 3 women's assessment shelters, the portals of entry into the New York City shelter system, run by the Department of Homeless Services and located throughout the city, over a 12-month period. A total of 445 newly homeless respondents consented to be in the study, and complete follow-up data was col- lected on 351 respondents. Baseline inter- views were carried out on the day of entry into the study in a private area in the assess- ment shelter Follow-up interviews were car- ried out in the project's offices or at the partic- ipant's home. Interviews were conducted in English or Spanish. The partidpants were also contacted each month by telephone to gather weekly timeline data relating to housing sta- tus, health status, service use, and criminal jus- tice contacts.

The interviewers engaged in assertive pro- cedures to minimize loss to follow-up. These included consistency of interviewing staff and frequent contacts over the follow-up period

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RESEARCH AND PRACTICE

to note any change in residence. Attempts to maintain contact were made even in the event that participants left the shelter system. The respondents also received a product voucher or a monetary incentive for each completed follow-up interview. The study was approved by the Columbia University Medical Center institutional review board.

Measures We used the Structured Clinical Interview

for the Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition {DSM-IV},

nonpatient edition, in a structured assessment designed to yield current or lifetime psychiat- ric diagnoses according to Z)5Af-/l/criteria."'̂ It has been shown to have good test-retest reliability for both Axis I and antisocial per- sonality disorder.''̂ '** Master's-level clinicians trained in the administration of the assess- ment battery conducted all of the structured interviews and other study procedures.

Demographic data and information on liv- ing arrangements, homelessness history, cur- rent housing status, education, employment, marital status, citizenship, and the respon- dents' reports of medical illnesses and insur- ance status were obtained with the Commu- nity Care Schedule.^"

Health data was also collected through the Medical Outcomes Study 36-Item Short Form Health Survey,"*" which evaluates gen- eral physical and mental health status as well as health perceptions. It has been shown to have good correlation to other health-rating scales. Health ratings were done at baseline, 6 months, 12 months, and 18 months.

The data were analyzed in a stepwise man- ner with SPSS version 13.0 (SPSS Inc, Chi- cago, III). Frequencies of reported baseline health problems were determined and com- pared with those reported for the general pop- ulation in the literature. Chi-square analysis was performed to identify significant differ- ences in reported health status between those who found housing and those who remained homeless at 18 months. McNemar tests were used to discover significant changes over time.

RESULTS

Follow-up rates over the course of the study were as follows: 85% (n=377) at 6 months.

82% {n=365) at 12 months, and 79% (n=351) at 18 months, despite continuous movement out of the shelter (at 18 months only 22% [n=82] of the participants re- mained in the shelter system). We compared the 94 respondents with incomplete data with the 351 cases with complete data for the full 18-month period on age; gender; race; lifetime diagnoses of substance abuse/dependence; lifetime DSM-IV Axis I disorder diagnosis; health insurance status; rates of medical com- plaints (Physical Health Index); the presence of diabetes mellitus, hypertension, and asthma; health care use in the year before becoming homeless; emergency department visits in the year before becoming homeless; and use of prescription medication. A greater number of men than women were lost to follow-up {P<.001), and fewer persons lost to follow-up complained of medical problems (/'=.007), but no other differences were observed.

Demographics The baseline sample was slightly more

than half male (n = 225). The majority of participants belonged to minority groups (n=401), with a mean age of 36.9 years and a mesui duration in New York City of 23.6 years before becoming homeless. Two thirds (n=290) of the respondents were Afiican American, one fifth (n=91) Hispanic, and just under 15% (n=64) White or other ethnici- ties. More than 85% (n=385) of the partici- pants were unemployed at the time of their entry into the shelter system. The median length of time homeless was 190 days. At 18

months, 265 participants had housing and 86 remained homeless.

At entry into the homeless shelter system, 60% (n=212) of the participants who re- mained in the study at 18 months had at least 1 medical complaint. The respondents re- ported a high rate of medical diseases; 17% of the respondents had hypertension, 6% dia- betes mellitus, and 17% asthma (Table 1). Mental health disorders were more prevalent; one third of the respondents had been diag- nosed with major depression and more than one half with a substance use disorder (Table 1). We found significant rates of co- morbidity between physical medical com- plaints and major depression (P<.005) and between physical medical complaints and substance use disorders {P<.001).

Despite the presence of multiple medical problems, the participants' sense of their health status and how their health affected their functioning, as indicated by their mean scores on the Medical Outcomes Study health survey, was equivalent to that of indi- viduals of similar age who were not home- less (35-44 years). The 1 exception was the participants' mean score on the mental health questions, which was 15 points lower than the mean norm score, although still within 1 standard deviation (Table 2).

The group that remained homeless at 18 months (chronic homeless) had higher rates of physical and mental illness, including sub- stance use disorders, than did respondents who had housing at 18 months, but the dif- ference did not reach the level of statistical

TABLE 1-Baseline Generai Heaith Status of Newly Homeiess Persons in the NewYori< City Sheiter System

Diagnosis or

Health indicator

Diabetes meiiitus, %

Hypertension, %

Asthma, %

Major depression, %

Substance use disorder, %

tJninsured, %

Aii Respondents

(N = 351)

6.3

17.1

17.4

35.0

53.0

54.1

Participants With

Housing at

18 mo (n = 265)

5.7

16.2

17.0

33.1

51.7

51.3

Participants

Homeless at

18 mo (n = 86)

8.1

19.8

18.6

36.0

57.0

62.8

US

Popuiation

(aged 18-44 y)

1.9"

7,4"

11.5"

6.5-10.1"

10-20"

25.3"

tJS Population

Living in Poverty

(ali ages)

9.5"

26 .1 "

14.6"

24.3"

Note. No significant differences between those who found housing and those who became homeless were observed. Eiiipses

indicate data not avaiiabie.

March 2007, Voi 97, No. 3 | American Journai of Public Healtfi Schanzer et al. \ Peer Reviewed | Research and Practice | 465

RESEARCH AND PRACTICE

TABLE 2 -Mean Scores of Newly Homeless Persons in the New York City Shelter System

on the Medical Outcomes Study 36-Item Short Form Health Survey

Medical Outcomes Study Category

Physical functioning

Role of physical functioning

Bodily pain

General health

Vitality

Social functioning

Role of emotional functioning

Mental health

All Respondents (N = 351)

Baseline Mean (SD)

87.2 (23.4)

83.8 (34.5)

82.2 (28.2)

71.9 (24.1)

58.7 (24.3)

80.6 (28.3)

76.2 (39.0)

60.0 (21.9)

Mean (SD) After 18 mo

84.8 (24.8)

80.5 (36.0)

83.8 (24.6)

74.3 (23.1)

57.9 (23.4)

88.1 (22.9)

82.5 (35.1)

65.4 (19.6)

Participants With Housing at 18 mo (n = 266)

Baseline Mean (SD)

88.6 (21.4)

84.4 (34.3)

83.2 (27.4)

73.4 (23.8)

60.3 (24.1)

81.2 (28.2)

76.0 (39.2)

60.1 (21.5)

Mean (SD) After 18 mo

85.7 (23.8)

81.0 (35.5)

83.4 (25.1)

74.1 (22.7)

57.4 (22.8)

87.3 (23.9)

82.3 (35.6)

64.9 (18.9)

Participants Homeless at 18 mo (n=86)

Baseline Mean (SO)

84.2 (28.3)

82.3 (36.2)

83.5 (28.3)

71.2 (24.5)

58.8 (23.8)

80.1 (28.3)

84.9 (31.8)

62.9 (20.1)

Mean (SD) After 18 mo

82.3 (27.5)

78.8 (37.7)

85.0 (22.6)

75.0 (24.2)

59.6 (25.2)

90.7 (19.4)

83.1 (34.0)

66.7 (21.6)

Norms' (aged 35-44 y)

89.7 (16.4)

86.7 (28.9)

77.1 (22.1)

75.9 (17.9)

62.4 (19.4)

85.75 (21.0)

82.8 (31.3)

75.1 (16.7)

Note. No significant difference between those who found housing and those who remained homeless was observed at either baseline or 18 months. 'Norms are determined by the Medical Outcomes Study for a healthy population.

significance. Nor was there a statistically sig- nificant difference in levels of health care use. A respondent's burden of medical illness at baseline was statistically unrelated to duration of homelessness.

Health Status and Health Care Use The participants' health status was fol-

lowed over the study period to determine the effects of homelessness on their physical health. Some aspects of the participants' health status showed improvement, and none significantly worsened. More positive change was noted in the group that found housing than in the group that remained homeless. Among the whole group, there

were statistically significant decreases in the number of visual (PK.OOl), dental (P< .001), and podiatric complaints {PK.005). The group that found housing also had a statistically significant decrease in the re- ported rates of high blood pressure (f<.05). The group that remained homeless had a statistically significant reduction in their number of visual (PK.OOX) and dental {P< .005) complaints (Table 3).

No significant change was found in the par- ticipants' subjective sense of their health sta- tus and its effect on their iunctioning over the course of the 18 months, regardless of whether the individuals found housing or re- mained homeless (Table 2).

TABLE 3-Changes in Health Status in Newly Homeiess Persons 18 Months After Entering

New Yori< City Shelter System

All Respondents (N = 351)

Diagnosis or Complaint

Baseline, 18 mo,

Participants With Housing at 18 mo (n = 265)

Baseline, 18 mo, % % P

Participants Homeless at 18 mo (n° 86)

Baseline, 18 mo, % % P

Any medical complaint

Visual complaints

Dental complaints

Podiatric complaints

Diabetes mellitus

Hypertension

Asthma

60.6

25.9

23.3

12.4

6.3

17.2

17.5

64,4

4.6

4,6

5,7

7,8

13.2

16.7

,241

<.005"

.332

<.05°

.749

61.1

25,6

23,7

12,6

5,7

16,4

17,2

65,3 ,266

4,2

3,4

6,5 <,05'

6,1 ,99

11,8 <,05'

16,8 .99

59.3

26.7

22.1

11.6

8,1

19,8

18.6

61,6

5.8

8,1

3,5

12,8

17,4

16,3

,839

,065

,125

,687

,754

"Statistically significant difference at P< ,05,

Necirly 80% of the respondents sought out medical treatment in the year before becoming homeless. Slightly more than one third of the group made a visit to the emergency depart- ment, cind a similar number took at least 1 nonpsychotropic prescription medication in the year before becoming homeless. More than 40% of the participants did not have any type of health insurance (Table 4). There was no association between employment status and health insurance status.

There were no changes over the study pe- riod in the use of health care services by ei- ther the group that found housing or those who remained homeless. There were signifi- cant increases in the number of individuals who became insured over the 18-month study period (PK.OOl), regardless of eventual housing status (Table 4),

DISCUSSION

Given the known association between so- cioeconomic status and health,'*'*'*^ it was not surprising that individuals who became home- less bore a heavy disease burden. This was particulcirly striking when comparing the study population's prevalence of disease to that found in all individuals aged 18 to 44 years who participated in the National Health Interview Survey (NHIS),''̂ Our sample con- sistently had higher rates of medical illness; psychopathology, including major depression and cinxiety; and substance use disorders than

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TABLE 4-Changes In Health Care Use hy Newly Homeless Persons 18 Months After

Entering New York City Shelter System

All Respondents Participants With Housing Participants Homeless (N = 351) at 18 mo (n-265) a t l8mo(n=86)

Baseline, 18 mo, Baseline, 18 mo. Baseline, 18 mo. Indicator

Sought medical treatment in past year 79.8 84.0 .155 79,2

Made a visit to emergency room 34,2 31.9 ,543 34.0

Took prescription medication in the past 36,5 40,5 ,175 35,9

Had health insurance 46,3 69,5 <,001' 49,2

83.0 ,295 81,4 87,2 ,405 32.1 .691 34,9 31,4 ,720 42,0 ,072 38,4 36,0 ,832 71,8 <,001° 37.2 62.8 <,001°

"Statistically significant difference at PS.001.

did participants in a similarly aged general population sample.''^''" Rates of medical ill- ness in our participants, however, were similar to rates dted for individuals of all ages classi- fied as poor (below the poverty threshold) by the NHIS.""

The results also highlight the active nature of these individuals' medical and psychiatric problems before becoming homeless. The vast majority sought out treatment of some sort in the year before entering the homeless shelter system, and more than one third were tciking prescription medication. They were coping with diseases when they became homeless and were reaching out to the medical commu- nity for assistance. Despite some improvement in their health status, however, this population continued to heavily use the medical system— in particular, emergency departments—while homeless and after finding housing.

Persons at risk of becoming homeless also stressed the health care system as they sought help for primary care medical and psychiatric problems in emergency departments instead of in outpatient clinics or private offices. They overused an already overcrowded eind expen- sive part of health delivery facilities, A survey of hospital directors found that emergency departments were overcrowded in almost every state, with 10% to 30% of hospitals surveyed reporting daily overcrowding,"* The NHIS found that fewer than 1% of Ameri- cans used the emergency department as their usual source of care,"^ but slightly more than one third of the newly homeless in this study reported using the emergency department for treatment The number of uninsured respon- dents in this study was also larger than the roughly 25% uninsured rate found in a

similarly aged US population (35-44 years) and in the US population defined as poor (earning less than $25000) by the US Census Bureau,^"

Most striking was what happened to this population over their time in the homeless shelter system and beyond. The health of these first-time homeless individuals did not significantly worsen, and certain aspects actu- ally improved. There was also a huge surge in the numbers of individuals who became insured.

We did not ask people why they felt their health status improved, but several explana- tions are possible. One is a bias toward suc- cessful follow-up among those whose health improved. Although this is possible, it is not likely because the group lost to follow-up had fewer medical complaints at baseline than did the group successfiiUy followed. Another pos- sibility is that improvement is simply a reflec- tion of regression to the mean over time. We are most intrigued, however, with explanations that can be related to the structure of the New York City homeless shelter system. This shel- ter system provides primary care and mental health services on-site in some of the shelters in the form of clinics staffed by nurse practi- tioners, internists, and psychiatrists. The avail- ability of these services might explain the im- provements in certain areas such as podiatric and dental problems. For many, this might have been the first time that they had ready access to primary care services outside of an emergency department, which is ill suited to address visual, dental, or podiatric complaints. It is not surprising that these complaints de- creased so dramatically over the course of the study period, when the participants had access

to primary ceire services with the ability to ad- dress these problems.

The improvement in health status included a decrease in the self-reported rate of hyper- tension among those who had housing at 18 months. We did not query participants about whether there were concomitant changes in lifestyle or compliance with medication upon becoming homeless. However, it is possible that with increased access to care, the partici- pants were better able to control their blood pressure in the 18 months after becoming homeless. Although the decrease did not reach the level of significance, a trend in the same direction was seen among those who remained homeless.

The shelter system also has case workers and benefits counselors who may have aided individuals in their attempts to gain Medic- aid/health insurance or other social service benefits that might have an overall positive ef- fect on their health. The increase in insurance rates was striking. Sadly, although the income of a majority of these individuals qualified them for Medicaid before they entered the homeless shelter system, they may not have had the knowledge or ability to attEiin it. Once they had the assistance of on-site benefits counselors, they were able to become insured in great numbers.

Although living in a homeless shelter ren- ders an individual homeless by definition, the New York City shelter system ensures that a person placed into a particular shelter re- mains in that shelter until he or she leaves the shelter system. This might have provided sufficient residential stability to allow individ- uals to focus on more long-standing physical problems that they could not address while struggling with housing instability.

Surprisingly, despite some evident im- provements in aspects of their physical health, the participants' subjective sense of their health status, as measured by the health survey of the Medical Outcomes Study, did not change. We can only hypothe- size about the reason. Even at baseline, the participants' scores were no different from norms seen in the general population of sim- ilarly aged individuals. It is possible that the survey questions did not adequately address the health concerns of this population, and thus, no change in the scores was evident

March 2007, Vol 97, No, 3 | American Journal of Public Health Schanzer et al. \ Peer Reviewed | Research and Practice | 467

RESEARCH AND PRACTICE

when their health status improved. It is also possible that their homeless state prevented the participants from fully appreciating the physical health improvements they had achieved, and their health survey scores therefore failed to increase.

Limitations

This study had several limitations. The participants' medical status at all time points was assessed via self-report because the study interviewers did not have access to any form of medical records. The partic- ipants' complaints and reports of disease were not corroborated with a physical ex- amination. Although this is a significant limitation, the rates were compared with the NHIS, which also relied on self-report- ing. Also, the group lost to follow-up may not be represented by these findings be- cause their gender makeup and baseline overall health status differed from those of the group for whom there was complete follow-up data. Finally, these findings spe- cifically apply to individuals who were homeless for the first time and who en- tered into the New York City shelter sys- tem; they cannot necessarily be general- ized to homeless individuals in shelters in other cities or to homeless individuals liv- ing on the street, who may not have access to the same level of medical and psychiat- ric care as that provided in the New York City shelter system.

Conclusions

Historically, policymakers have attempted to treat the mediccJ or psychiatric problems of the homeless by bringing services to the shelters—whether in the form of primary care nurses on-site or tuberculosis treatment units or specialized mental health shelters for those with severe psychiatric illness, '̂ Clearly, these services play an important role in improving the overall health status of individuals using the shelter system and may explain the re- sults of this study. However, many individu- als who are newly homeless were quite ill be- fore becoming homeless and might have benefited equally from receiving attention for their health issues before they entered the shelter system. People should not have to enter a homeless shelter to experience an

improvement in their health status and in- creased access to health insurance.

The individuals in our study represent a population struggling under the combined burdens of residential instabihty, poor social networks, and significant levels of physical and mental health disease. Over the past few years, a potential response to the health problems of this population has arisen in the form of innovative projects that focus on neighborhood interventions that promote prevention of disease among individuals who are most at risk of becoming homeless— before losing their housing,^ It is unclear whether additional primary care services in the community would have prevented homelessness or improved the health status of our respondents. However, if people liv- ing with poverty have available medical and social services in the community and are able to make use of them, they may be able to improve their health status and to avoid homelessness, •

About the Authors Bella Schanzer is with the Department of Psychiatry, Columbia College of Physicians and Surgeons, and the Center for Homelessness Prevention Studies, Mailman Sehool of Public Health, Columbia University, New York, NY. At the time of the study, Boanerges Dominguez was with the Department of Sociomedical Sciences, Mailman School of Public Health. Patrick E. Shrout is with the Department of Psychology, New York University, New York. Carol L. M Caton is with the Center for Homelessness Prevention Studies, the Depart- ment of Sociomedical Sciences, Mailman School of Pub- lic Health, and the Department of Psychiatry, Columbia College of Physicians and Surgeons.

Requests for reprints should be sent to Bella Schanzer, MD, MPH, Mailman School of Public Health, Columbia University, 600 W 168th St, New York, NY 10032. (e-mail: [email protected]).

This article was accepted March 7, 2006.

Contrihutors B, Schanzer drafted the article and conducted the pri- mary data analysis, B, Dominguez and P, E, Shrout as- sisted in the data analysis, C,L,M, Caton originated and supervised all aspects of the study. All the authors par- ticipated in reviewing and drafting the article.

Acknowledgments Support for this investigation was provided by the Na- tional Institute on Drug Abuse (grant ROI 128740),

Presented in part at the American Public Health Association Annual Meeting, Washington, DC, Novem- ber 2004,

The authors are indebted to Ingrid Ramirez, Mila- gros Ventura, and Eustace Hsu for their assistance with data processing.

Human Participant Protection This study was approved by the institutional review board of the Columbia University Medical Center,

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