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PubMed1995

Components of an effective transitional residential program for homeless mentally ill clients.

UNLABELLED: Review of clinical records of 228 former clients of a Transitional Residential PROGRAM for severely, persistently mental ill homeless persons was conducted to examine PROGRAM results for completers and noncompleters. Of the 228 clients, 110 (48.3%) completed the PROGRAM: they became psychiatrically stabilized, found secure housing, and began receiving disability pensions. Completers participated in significantly more activities than noncompleters. Psychiatric diagnosis was unrelated to successful PROGRAM completion. Individuals who left against advice had significantly fewer previous hospitalizations.

Activities of Daily Living↗
PubMed2001

Mental health training in emergency homeless shelters.

The prevalence of mental illness among homeless persons points to the importance of providing mental health training to emergency shelter staff. The authors report on their own work and argue that such training offers the potential to significantly improve shelter staffs ability to respond to the needs of shelter residents with mental illness, and to the behavioral problems some of these individuals may pose for shelter operation. Mental health care providers should take into consideration organizational dynamics when planning and implementing such training.

Case Management↗
PubMed2000

Measurement properties of the Center for Epidemiologic Studies-Depression Scale in a homeless population.

The measurement properties of the Center for Epidemiologic Studies--Depression Scale (CES-D; L. S. Radloff, 1977) were evaluated in a probability sample of homeless adults residing in a large and demographically diverse community. The findings from this investigation suggest that the CES-D is a reliable measure of depressive symptoms among homeless adults and that the factor structure of the scale replicates the factor structure found in the general population. Change in the CES-D scores was associated with change in residential status, with participants who had made a transition from homelessness to regular domicile, reporting significantly lower levels of depressive symptomatology. This result indicates the scale's sensitivity to current depressive mood, as affected by significant life events encountered by homeless persons.

Adult↗
PubMed2001

Clinical responsibility and client autonomy: dilemmas in mental health work at the margins.

Mental health outreach to homeless persons requires practice standards for cases in which clinical assessment and client autonomy conflict. After reviewing the principles of mental health outreach and presenting case examples, conditions and boundaries within which outreach workers negotiate the clinical responsibility/client autonomy dilemma are discussed. Guidelines to support sound clinical practice while respecting client autonomy are also discussed.

Community-Institutional Relations↗
PubMed2001

The Supervised Methadone and Resettlement Team nurse: an effective approach with opiate-dependent, homeless people.

Homelessness and substance misuse have risen dramatically over the past 30 years in the UK. The role of the primary care nurse has been signalled as important in working with people who have drug and alcohol problems, and for improving the general health of homeless people. This article focuses on the role of the primary care nurse in a Supervised Methadone and Resettlement Team (SMART). The team works in central Bristol, in southwest England, with people who are homeless and using illegal opiates. The aim of this report is to provide descriptive information that demonstrates the value of the primary care nurse, working in a multiagency partnership, in dealing with the problems of this homeless population, many of whom have problems associated with illicit drug use. Client outcomes from a small sample of homeless persons are also described.

Community Mental Health Services↗
PubMed2004

[Psychiatric epidemiology in Germany].

OBJECTIVE: The paper reviews psychiatric epidemiological research in Germany focusing on studies conducted over the last two decades. METHOD: Relevant studies were identified using Medline and Psyndex databanks. RESULTS: Inspired mainly by Anglo-American research, a substantial body of studies demonstrates the constitution of psychiatric epidemiology as a research field in Germany. The paper reviews field studies in children and adolescents, in adults and the elderly concerning scope, design and methods. Also those studies regarding special populations (i. e. homeless, persons living in nursing homes) usually not covered by field studies were included. Selected results of current surveys were reported to illustrate that mental disorders are common. CONCLUSIONS: Future challenges of psychiatric-epidemiological research include (1) the provision of internationally comparable data and (2) the description of individual and contextual risk- and protective factors of mental disorders. The latter can only be achieved by employing longitudinal designs where researcher should adopt a multi-level perspective in questioning and analysis.

Adolescent↗
PubMed2006

[How to care for homeless mentally ill men in the community - a randomised intervention study].

OBJECTIVE: The aim of the present study was to clarify whether the mediation of homeless persons identified as mentally ill into the sociopsychiatric or the help-seeking system can be facilitated by a short-term intervention. METHOD: Probands with at least one psychiatric diagnosis according to ICD-10 (73 % of the sample) were randomized to the intervention group (manualized procedure with five brief contacts) or to the control group (no intervention). The course of the contacts and the further help-seeking behavior after 4 and 8 months were registered. RESULTS: The very sporadic participation of the patients in the therapeutic discussion permitted a manualized procedure in individual cases only. The establishment of contact was very successful, but the problem-centered procedure only within limits. The intergroup comparison revealed no fundamental differences in the utilization of offers of support during the course of the study. Overall, however, the number of users tended to increase, with an increased contact frequency being recorded especially among those participating in therapeutic discussions. CONCLUSIONS: Only a relatively small proportion of the clientele can be reached through short-term behavior therapy. Fundamentally a low-profile, primarily outreach-based offer founded on longer-term contact appears to be more promising.

Adult↗
PubMed2001

Prevalence of nonpsychotic mental disorders does not affect treatment outcome in a homeless cocaine-dependent sample.

This study presents the prevalence and treatment outcome of DUAL diagnoses (psychoactive substance use disorders [PSUD] plus other nonpsychotic mental disorders) among a population of homeless persons participating in a behavioral day treatment and contingency management drug abuse treatment program. Participants were 128 persons: 76.6% male, 23.4% female; 82.2% African-American, 17.2% Caucasian. There were 46 (35.9%) PSUDs and 82 (64.1%) DUAL participants. Cocaine (96.9%) and alcohol disorders (57.8%) were most prevalent overall, and 60.2% of participants had two or more psychoactive substance use disorders. DUAL participants had significantly more alcohol disorders than PSUDs (62.2% versus 50.0%). The most prevalent mental disorders (other than substance use) for the total and DUAL samples were, respectively, mood (51.6% and 80.5%) and anxiety (35.9% and 56.1%), and 31.3% and 48.8% had more than two mental disorders. The DUAL group had more severe problems than the PSUD group at baseline in alcohol, medical condition, employment/support, and psychiatric status areas on the ASI. Both groups showed treatment improvements at 6-months follow-up with the DUAL group showing greater mean changes than the PSUD group in five of the seven ASI areas. These findings are discussed in terms of effect of dual diagnoses on treatment outcome and study limitations related to a retrospective design and select sample of nonpsychotic mental disorders.

Comorbidity↗
PubMedDate not supplied

Homelessness, substance misuse, and access to public entitlements in a soup kitchen population.

The study examined the effects of homelessness on access to public entitlements (Medicaid and food stamp programs) in a soup kitchen population. Data were collected between 1997 and 1999 from a sample of 343 adults at two soup kitchen sites in New York City. Five hypotheses, focusing on the effects of housing status (literal homelessness, unstable housing, and domiciled), frequency of drug/heavy alcohol use, drug/alcohol-user treatment history and childcare responsibilities on access to Medicaid and food stamp programs were tested. Multiple logistic regression analysis indicated that both literal homelessness and unstable housing were associated with less access to Medicaid and food stamps. Other significant findings were: current drug/alcohol-user treatment experience was associated with greater access to both Medicaid and food stamps, frequency of drug/heavy alcohol use was associated with less access to Medicaid only, and caring for children was associated with greater access to food stamps only. These findings support the crucial role of housing status in mediating access to entitlements, and the importance of drug/alcohol-user treatment involvement as a cue to seeking entitlements. The need to reduce health disparities through active and sustained outreach programs designed to enhance homeless persons' access to Medicaid and food stamp programs was discussed.

Adolescent↗
PubMed1990

Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults.

This study describes use of medical, mental health, alcohol, and drug services by 832 adult residents of the New York City homeless shelter system and examines associations between service use during the past three months and an array of predisposing, enabling, and need factors. Utilization rates were 23% for medical services, 13% for mental health services, and 10 and 7.5% for alcohol and drug treatment services, respectively. Service contacts were more often hospitals than ambulatory care clinics. Logistic regression analyses revealed that need factors were stronger predictors of all four types of service use. Predisposing factors other than education and black ethnic status were not significant, and the enabling factor of enrollment in Medicaid and/or Medicare was significant only for use of medical and drug services. Among the need factors, measures of mental health status were analyzed as indices of distress to test a stress-utilization model of prediction for all four types of service use. While these measures did not predict use of nonmental health services, physical health problems were associated with use of all four types of services. Implications for future health services research and for service delivery to the homeless are discussed, including the need for more information on availability of services and on psychosocial and cultural characteristics of homeless persons that may affect their help-seeking behavior.

Adolescent↗
PubMed1993

Substance use among impoverished medical patients: the effect of housing status and other factors.

Four hundred forty-three impoverished medical patients, many of whom were homeless, were studied to determine whether homelessness is an independent predictor of current substance use. Twenty-four percent of the sample of patients were frequent alcohol users (i.e., daily or almost daily), and 18% had recently used illegal drugs (cocaine, heroin, PCP, LSD). Marijuana use was not included in the drug use variable. Bivariate analyses revealed that frequent alcohol was associated with being homeless, male, less educated, a veteran, unemployed, and having more children. Frequent alcohol users also were more likely to be sexually active, have had suicidal thoughts, a previous psychiatric hospitalization or felony conviction, an accident or injury, and poor physical health. Self-reported use of illegal drugs was associated with being younger, U.S. born, never married, having a poor mood, and a mental health problem or substance use by a parent. Use of illegal drugs was associated with being homeless, male, less educated, sexually active, and having a previous felony conviction or psychiatric hospitalization. Once demographic and family characteristics were controlled for, housing status was not related to either frequent alcohol or illegal drug use. Substance use among impoverished patients was a reflection of their historical social backgrounds rather than of their current housing status. Helping these patients to obtain stable housing may not impact the substance use of homeless persons.

Adult↗
PubMed2003

Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans.

BACKGROUND AND OBJECTIVES: This study used the Behavioral Model for Vulnerable Populations to identify determinants of receipt of outpatient medical care within 6 months of initial contact with a national homeless veterans outreach program. RESEARCH DESIGN: Prospective study. SUBJECTS: Homeless veterans contacted through the program in 1999 (n = 26,926). MEASURES: Data from structured interviews conducted at the time of program intake were merged with Veterans Affairs administrative data to determine subsequent medical service use. Logistic regression modeling was used to identify predisposing, enabling, and need factors from traditional and vulnerable domains predictive of receiving medical care. RESULTS: Overall, 41.8% of subjects received at least one medical visit in the 6 months after program intake; of these, 48.7% had three or more visits. In multivariate analyses, the likelihood of receiving medical care was, among other things, positively associated with age, female gender, and placement in residential treatment and negatively associated with duration of homelessness and being contacted through outreach versus referred or self-referred into the homeless program. Mental illness did not appear to be an additional barrier to initiating medical care; however, a diagnosis of substance abuse or schizophrenia was associated with a decreased likelihood of receiving three or more visits. CONCLUSION: A majority of homeless veterans contacted through a national outreach program failed to receive medical services within 6 months of program entry. Vulnerable-domain factors were important supplements to traditional variables in predicting use of medical services in the homeless population. Greater efforts are needed to ensure that mentally ill homeless persons are successfully linked with and engaged in medical treatment.

Adult↗
PubMed2003

Participatory mapping of sex trade and enumeration of sex workers using capture-recapture methodology in Diego-Suarez, Madagascar.

BACKGROUND: Capture-recapture methodology has been employed to estimate the size of hidden or difficult-to-reach human populations such as sex workers, homeless persons, and intravenous drug users. This study took place in the context of efforts to improve the quality of curative and preventive services for sexually transmitted infections offered to sex workers in Diego-Suarez, Madagascar in partnership with sex workers. GOAL: The goal of this study was to better understand sex-trading practices, map out sex work sites, and estimate the size of a mobile sex-worker population in Diego-Suarez, Madagascar using methods that can be reproduced in other resource-poor settings. STUDY DESIGN: Forty sex workers were trained to function as field researchers. Key informants in designated neighborhoods were identified and interviewed. Basic maps of sex-trade sites were designed by hand. The number of sex workers in Diego-Suarez was estimated using capture-recapture methodology. An educational brochure was used to "capture" sex workers during a first phase, and "recapture" 2 weeks later. RESULTS: Most sex trade was street based and mobile. Capture-recapture methods estimated a total of 2684 sex workers (95% CI: 2588-2780) in Diego-Suarez, or approximately 12% of the 15- to 49-year-old female population in the city. CONCLUSION: Geographic mapping and capture-recapture proved to be low-cost and relatively easy to use techniques for counting a hard-to-reach population, such as female street-based sex workers. Sex workers can be capable fieldworkers, and their active participation in research concerning sex work should be considered whenever possible. A high proportion of women of reproductive age were found to engage in sex work, indicating that there is an urgent need to scale up sexually transmitted infection and HIV prevention activities targeting sex workers, their sexual partners, and the general population.

Adolescent↗
PubMed1988

The homeless mentally ill in Tucson: implications of early findings.

Homeless persons who received emergency psychiatric screening in a public general hospital exhibited patterns of gross geographic mobility. They did not uniformly avail themselves of community services, such as soup kitchens, and there were marked sex differences within the sample.

Adult↗
PubMed2000

Service use over time and achievement of stable housing in a mentally ill homeless population.

OBJECTIVE: Service use among clients of a multiservice agency serving homeless persons with severe mental illness was examined to determine whether patterns of service use reflected two stages in an adaptation of the transtheoretical model of change. In the adapted model, change occurs in five stages-pre-engagement, contemplation, engagement, the strategic moment, and consolidation. It was hypothesized that rates of service use would be highest immediately after clients obtained housing (the strategic moment) and would decrease in the months afterward (consolidation stage), with the greatest decreases occurring immediately after housing was obtained. METHODS: Service use data were collected for two groups: a housed group of 58 clients who had obtained and sustained stable housing for at least 24 consecutive months at the time of sampling and an unhoused group of 55 clients who were matched with the housed clients on month of service entry. Total service use and use of three service types-a drop-in center, counseling, and health services-were examined to test the hypotheses. It was hypothesized that use of services by the unhoused group would show a consistent linear decline rather than a two-stage decline. Linear spline regression using bootstrap sampling methods was used to fit service use data for both groups. RESULTS: The two-stage solution significantly modeled the patterns of service use by the housed but not the unhoused clients, supporting the hypotheses. For the housed group, use of the drop-in center and counseling fit the model, and use of health services did not. CONCLUSIONS: The results provide limited support for the hypothesized five-stage model for achieving change.

Adult↗
PubMed2002

Overview of the ACCESS Program. Access to Community Care and Effective Services and Supports.

The authors provide an overview of the ACCESS program (Access to Community Care and Effective Services and Supports), which evaluated the integration of service systems and its impact on outcomes for homeless persons with severe mental illness. The ACCESS program provided funds and technical assistance to nine community sites to implement strategies for system change that would promote systems integration. These experimental sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment for 100 clients a year for four years at each site. Data on the implementation of system change strategies were collected from 1994 to 1998 during annual visits to the sites. Data on changes in systems integration were obtained from interviews with key informants from relevant organizations in each community. Client outcome data were obtained at program entry and three and 12 months later from 7,055 program participants across the four annual client cohorts at all sites. Detailed findings from the ACCESS evaluation are presented in two accompanying articles, and overall conclusions are offered in a fourth article.

Community Mental Health Services↗
PubMed1995

Assertive community treatment: an update of randomized trials.

OBJECTIVE: Results of randomized clinical trials of assertive community treatment for seriously mentally ill patients published between 1990 and 1994 are reviewed to synthesize the state of knowledge about this research and to clarify continuing research directions. METHODS: Randomized trials of interventions that used treatment principles and practices consistent with the Program for Assertive Community Treatment model or close adaptations whose results were published since 1990 were identified by literature searches using MEDLINE and PsychLit and by contact with investigators of ongoing trials. RESULTS: Controlled clinical trials have been conducted with a wide range of severely mentally ill populations, including patients in Great Britain, patients with recent-onset schizophrenia, veterans, dually diagnosed clients, and homeless persons. Methodological improvements in some studies include increased attention to monitoring the experimental and comparison interventions, as well as larger sample sizes and longer duration of the clinical trials than in earlier efficacy trials. Strong positive effects of assertive community treatment on hospital days and on patient and family satisfaction were found. Gains in functional outcomes, such as employment, may require interventions specifically targeted to these outcomes. CONCLUSIONS: Questions about the role of assertive community treatment as time-limited treatment, as an adjunct to other services and treatment, or as a comprehensive and continuous service system for adults with severe mental illness require further research. The growing research base should provide valuable information on costs, outcomes, and indications for assertive community treatment that can be evaluated by policy-makers.

Adult↗
PubMed1997

Homeless mentally ill clients' and providers' perceptions of service needs and clients' use of services.

OBJECTIVE: Clients' and providers' perceptions of clients' needs were compared in 18 community treatment programs participating in the Access to Community Care and Effective Services and Supports program of the Center for Mental Health Services, a national demonstration project on treatment of homeless persons with mental illness. The study sought to determine whether perceptions differed and whether assessed needs for services were related to service use. METHODS: A total of 1,482 clients contacted through community outreach who entered the case management phase of the program after an average of 32 days were given an evaluation interview at entry into the program. The clients and outreach workers identified clients' needs in seven core domains-mental health, general health, substance abuse, public financial support, housing assistance and support, dental care, and employment. Use of related services in the 60 days before the case management evaluation was determined. RESULTS: The greatest differences between clients' and providers' perceptions of service needs were in dental and medical services, which were more frequently identified as needs by clients, and in substance abuse and mental health services, which were more frequently identified by providers. Clients' and providers' assessments of need were significantly, but not strongly, correlated with each other, and both were correlated with use of mental health and substance abuse services. CONCLUSIONS: Mental health service providers are less likely than clients to identify needs for services other than mental health services. Service use, at least in the short run, is related to both clients' and providers' assessments of need.

Adult↗