How to help homeless youth suffering from first episode psychosis and substance use disorders? The creation of a new intensive outreach intervention team

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Homeless people: a review of personality disorders

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec

OBJECTIVES

Specialized early intervention for psychosis can reduce the duration of untreated psychosis and improve clinical and functional outcomes. However, poor adherence to treatment is frequent. The literature on community treatment orders (CTOs) use in first-episode psychosis (FEP) as a means to improve treatment adherence is limited. In the context of early intervention for psychosis services (EIS), this study aims to describe (1) the frequency of CTOs utilisation, (2) the trend of CTOs use over time, (3) the timing and reasons for requesting CTOs and (4) the baseline characteristics of FEP patients on CTOs compared to those who were not.

METHOD

A 5-year prospective longitudinal study describing the use of CTOs among persons with FEP admitted to two urban EIS in Montreal, Quebec, from 2005 to 2013. At admission, and then annually for 5 years, CTOs data were collected through chart review. Baseline characteristics, assessed by patient interviews, standardized questionnaires and chart review, included socio-demographic data, illness severity, functioning and alcohol and substance use. Descriptive analyses were performed, and FEP patients on CTOs during follow-up and those who were not were compared using analyses of variance, chi-square test and multivariate logistic regression.

RESULTS

Among 567 FEP patients, 19.2% were placed on CTOs. The main reasons for requesting CTOs were to prevent further deterioration in mental state, social functioning, harmful behaviours to self and others and homelessness. FEP patients on CTOs had poorer premorbid and baseline functioning, more severe symptoms and social dysfunction at admission, including legal problems and homelessness.

CONCLUSIONS

CTOs can be a tool to improve adherence to treatment, which is crucial for relapse prevention in FEP. However, since it is a coercive method that limits a person's fundamental rights, further research is warranted to assess its impact on patients' lives, clinical and functional outcomes, as well as patients' and carers' perception.

Engagement and outcomes of marginalised young people in an early intervention youth alcohol and other drug program: The Street Universities model

BACKGROUND

Early intervention alcohol and drug (AOD) programs for disadvantaged young people have the potential to substantially decrease the need for future intervention, however there is little research about how young people use these programs or the substance use and other outcomes of such programs. This paper uses data from an Australian AOD early intervention program, The Street Universities, to: describe young people's participation; examine changes in substance use and wellbeing over 90 days; and assess which young people are most positively impacted.

METHODS

Data come from a prospective study of new attendees, measuring retention in and attendance patterns in an 'engagement' program focussed on arts and lifestyle activities (n = 95), and a routine service dataset collected from seven years of therapeutic intervention (n = 3,893), measuring substance dependence (SDS), psychological distress (K10) and quality of life (EQoL).

RESULTS

Analysis reveals that young people were retained in the program at high proportion (63% at six months) and more than half of these returned at a frequency of weekly or more often. Young people participating in the therapeutic component of the program reported significant improvements in all key wellbeing indicators with SDS, K10 and EQoL scores significantly improving (at p < .001). These improvements occurred rapidly, within the first 30 days, and were maintained over the 90 day study period. Moreover, young people with the highest SDS and K10 scores and lowest quality of life at baseline experienced the most positive changes.

CONCLUSION

Aligning engagement program with therapeutic intervention can provide comprehensive support to disadvantaged young people, producing substantial improvements in AOD use, distress and wellbeing.

Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) are strong risk factors for homelessness and poor health and functioning. We aimed to evaluate the lifetime prevalence of ACEs and their associations with health-related and functioning-related outcomes among homeless adults.

METHODS

In this systematic review and meta-analysis, we searched from database inception to Nov 11, 2020, for original and peer-reviewed studies in English that documented lifetime prevalence of ACEs or associations between ACEs and health-related or functioning-related outcomes. We selected studies if they included a definable group of homeless adults and measured at least four ACE categories. We calculated pooled estimates of lifetime prevalence of one or more ACEs and four or more ACEs with random-effects models. We used the leave-one-out method in sensitivity analyses and studied meta-regressions to explore potential moderators of ACE prevalence. We also did a narrative summary of associations between ACEs and health-related and functioning-related outcomes, as there were too few studies on each outcome for quantitative meta-analysis. This study is registered with PROSPERO, CRD42020218741.

FINDINGS

We identified 2129 studies through systematic search, of which 29 studies (16 942 individuals) were included in the systematic review, 20 studies (10 034 individuals) were included in the meta-analysis for one or more ACEs, and 15 studies (5693 individuals) were included in the meta-analysis for four or more ACEs. Studies included samples of adults experiencing homelessness in the USA, Canada, and the UK; participants in the included studies were predominantly male (65·2%) and mean ages ranged between 18·3 and 58·1 years, but many studies did not report race, ethnicity, and sexual and gender minority data. Lifetime prevalence of one or more ACEs among homeless adults was 89·8% (95% CI 83·7-93·7) and the lifetime prevalence of four or more ACEs was 53·9% (45·9-61·7). Considerable heterogeneity was identified in both meta-analyses (I²>95%). Of the potential moderators analysed, the ACE measurement tool significantly moderated the estimated lifetime prevalence of one or more ACEs and four or more ACEs, and age also significantly moderated the estimated lifetime prevalence of four or more ACEs. In the narrative synthesis, ACEs were consistently positively associated with high suicidality (two studies), suicide attempt (three studies), major depressive disorder (two studies), substance misuse (two studies), and adult victimisation (two studies).

INTERPRETATION

The lifetime prevalence of ACEs is substantially higher among homeless adults than among the general population, and ACE exposure might be associated with prevalence of mental illness, substance misuse, and victimisation. Policy efforts and evidence-based interventions are urgently needed to prevent ACEs and address associated poor outcomes among this population.

FUNDING

Rhodes Trust and Canadian Institutes of Health Research.

Sociodemographic, clinical and help-seeking characteristics of homeless young people with recent onset of psychosis enrolled in specialized early intervention services

AIM

To examine differences in demographic, clinical, social, functional and help-seeking characteristics of homeless vs housed individuals enrolled in specialized early intervention teams in the United States.

METHODS

Participants comprised 1349 individuals enrolled across 21 teams. Teams report individual-level data including homelessness status at admission. Bivariate differences between homeless and housed participants were analysed using Wilcoxon-rank, chi-square, Fisher-exact and t tests, as appropriate.

RESULTS

Approximately 5% of participants were homeless at admission. Homeless participants were less likely to be enrolled in school and/or employed (12.2% vs 43.4%); to have more involvement in the legal system (23.0% vs 6.2%); and to have had a more restrictive pathway to care, than housed participants.

CONCLUSIONS

Homeless young people with recent-onset psychosis have a substantially greater need for a diversity of services for psychosocial needs. Homeless individuals may also have a more adverse pathway to care and directed outreach to engage this population may be needed.

Structural Disadvantage and Culture, Race, and Ethnicity in Early Psychosis Services: International Provider Survey

OBJECTIVE

Little is known about provider perspectives on programmatic responses to structural disadvantage and cultural differences within early intervention in psychosis (EIP) services, programs, and models. The primary objective of this study was to investigate providers' perspectives on the impacts of disadvantage and minority race, ethnicity, and culture and to describe current practices and perceived gaps and concerns.

METHODS

An online survey of specialized EIP providers was disseminated in the United Kingdom, United States, Canada, Australia, and Chile. A total of 164 providers, representing 110 unique sites, completed the survey. Closed-ended questions gathered demographic and program data, including information on formal assessment of trauma or adversity, integration of trauma-informed care, integration of formal cultural assessment tools, training focused on culture, programmatic changes to address culture-related issues, and consultation with cultural insiders. Open-ended questions addressed the demographic mix of the program's client population; the perceived role and influence of trauma, structural disadvantage, and cultural differences; and concerns and needs related to these topics. Frequencies were examined for closed-ended items; open-ended responses were systematically coded.

RESULTS

Overall, survey findings suggested low levels of implementation of a variety of assessment and support practices related to cultural diversity in EIP programs. Coding of open-ended responses revealed numerous concerns regarding the impacts of disadvantage and cultural difference on clients and perceived gaps in policy and implementation.

CONCLUSIONS

An expansion of research and service development aimed at better meeting the disadvantage- and culture-related needs of young people with early psychosis and their families should be a priority for the field.

Types, prevalence and gender differences of childhood trauma in first-episode psychosis. What is the evidence that childhood trauma is related to symptoms and functional outcomes in first episode psychosis? A systematic review

This paper reviews and discusses the literature on childhood trauma (CT) in people with first-episode psychosis (FEP). The aim is to update the knowledge on the prevalence and the types of CT suffered by FEP people, to compare them with other samples, to study the impact of gender, and to examine the relationship between CT and symptoms and functional outcomes. We conducted a literature search (1995-2019), to identify reported data on any topic related to CT in FEP samples. The following terms were used in the search: CT or sexual abuse or physical abuse or neglect, and first-episode psychosis. We found 493 studies, of which 68 were included in the review. FEP presented a higher prevalence of CT than controls. Women suffer more sexual abuse. The effect of CT on the severity, the prognosis and the evolution of FEP is unclear. FEP have a high prevalence of CT. Its relationship with symptoms and functional outcomes indicates its importance within treatment. This suggests the importance of creating and implementing specific interventions and personalized therapies addressed to work through their past traumatic experiences to improve their quality of live and their prognosis.

Support Services for Young Adults With Substance Use Disorders

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among young adults, this special article reviews principles of care concerning recovery support services for this population. Young adults in recovery from SUDs can benefit from a variety of support services throughout the process of recovery. These services take place in both traditional clinical settings and settings outside the health system, and they can be delivered by a wide variety of nonprofessional and paraprofessional individuals. In this article, we communicate fundamental points related to guidance, evidence, and clinical considerations about 3 basic principles for recovery support services: (1) given their developmental needs, young adults affected by SUDs should have access to a wide variety of recovery support services regardless of the levels of care they need, which could range from early intervention services to medically managed intensive inpatient services; (2) the workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction; and (3) recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support.

Specialized assertive community treatment intervention for homeless youth with first episode psychosis and substance use disorder: A 2-year follow-up study

AIM

No previous study has investigated interventions for homeless youth suffering from first episode psychosis and comorbid substance use disorder (HYPS). An intensive assertive community intervention team (IACIT) offering outreach interventions, housing support as well as integrated care for early psychosis and substance use disorder (SUD) was created in 2012 at the Centre Hospitalier de l'Université de Montréal (CHUM). To explore the impact of the addition of an IACIT to an early intervention for psychosis service (EIS) on housing stability, functional and symptomatic outcomes and mental health service use.

METHODS

A two-year longitudinal study comparing the outcome of HYPS receiving combined EIS and IACIT since 2012, to a historical cohort of HYPS receiving EIS only between 2005 and 2011. Socio-demographic data, housing stability, functioning, illness severity, SUD severity, emergency room visits and hospitalizations were assessed at admission, at 1 month, and every 3 months thereafter.

RESULTS

HYPS receiving EIS + IACIT achieved housing stability more rapidly and spent less time hospitalized than HYPS getting EIS only (RR 2.38, P = .017). HYPS with cocaine misuse were less likely to attain housing stability (RR 0.25, P = .04). No between-group differences were found for psychiatric symptoms, functioning and SUD outcomes.

CONCLUSION

The addition of IACIT-HYPS to EIS was associated with earlier housing stability and reduced total hospitalization days compared to EIS alone.

A Promising Route Towards Improvement of Homeless Young People's Access to Mental Health Services: The Creation and Evolution of an Outreach Service Network in Montréal

Youth homelessness is a complex phenomenon as well as an important public health issue often compounded by mental illness of varying severity, in turn creating numerous deleterious consequences. While emergency health services usage remains high, access to mental health services is arduous and conventional interventions often fall short on providing integrated care and seldom lead to sustained positive outcomes for this group. From this observation, clinicians in Montreal, Canada, initiated collaborative meetings, eventually attended by a growing number of institutional and community stakeholders working with homeless youth. Acknowledging the unique needs of this population, the Réseau d'intervention de proximité auprès des Jeunes de la Rue (RIPAJ) or Montreal Homeless Youth Network was created to engage and seamlessly connect youth with the right resources within the network including mental health services amongst others. The genesis, philosophy and unique features of RIPAJ that allow for effective and cohesive interventions as well as future directions are discussed.

Homeless youth with first-episode psychosis: A 2-year outcome study

BACKGROUND

Psychosis augments the risk of homelessness, the latter is associated with increased morbidity and mortality. Young adults experiencing first-episode psychosis (FEP) are increasingly recognized as being vulnerable to homelessness. However, data on homeless in youth with FEP are sparse.

OBJECTIVES

To compare symptomatic and functional outcomes in homeless v. never homeless FEP, at admission and two years after admission to an Early Psychosis Intervention Service (EIS).

METHOD

From October 2005 to April 2011, 167 FEP consecutive admissions (aged 18-30 years old), were recruited in a 2-year prospective longitudinal study in an inner city EIS in Montreal, Canada. Socio-demographic characteristics, symptomatic and functional outcomes, as well as treatments and service use data were collected at admission and annually.

RESULT

26% of FEP were homeless, prior or during the follow-up. Attrition rate was similar among the two groups. At baseline, the homeless group were more likely to have childhood abuse, forensic history, non-affective psychosis, negative symptoms, substance use disorder and cluster B personality. Despite the intensive care of EIS, the similarity of illness severity at baseline and medication adherence rate, homeless FEP had poorer 2-year symptomatic and functional outcomes, although having more long-acting injectable antipsychotics (LAI) (vs oral antipsychotics), community treatment order and hospitalizations.

CONCLUSION

Homelessness is a serious and prevalent phenomenon among FEP youth associated with worse symptomatic and functional outcomes. More studies on interventions focusing on potentially modifiable factors (e.g. substance use disorders, social support) are warranted.