Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study

Psychiatric advance directives facilitated by peer workers among people with mental illness: economic evaluation of a randomized controlled trial (DAiP study)

AIMS

We aimed to assess the cost-effectiveness of psychiatric advance directives (PAD) facilitated by peer workers (PW-PAD) in the management of patients with mental disorders in France.

METHODS

In a prospective multicentre randomized controlled trial, we randomly assigned adults with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of schizophrenia, bipolar I disorder or schizoaffective disorders, who were compulsorily hospitalized in the past 12 months, to either fill out a PAD form and meet a peer worker for facilitation or receive usual care. We assessed differences in societal costs in euros (€) and quality-adjusted life-years (QALYs) over a year-long follow-up to estimate the incremental cost-effectiveness ratio of the PW-PAD strategy. We conducted multiple sensitivity analyses to assess the robustness of our results.

RESULTS

Among the 394 randomized participants, 196 were assigned to the PW-PAD group and 198 to the control group. Psychiatric inpatient costs were lower in the PW-PAD group than the control group (relative risk, -0.22; 95% confidence interval, [-0.33 to -0.11]; P < 0.001), and 1-year cumulative savings were obtained for the PW-PAD group (mean difference, -€4,286 [-4,711 to -4,020]). Twelve months after PW-PAD implementation, we observed improved health utilities (difference, 0.040 [0.003-0.077]; P = 0.032). Three deaths occurred. QALYs were higher in the PW-PAD group (difference, 0.045 [0.040-0.046]). In all sensitivity analyses, taking into account sampling uncertainty and unit variable variation, PW-PAD was likely to remain a cost-effective use of resources.

CONCLUSION

PW-PAD was strictly dominant, that is, less expensive and more effective compared with usual care for people living with mental illness.

Mortality among inpatients with bipolar disorders and COVID-19: a propensity score matching analysis in a national French cohort study

BACKGROUND

It remains unknown whether coronavirus disease 2019 (COVID-19) patients with bipolar disorders (BDs) are at an increased risk of mortality. We aimed to establish whether health outcomes and care differed between patients infected with COVID-19 with BD and patients without a diagnosis of severe mental illness.

METHODS

We conducted a population-based cohort study of all patients with identified COVID-19 and respiratory symptoms who were hospitalized in France between February and June 2020. The outcomes were in-hospital mortality and intensive care unit (ICU) admission. We used propensity score matching to control for confounding factors.

RESULTS

In total, 50 407 patients were included, of whom 480 were patients with BD. Patients with BD were 2 years older, more frequently women and had more comorbidities than controls without a diagnosis of severe mental illness. Patients with BD had an increased in-hospital mortality rate (26.6% v. 21.9%; p = 0.034) and similar ICU admission rate (27.9% v. 28.4%, p = 0.799), as confirmed by propensity analysis [odds ratio, 95% confidence interval (OR, 95% CI) for mortality: 1.30 (1.16-1.45), p < 0.0001]. Significant interactions between BD and age and between BD and social deprivation were found, highlighting that the most important inequalities in mortality were observed in the youngest [OR, 95% CI 2.28 (1.18-4.41), p = 0.0015] and most deprived patients with BD [OR, 95% CI 1.60 (1.33-1.92), p < 0.001].

CONCLUSIONS

COVID-19 patients with BD were at an increased risk of mortality, which was exacerbated in the youngest and most deprived patients with BD. Patients with BD should thus be targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies.

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness

Background:

People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness.

Methods:

Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, emergency department visits and physician visits for comparison across the 2 cohorts.

Results:

During the 1-year follow-up period, a higher proportion of people in the cohort with a mental illness used any inpatient (27% vs 14%), emergency (63% vs 53%), or physician services (90% vs 76%) compared to the general homeless cohort. People from racialized groups were less likely use nearly all health services, most notably physician services. Other factors, such as reporting of a regular source of care, poor perceived general health, and diagnosed chronic conditions were associated with higher use of all health services except psychiatric inpatient care

Conclusion:

When implementing interventions for patients with the greatest health needs, we must consider the unique factors that contribute to higher healthcare use, as well as the barriers to healthcare access.

The Homeless People in China During the COVID-19 Pandemic: Victims of the Strict Pandemic Control Measures of the Government

Background: By implementing aggressive control measures, China has rapidly and effectively controlled the Coronavirus disease 2019 (COVID-19) pandemic. However, the neglected homeless population may become victims of that perceived success. Due to political sensitivity, we know little about them. Aims: This study aimed to investigate how the pandemic and the pandemic control strategies of the government affected the lives of the homeless people in mainland China. Methods: A total of 103 eligible participants experiencing absolute homelessness were recruited from Guangzhou City during July and August 2020. Surveys measured demographic characteristics including health status, changes in daily living, and actions of the government toward the homeless during the pandemic. Sankey diagrams and ordered logit regression models were used to examine the impact on the homeless of inhumane government efforts to drive the homeless away. Qualitative materials were analyzed by using an inductive approach to provide more details. Results: First, the homeless people in Guangzhou tended to be male, aged 40 to 64 years, less well-educated, and they originated from outside Guangdong although they were living in the city center. Most had little connection with their families. After a long period of homelessness, almost half of the participants were in poor health with various conditions, which made them extremely vulnerable to COVID-19. Second, the pandemic caused a substantial decline in incomes of homeless people, had less of a negative impact on their food intake, and affected sleep time in different ways. Third, during the COVID-19 pandemic, humanitarian aid from local governments of China decreased, whereas inhumane efforts to drive the homeless away intensified. Fourth, quantitative models and qualitative materials demonstrate the devastating effect of the strict pandemic control strategy of the government on the lives of homeless people, which may further cause their health problems. Conclusion: This study for the first time illustrated the characteristic features of the street homeless population in mainland China and their living situation during the COVID-19 pandemic, and most importantly demonstrated the devastating effect of the strict pandemic control of the government, which has been considered a great success in previous studies, on lives of homeless people. Urgent measures should be taken to ensure the protection of the homeless population and prevent an impending humanitarian crisis.

Homelessness: care for the most vulnerable - a narrative review of risk factors, health needs, stigma, and intervention strategies

PURPOSE OF REVIEW

To summarize the most recent literature on risk factors of homelessness, mental, and somatic health needs, healthcare use, stigma as well as intervention strategies for people experiencing homelessness.

RECENT FINDINGS

Studies identified adverse life events as well as mental health problems like drug use or suicidality as significant predictors of becoming homeless. Prevalence rates of mental disorders, especially substance use disorders, psychotic disorders, and depression are high. Barriers of healthcare use are financial resources and insurance status as well as experiences of discrimination. Aspects of trust and safety as well as age and gender were identified of high importance in the design of interventions. Strategies of permanent supportive housing like Housing First have shown a stable positive effect on housing stability, but not mental health outcomes. Peer support, forms of intensive case management, and harm reduction strategies are the most promising approaches to address these further needs.

SUMMARY

Exploration into the relationship of homelessness and mental health as well as adequate intervention strategies is far from being conclusive. Especially, the development of effective interventions addressing issues of trauma, stigma and discrimination, community integration, and mental health needs is still in its infancy.