Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal

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.

Homeless Outreach Psychiatric Engagement for Lisboa (HOPE 4 Lisboa): One year of marontology, and one John Doe living with Diogenes syndrome

BACKGROUND

In Europe, psychiatric disorders seem to affect up to 50% of the homeless. In Portugal there were, at a certain time, circa 3,396 homeless people, half living in the capital city, Lisboa.

AIMS

The Homeless Outreach Psychiatric Engagement for Lisboa (HOPE 4 Lisboa) was created, in January 1st 2022, as a collaboration including staff from the local state asylum, medical school and town hall in Lisboa, Portugal, in order to provide better treatment for the super difficult cases of psychiatric patients living homeless in Lisboa.

METHOD

During 2022, the HOPE 4 team made night rounds, every 15 days on Tuesday's night (20:30 to 23:30) trying to reach, at least, one dozen of homeless psychiatric patients, previously identified.

RESULTS

The HOPE 4 Lisboa interviewed 101 patients (53.4%) out of the 189 programed visits. From this group, 72 (72%) had already a previous psychiatric diagnosis. From those 101 patients, reports for 47 (47%) were sent for an eventual compulsory psychiatric assessment. From those 47 only 21 patients (21%) were admitted in the psychiatry ward. Finally we discuss the most super difficult patient we found, as a small case report: a John Doe living in complete Diogenes syndrome.

CONCLUSIONS

there are still a few psychiatrists interested in treating homeless people completely or partially out of the classic mental health care systems. Some claim to be doing interstitial psychiatry, others street psychiatry, but we could also call it marontology.

Personality and attachment in the homeless: A systematic review

BACKGROUND

Homeless people present high rates of psychopathology, including personality disorders. Given the link between personality disorders and attachment, and the potential importance of these two traits for understanding homeless populations.

AIMS

Our aim was to review all studies focusing on attachment and on the full assessment of personality disorders in the homeless.

METHOD

Overall, 213 studies were screened through title and abstract. Of these, 63 articles were chosen for full-text assessment.

RESULTS

A total of 14 articles met eligibility criteria and were included in the present review. Six studies evaluated personality disorders and eight studies assessed attachment in the homeless. In general, reports suggested that personality disorders are highly common in the homeless, with frequencies ranging between 64% and 79% for any personality disorder. The most common personality diagnoses were paranoid (14%-74%), borderline (6%-62%), avoidant (14%-63%), and antisocial (4%-57%) personality disorders. Attachment reports differed in the methods used and presented diverse results and correlates. Even so, insecure types of attachment dominated in the homeless, accounting for 62% to 100% of the samples.

CONCLUSIONS

The high prevalence of personality disorders and insecure types of attachment in the homeless may impact intervention strategies for these people. The available literature evaluating attachment and the full assessment of personality disorders in the homeless is scarce, which supports the need for more research on these two topics.

The revolving door phenomenon in severe psychiatric disorders: A systematic review

BACKGROUND

The treatment of psychiatric patients has suffered a major change over the last decades, with long-term hospitalizations being replaced by short-term stays and appropriate aftercare in outpatient services. Some chronically ill patients exhibit a pattern of multiple hospitalizations, designated as the Revolving Door (RD) phenomenon.

AIMS

This review aims to analyse the existing literature regarding sociodemographic, clinical and other factors associated with multiple hospitalizations in psychiatric facilities.

METHOD

The search performed in the PubMed database for the terms revolving[Title] AND (psyc*[Title] OR schizo*[Title] OR mental[Title]) presented 30 citations, 8 of which met the eligibility criteria. Four other studies found in references of these articles were also included in the review.

RESULTS

Albeit the use of different criteria to define the RD phenomenon, it is more likely to be associated with patients who are younger, single, with low educational level, unemployed, diagnosed with a psychotic disorder, particularly schizophrenia, and with alcohol and/or substance use. It is also associated with a younger age on disease onset, suicidality, noncompliance and voluntary type of admission.

CONCLUSION

Recognizing patients with a RD pattern of admissions and prediction of rehospitalization can help the development of preventive intervention strategies and identify potential limitations in existing health care delivery systems.

Problemas ligados ao álcool em centros de emergência (PLACE)-People experiencing homelessness with alcohol-related problems in Lisbon's emergency shelters during the COVID-19 pandemic: a description and analysis of a harm reduction intervention

Introduction

Alcohol-related problems disproportionally affect people experiencing homelessness. As the first wave of the COVID-2019 pandemic spread in 2020, a number of emergency shelters were opened in Lisbon. Increased difficulties in obtaining alcohol could have led to an increased incidence of alcohol withdrawal. Therefore, a low-threshold harm reduction intervention was introduced to these emergency shelters. This consisted of a fixed medication treatment, made available immediately for those with specific conditions, without the need for a medical evaluation or abstinence from alcohol, together with an offer of subsequent access to specialized addiction centers. The Problemas Ligados ao Álcool em Centros de Emergência (PLACE) study (alcohol-related problems in emergency shelters) is a retrospective mixed-methods observational study. It describes the demographic, health, and social characteristics of shelter users participating in the program and aims to evaluate the intervention as well as the experience of the patients, professionals, and decision-makers involved.

Results

A total of 69 people using shelters self-reported alcohol-related problems. Among them, 36.2% of the people accepted a pharmacological intervention, and 23.2% selected an addiction appointment. The take-up of the intervention was associated with better housing outcomes. A description of an individual's trajectory after leaving the shelter is provided.

Discussion

This study suggests that non-abstinence-focused interventions can be useful and well-tolerated in treating addiction in this population.

Schizoaffective disorder in homeless patients: A systematic review

BACKGROUND

Schizoaffective psychosis is a severe and chronic psychiatric disorder defined by the presence of mood symptoms, like mania and/or depression and schizophrenia, such as hallucinations and/or delusions.

AIMS

We aim to find out whether there is a correlation between schizoaffective psychosis and being homeless.

METHOD

To do so, a literature search was carried out in the PubMed platform in April 2022, using the keywords 'schizoaffective' and 'homeless'.

RESULTS

In this review, 28 articles from this search were included. Intrinsic characteristics, rates of psychiatric readmission, prediction of homelessness, medication noncompliance, and substance use were explored, as they were the main themes of the results.

CONCLUSIONS

The homeless population suffers from great diagnostic variability and the diagnosis schizoaffective psychosis is still evolving contributing to such diagnostic and treatment difficulties. Their frequent visits to the healthcare services, especially emergency room leads to consequent interaction with multiple healthcare professionals, resulting in a myriad of diagnoses, with clinical remission and therapeutic goals not being attained. More studies are necessary for a better evaluation of this super difficult population.