Tenure in supportive housing for homeless persons with severe mental illness

Effect of a Logotherapy-Based Empowerment Program for Achieving Self-Reliance Among Persons Living Houseless

The lives of houseless individuals are characterized by powerlessness, meaninglessness, hopelessness, and despair, yet they have a desire to escape homelessness. While the economic aspect is essential for escaping homelessness, psychological resources are crucial, as they form the basis of the strength needed to achieve independence. The study aimed to examine the effectiveness of a logotherapy-based empowerment program developed to strengthen the capabilities of persons living houseless and ultimately develop competencies that serve as a foundation for self-reliance. The study was performed in a homeless support center for men living houseless in South Korea using a repeated-measures design with a control group. The experimental group received an eight-session empowerment program over 8 weeks. The participants were assessed at three intervals: pretest, posttest immediately after the program, and follow-up test 4 weeks after the posttest. The follow-up tests were completed by 22 and 16 participants in the experimental and control groups, respectively. We found that the empowerment program significantly enhanced the meaning of life, hope, and empowerment of houseless individuals. Community mental health nurses, who are in a position to interact with persons living houseless, must empower them to escape homelessness and achieve self-reliance, an important goal for this population.

The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

Rates and Predictors of Returns to Homelessness Among Veterans, 2018-2022

INTRODUCTION

The progress made by the U.S. Department of Veterans Affairs toward ending veteran homelessness requires that attention be paid to preventing returns to homelessness.

METHODS

Using national Veterans Affairs data on 293,820 exits from a Veterans Affairs homeless program to a permanent housing destination between January 2018 and December 2022, rates and predictors of returns to homelessness among veterans were examined. Analyses were conducted in June-August 2023. A return to homelessness was operationally defined as a return encounter with a Veterans Affairs homeless program.

RESULTS

A total of 5.8% of successful exits to permanent housing resulted in a return to homelessness within 6 months, 10.2% resulted in a return within 12 months, and 16.7% resulted in a return within 24 months. In the total sample, veterans who were male (hazard ratio=1.47), were widowed (hazard ratio=1.29), had diagnoses of drug use disorder (hazard ratio=1.40) or psychotic disorder (hazard ratio=1.20), and had used more inpatient or urgent care services in the previous year (hazard ratio=1.05-1.15) were at significantly greater risk of returning to homelessness. Many of these predictors remained significant in subgroup analyses of female veterans, veterans aged ≥65 years, and veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing program.

CONCLUSIONS

Most homeless veterans served by Veterans Affairs who exit to permanent housing do not return to homelessness within two years. The most critical period seems to be the first year, when 1 in 10 veterans return to homelessness. Knowledge of these risk factors may be important in planning secondary and tertiary prevention efforts for homelessness.

Beyond Supported Housing: Correlates of Improvements in Quality of Life Among Homeless Adults with Mental Illness

BACKGROUND

The goal of supported housing, aside from exiting homelessness, is to improve overall quality of life. The contribution of factors that enhance quality of life in supported housing programs, beyond housing itself, have not been empirically identified.

METHODS

Five-year follow-up data from two arms of a randomized trial comparing case management with and without housing vouchers (n = 278) were examined to identify correlates of improved quality of life, beyond housing resources.

RESULTS

Access to a housing contributed to 4% of the variance in improved quality of life. Improvement in psychiatric symptoms, alcohol and drug use, employment, total income, and social support were associated with an additional 34-43% of variance in improved quality of life above and beyond housing.

CONCLUSION

Improvements in quality of life were more strongly associated with improvements in mental health and other aspects of social well-being than housing alone.

Homelessness and Vulnerably-Housed Defined: A Synthesis of the Literature

There is no single accepted definition used in policy or research for the concepts of homelessness and vulnerably housed. Neuman's systems model (NSM) was the framework for this mixed-studies review, with the client system defined as these social issues and categorized as environmental stressors. Eighteen unique definitions of the concepts were identified in 30 studies. Extrapersonal stressors included housing history, interpersonal stressors included dependence on others for housing, and intrapersonal stressors included self-identification. Each level of stressor should be considered when defining these populations for inclusion in future research. Proposed definitions were formulated from the analysis of the results.

Service utilisation changes in the transition to permanent supportive housing: The role of the housing environment and case management

This study examines whether routine, low-cost service use changes in the transition from homelessness to permanent supportive housing (PSH) and explores whether housing model, neighbourhood and level of case management engagement affect utilisation of routine services. Data come from a prospective longitudinal study of adults experiencing homelessness who entered PSH in Los Angeles between 2014 and 2016 and participated in four interviews: pre-housing (i.e., while experiencing homelessness), and 3, 6 and 12 months after move-in. Mixed effects logistic regression assessed the effects of demographics, case management, housing model and neighbourhood location on service utilisation at each time point across five domains: basic needs, financial, educational, mental health and physical health. Longitudinal unmet need for services and onsite service use contextualised findings. Service utilisation significantly decreased at each time point in the domains of basic needs, financial and mental health. Neighbourhood was significantly associated with basic needs and mental health service use, while housing model was associated with financial service utilisation. Case management was associated with all service use outcomes with all relationships demonstrating more case management visits was associated with greater odds of routine service utilisation. Unmet service needs were consistent over time. Onsite service utilisation was low across all residents. Results indicate that routine service use declines with length of tenancy while unmet need for services remain prevalent. Case management appears to be critical in facilitating routine service use, while the housing environment should be considered to ensure residents have accessible and proximal routine care.

Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities

People with disabilities can face substantial barriers to living stably in community settings. Evidence shows that permanent supportive housing (PSH), which combines subsidized housing with individualized support services, can improve housing stability among subpopulations of people with disabilities, including those with behavioral health conditions. PSH has also been shown to improve some health outcomes among people with severe mental illness or substance use disorder, but effects varied by participants' program tenure. This study assessed retention in a PSH program serving a broad population of adults with disabilities and identified factors associated with program tenure. Administrative data from 2093 individuals who began participating in a North Carolina PSH program between 2015 and 2018 were analyzed. Participants' unadjusted probability of remaining in a PSH placement at specific time points was estimated, with censoring due to death or the end of the study period (July 2020). Using Cox regression, program tenure was modeled as a function of participant and PSH placement location characteristics. Participants had a 71% probability of remaining in PSH after 2 years. Older age, female gender, and non-Hispanic Black race/ethnicity were associated with lower hazard of PSH departure. Having a severe mental illness diagnosis was associated with greater departure hazard. Level of socioeconomic deprivation and rurality of the PSH placement ZIP code were not associated with departure hazard. PSH programs may be able to successfully retain a heterogeneous population of adults with disabilities, although tenure may vary by participant demographic and clinical characteristics.

Exploring factors related to supportive housing tenure and stability for people with serious mental illness

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject. Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28 papers reveals that the factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

Accommodation-based interventions for individuals experiencing, or at risk of experiencing, homelessness

Background

Globally, almost 1.6 billion individuals lack adequate housing. Many accommodation-based approaches have evolved across the globe to incorporate additional support and services beyond delivery of housing.

Objectives

This review examines the effectiveness of accommodation-based approaches on outcomes including housing stability, health, employment, crime, wellbeing, and cost for individuals experiencing or at risk of experiencing homelessness.

Search Methods

The systematic review is based on evidence already identified in two existing EGMs commissioned by the Centre for Homelessness Impact (CHI) and built by White et al. The maps were constructed using a comprehensive three stage search and mapping process. Stage one mapped included studies in an existing systematic review on homelessness, stage two was an extensive search of 17 academic databases, three EGM databases, and eight systematic review databases. Finally stage three included web searches for grey literature, scanning reference lists of included studies and consultation with experts to identify additional literature. We identified 223 unique studies across 551 articles from the effectiveness map on 12th April 2019.

Selection Criteria

We include research on all individuals currently experiencing, or at risk of experiencing homelessness irrespective of age or gender, in high-income countries. The Network Meta-Analysis (NMA) contains all study designs where a comparison group was used. This includes randomised controlled trials (RCTs), quasi-experimental designs, matched comparisons and other study designs that attempt to isolate the impact of the intervention on homelessness. The NMA primarily addresses how interventions can reduce homelessness and increase housing stability for those individuals experiencing, or at risk of experiencing, homelessness. Additional outcomes are examined and narratively described. These include: access to mainstream healthcare; crime and justice; employment and income; capabilities and wellbeing; and cost of intervention. These outcomes reflect the domains used in the EGM, with the addition of cost.

Data Collection and Analysis

Due to the diverse nature of the literature on accommodation-based approaches, the way in which the approaches are implemented in practice, and the disordered descriptions of the categories, the review team created a novel typology to allow meaningful categorisations for functional and useful comparison between the various intervention types. Once these eligible categories were identified, we undertook dual data extraction, where two authors completed data extraction and risk of bias (ROB) assessments independently for each study. NMA was conducted across outcomes related to housing stability and health.Qualitative data from process evaluations is included using a "Best Fit" Framework synthesis. The purpose of this synthesis is to complement the quantitative evidence and provide a better understanding of what factors influenced programme effectiveness. All included Qualitative data followed the initial framework provided by the five main analytical categories of factors of influence (reflected in the EGM), namely: contextual factors, policy makers/funders, programme administrators/managers/implementing agencies, staff/case workers and recipients of the programme.

Main Results

There was a total of 13,128 people included in the review, across 51 reports of 28 studies. Most of the included studies were carried out in the United States of America (25/28), with other locations including Canada and the UK. Sixteen studies were RCTs (57%) and 12 were nonrandomised (quasi-experimental) designs (43%). Assessment of methodological quality and potential for bias was conducted using the second version of the Cochrane Risk of Bias tool for Randomised controlled trials. Nonrandomised studies were coded using the ROBINS- I tool. Out of the 28 studies, three had sufficiently low ROB (11%), 11 (39%) had moderate ROB, and five (18%) presented serious problems with ROB, and nine (32%) demonstrated high, critical problems with their methodology. A NMA on housing stability outcomes demonstrates that interventions offering the highest levels of support alongside unconditional accommodation (High/Unconditional) were more effective in improving housing stability compared to basic support alongside unconditional housing (Basic/Unconditional) (ES=1.10, 95% confidence interval [CI] [0.39, 1.82]), and in comparison to a no-intervention control group (ES=0.62, 95% CI [0.19, 1.06]). A second NMA on health outcomes demonstrates that interventions categorised as offering Moderate/Conditional (ES= 0.36, 95% CI [0.03, 0.69]) and High/Unconditional (ES = 0.22, 95% CI [0.01, 0.43]) support were effective in improving health outcomes compared to no intervention. These effects were smaller than those observed for housing stability. The quality of the evidence was relatively low but varied across the 28 included studies. Depending on the context, finding accommodation for those who need it can be hindered by supply and affordability in the market. The social welfare approach in each jurisdiction can impact heavily on support available and can influence some of the prejudice and stigma surrounding homelessness. The evaluations emphasised the need for collaboration and a shared commitment between policymakers, funders and practitioners which creates community and buy in across sectors and agencies. However, co-ordinating this is difficult and requires sustainability to work. For those implementing programmes, it was important to invest time in developing a culture together to build trust and solid relationships. Additionally, identifying sufficient resources and appropriate referral routes allows for better implementation planning. Involving staff and case workers in creating processes helps drive enthusiasm and energy for the service. Time should be allocated for staff to develop key skills and communicate engage effectively with service users. Finally, staff need time to develop trust and relationships with service users; this goes hand in hand with providing information that is up to date and useful as well making themselves accessible in terms of location and time.

Authors' Conclusions

The network meta-analysis suggests that all types of accommodation which provided support are more effective than no intervention or Basic/Unconditional accommodation in terms of housing stability and health. The qualitative evidence synthesis raised a primary issue in relation to context: which was the lack of stable, affordable accommodation and the variability in the rental market, such that actually sourcing accommodation to provide for individuals who are homeless is extremely challenging. Collaboration between stakeholders and practitioners can be fruitful but difficult to coordinate across different agencies and organisations.

The Effect of Various Supportive Housing Models on ART Adherence Among Persons Living With HIV in Supportive Housing

BACKGROUND

Providing permanent supportive housing to chronically homeless persons living with human immunodeficiency virus (PLH) contributes to improved human immunodeficiency virus (HIV) outcomes, including adherence to antiretroviral therapy (ART). This study seeks to understand whether certain components of housing, namely intensity of case management and specialized HIV housing programs, affects ART adherence for PLH in supportive housing.

METHODS

From 2015 to 2019 we conducted quantitative assessments with 157 PLH in supportive housing at baseline, 6-, 12-, and 18-month postbaseline to identify factors associated with ART adherence. General Estimating Equations for repeated measures were performed to assess bivariate and multivariate measures.

RESULTS

Two thirds of PLH in supportive housing reported 95% or greater adherence to ART. Multivariate analyses indicate that neither intensity of case management services nor specialized housing for PLH were associated with greater ART adherence. Greater time since diagnosis was positively associated with ART adherence. Greater depressive symptoms and African American race were negatively associated with ART adherence.

CONCLUSIONS

Study findings reveal that although prior research has established the importance of receipt of housing for homeless PLH, the type or intensity of case management services associated with that housing may not be as important as simply being housed. Our results highlight the importance of considering mental health and more recent HIV diagnosis when developing treatment and case management plans to enhance residents' ART adherence.

Supported Housing as a recovery option for long-stay patients with severe mental illness in a psychiatric hospital in South India: Learning from an innovative de-hospitalization process

Individuals with severe mental illness have long been segregated from living in communities and participating in socio- cultural life. In recent years, owing to progressive legislations and declarations (in India and globally), there has been a growing movement towards promoting social inclusion and community participation, with emphasis on the need to develop alternative and inclusive care paradigms for persons with severe mental illness. However, transitions from inpatient care to community settings is a complex process involving implications at multiple levels involving diverse stakeholders such as mental health service users, care providers, local communities and policy makers. This article studies how the transition from a hospital setting to a community-based recovery model for personals with severe mental illness can be facilitated. It reflects on the innovative process of creating a Supported Housing model in South India, where 11 MH Service users transitioned from a psychiatric ECRC to independent living facilities. Experiences in various phases of the project development, including care provider- and community level responses and feedback were scrutinised to understand the strategies that were employed in enabling the transition. Qualitative methods (including in-depth interviews and naturalistic observations) were used with residents and staff members to explore the challenges they encountered in stabilizing the model, as well as the psychosocial benefits experienced by residents in the last phase. These were complemented with a Brief Psychiatric Rating Scale (BPRS) and WHO Quality of Life scale to compare baseline and post-assessment results and an increase of quality of life. Results display a significant reduction of psychiatric symptoms in patients (p< 0.5). It also describes the challenges encountered in the current context, and strategies that were used to respond and adapt the model to address these concerns effectively. Positive behavioural and psycho-emotional changes were observed amongst the residents, significant amongst those being enhanced in their mobility and participation. The article concludes by discussing the implications of this study for the development of innovative community-based models in wider contexts.

The Effectiveness of Mental Health Rehabilitation Services: A Systematic Review and Narrative Synthesis

Introduction: Mental health rehabilitation services provide essential support to people with complex and longer term mental health problems. They include inpatient services and community teams providing clinical input to people living in supported accommodation services. This systematic review included international studies evaluating the effectiveness of inpatient and community rehabilitation services. Methods: We searched six online databases for quantitative studies evaluating mental health rehabilitation services that reported on one or both of two outcomes: move-on to a more independent setting (i.e. discharge from an inpatient unit to the community or from a higher to lower level of supported accommodation); inpatient service use. The search was further expanded by screening references and citations of included studies. Heterogeneity between studies was too great to allow meta-analysis and therefore a narrative synthesis was carried out. Results: We included a total of 65 studies, grouped as: contemporary mental health rehabilitation services (n = 34); services for homeless people with severe mental health problems (n = 13); deinstitutionalization programmes (n = 18). The strongest evidence was for services for homeless people. Access to inpatient rehabilitation services was associated with a reduction in acute inpatient service use post discharge. Fewer than one half of people moved on from higher to lower levels of supported accommodation within expected timeframes. Conclusions: Inpatient and community rehabilitation services may reduce the need for inpatient service use over the long term but more high quality research of contemporary rehabilitation services with comparison groups is required. Review registration: This review was prospectively registered on PROSPERO (ID: CRD42019133579).

Systematic review and meta-analyses of randomized control trials of the effectiveness of psychosocial interventions for homeless adults

AIMS

To evaluate the effect of psychosocial interventions for homeless adults on their psychosocial outcomes.

DESIGN

A systematic review and meta-analyses were performed for critical appraisal and synthesis of the included studies.

DATA SOURCES

A systematic search of studies published before 10 September 2018 was performed using PubMed, Cochrane Library, EMBASE, PsycINFO, and CINAHL.

REVIEW METHODS

The review included randomized controlled trials conducting psychosocial interventions and assessing psychosocial outcomes for homeless adults. After systematically describing study and intervention characteristics, we conducted meta-analyses by the type of outcome and subgroup meta-analyses by the type of intervention and outcome. Fourteen studies were included in this review and 11 were included in the meta-analyses.

RESULTS

A significant effect of psychosocial interventions in reducing anxiety and enhancing mental health status among homeless adults was noted.

CONCLUSION

The meta-analyses showed that psychosocial interventions may reduce anxiety and enhance the mental health status of homeless people. Specifically, we suggest that relaxation response training may be effective in improving anxiety and mental health status and cognitive behavioural therapy may reduce anxiety.

IMPACT

Although psychosocial interventions for homeless persons have been implemented for a decade, their impact for psychosocial outcomes among homeless adults has not been evaluated. This review suggest that psychosocial interventions may improve anxiety and mental health status among homeless adults. The findings of the present study may provide directions for developing psychosocial interventions to help vulnerable homeless adults in managing psychological outcomes.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks

AIMS

Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood.

METHODS

Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes.

RESULTS

Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective.

CONCLUSION

Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

Unmet needs of persons with a severe and persistent mental illness and their relationship to unmet accommodation needs

This is a cross-sectional study of unmet needs of persons enrolled in Australia's Partners in Recovery (PIR) initiative. It aimed to explore the unmet needs reported by persons with a severe and persistent mental illness (SPMI) and to examine the associations between unmet accommodation needs and other unmet needs. The study was undertaken in the Gippsland region of Victoria from February to May 2015. Data were collected from the administrative database for the PIR initiative in Gippsland, which was held by the Gippsland Primary Health Network. Data on unmet needs, as measured by the Camberwell Assessment of Needs Short Appraisal Schedule, were analysed using proportions and logistic regression. Psychological distress, daytime activities, company/someone to spend time with and employment and volunteering were the most commonly reported unmet needs. Participants with unmet accommodation needs were less likely to receive information on their condition or access other services. They also had unmet needs relating to food, money, transport, childcare, looking after home, physical health, psychological distress and self-care. Supported accommodation may not be enough for persons with SPMI who have poor functioning skills and are incapable of looking after themselves. Services such as Housing First that have shown promising results need to be part of a comprehensive strategy to care for persons with severe and enduring mental illness.

Social networks and substance use after transitioning into permanentsupportive housing

BACKGROUND

Substance use disorders are common among persons experiencing homelessness, and research has identified social networks as important correlates of substance use in this population. Permanent supportive housing (PSH), particularly Housing First, which uses a harm reduction model not requiring substance abstinence, is a key solution for ending homelessness. However, conflicting evidence exists regarding the associations between moving into PSH and changes in substance use, and there is limited understanding of how networks may influence such changes.

METHODS

Using observational, longitudinal data from 421 persons before they moved in and over their first year in PSH (collected as part of a HIV-risk study), this paper assesses substance use change (alcohol, marijuana, and illicit drugs) and associations between perceived network characteristics and individual substance use.

RESULTS

Substance use remained relatively stable among participants over their first year living in PSH, although illicit substance use reduced somewhat at six months compared to baseline levels (from 18.5%-14.5%) and marijuana use increased slightly at 12 months (from 26.6% at baseline to 32.9%). Substance use among social network members was consistently associated with individual-level substance use, both cross-sectionally and longitudinally. Specific network substance use characteristics, such as proximity, location met, and social support, had differential relationships with particular substance types.

CONCLUSIONS

These findings provide longitudinal evidence that changes within substance-using social networks are associated with subsequent changes in individual use and underscore the importance of interventions aimed at promoting positive social relationships for formerly homeless persons and improving PSH's social environments.

Barriers and facilitators to housing access and maintenance in HUD-VASH: Participant and staff perspectives

Though the U.S. Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA) supportive housing (HUD-VASH) program endeavors to address barriers to Veterans accessing and maintaining housing, participants report challenges that lead to program exits. This study aims to understand participants' views on the factors contributing to their exits from HUD-VASH, as well as how program staff may respond to challenges. This mixed methods study includes four sources of data: (1) surveys with Veterans, (2) semi-structured interviews with a subsample of surveyed Veterans, (3) Veterans' administrative data from VA electronic data systems, and (4) focus groups with staff from local public housing authorities and VA case management teams. Veterans reported barriers to housing access (e.g., difficult procedures, lack of communication, lack of affordable and adequate housing stock) and housing maintenance (e.g., program rules, mental health and substance use, access to resources), and staff described strategies devised, at the local level, in response to these issues (e.g., better engagement with property owners, funds for deposits and household goods, increased interagency collaboration through HUD-VASH Boot Camps). Findings can inform communities seeking to eliminate Veteran homelessness through HUD-VASH and other supported housing programs.

How do Housing Subsidies Improve Quality of Life Among Homeless Adults? A Mediation Analysis

Supported housing, combining rent subsidies with intensive case management, is associated with improvements in quality of life of homeless adults, but factors mediating their impact on quality of life have not been studied. Twelve-month outcome data from a randomized trial of the Housing and Urban Development- Veterans Affairs Supported Housing program (HUD-VASH) showed that access to a housing rent subsidy plus intensive case management (ICM) was associated with greater improvement in subjective quality of life than ICM alone. Multiple mediation analyses were applied to identify variables that significantly mediated the relationship between receipt of housing voucher and improvements in quality of life. Significant mediating covariates were those whose 95% bias-corrected confidence intervals, when added to the model predicting improvement in quality of life, did not overlap zero. Increases in the number of days housed, size of social network, and availability of emotional support appear to mediate improvement in quality of life and account for 71% of the benefit attributable to having a rent subsidy. Improvement in subjective quality of life though housing subsidies is mediated by gains in both material and psychosocial factors. Mediating factors deserve special attention in supported housing services.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes

BACKGROUND

Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services.

METHODS

Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'.

RESULTS

Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research.

CONCLUSIONS

A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes

Supportive housing has become the dominant model in the United States to provide housing to the chronically homeless and to improve their housing stability and health. Most supportive housing programs follow a "housing first" paradigm modeled after the Pathways to Housing program in New York City. However, components of housing first supportive housing models were poorly defined, and supportive models have varied considerably in their dissemination and implementation to other parts of the country. Recently, research has been conducted to determine the fidelity by which specific housing programs adhere to the Pathways Housing First model. However, evidence regarding which combination of components leads to better health outcomes for particular subpopulations is lacking. This article presents results from qualitative interviews with supportive housing providers in the Chicago, Illinois, metropolitan area. Supportive housing varied according to housing configuration (scattered-site vs. project-based) and service provision model (low-intensity case management, intensive case management and behavioral health), resulting in 6 basic types. Supportive housing programs also differed in services they provided in addition to case management and the extent to which they followed harm-reduction versus abstinence policies. Results showed advantages and disadvantages of each of the 6 basic types. Comparative effectiveness research may help identify which program components lead to better health outcomes among different subpopulations of homeless. Future longitudinal research will use the identified typology and other factors to compare the housing stability and health outcomes of supportive housing residents in programs that differ along these dimensions. (PsycINFO Database Record

The relationship between housing subsidies and supportive housing on neighborhood distress and housing satisfaction: does drug use make a difference?

Background

Since the 1970s, the dominant model for U.S. federal housing policy has shifted from unit-based programs to tenant-based vouchers and certificates. Because housing vouchers allow recipients to move to apartments and neighborhoods of their choice, such programs were designed to improve the ability of poor families to move into neighborhoods with less concentrated poverty. However, little research has examined whether housing voucher recipients live in less distressed neighborhoods than those without housing vouchers. There is much reason to believe that drug users may not be able to access or keep federal housing subsidies due to difficulties drug users, many of whom may have criminal histories and poor credit records, may have in obtaining free market rental housing. In response to these difficulties, permanent supportive housing was designed for those who are chronically homeless with one or more disabling condition, including substance use disorders. Little research has examined whether residents of permanent supportive housing units live in more or less economically distressed neighborhoods compared to low-income renters.

Methods

This paper uses survey data from 337 low-income residents of Hartford, CT and geospatial analysis to determine whether low-income residents who receive housing subsidies and supportive housing live in neighborhoods with less concentrated poverty than those who do not. We also examine the relationships between receiving housing subsidies or supportive housing and housing satisfaction. Finally, we look at the moderating effects of drug use and race on level of neighborhood distress and housing satisfaction.

Results

Results show that low-income residents who receive housing subsidies or supportive housing were not more or less likely to live in neighborhoods with high levels of distress, although Black residents with housing subsidies lived in more distressed neighborhoods. Regarding housing satisfaction, those with housing subsidies perceived significantly more choice in where they were living while those in supportive housing perceived less choice. In addition, those with rental subsidies or supportive housing reported living closer to needed services, unless they also reported heavy drug use.

Conclusions

Housing subsidies and supportive housing have little impact on the level of neighborhood distress in which recipients live, but some effects on housing satisfaction.

The self-efficacy model of medication adherence in chronic mental illness

AIM

In this position paper, the self-efficacy model of medication adherence in chronic mental illness is presented, and its application to antipsychotic medication adherence is considered.

BACKGROUND

Poor adherence to antipsychotic medications is common in chronic mental illness. Major implications of this are relapse and re-hospitalisation. Several conceptual frameworks have been developed about adherence and, in some instances, have been incorporated in medication taking studies, but have resulted in inconsistent outcomes.

METHOD

This paper draws on a review of literature from databases to inform the development of the self-efficacy model of medication adherence. Inclusion and exclusion criteria were developed from primary and secondary research questions.

RESULTS

The model places the person with chronic mental illness as an active participant central to the process of medication taking. It has three components: core factors, contextual influences and a continuum. The factors comprise a central factor, self-efficacy and four interrelated supporting influences: perceived medication efficacy; access to, and relationships with, health professionals; significant other support and supported living circumstances. The factors are affected by three broad contextual influences - personal issues, medication side-effects and complexity, and social stigma - which affect the way individuals take their medications. A continuum exists between adherence and non-adherence.

CONCLUSION

The model positions service users at the heart of adherence by giving prominence to self-efficacy, medication efficacy and to immediate social, psychological and environmental supports. Further work is needed to validate, refine and extend the model.

RELEVANCE TO CLINICAL PRACTICE

For practitioners involved in prescribing and medication management in people with chronic mental illness, the model provides a theoretical framework to strengthen adherence. It highlights the need to consider broader influences on medication taking. Moreover, it places the person with chronic mental illness as an active participant at the centre of strategies to enhance adherence.

Development of a Measure of Housing and Housing Services

The Housing Program Measure (HPM) was designed to document critical elements of a range of housing program types and associated services. Qualitative methods, including literature review and open-ended interviews, were used to determine pertinent HPM domains and to develop the pool of items. The measure was pre-tested, and reliability and validity analyses were applied to revise and strengthen the measure. The resulting measure furthers homelessness research by providing a tool that can be used to define housing and housing services interventions across diverse projects and disciplines, to facilitate program management by matching housing resources to the needs of homeless individuals, and to support model development by measuring progress to goals.

Changes in daily substance use among people experiencing homelessness and mental illness: 24-month outcomes following randomization to Housing First or usual care

AIMS

Housing First (HF) is an established intervention for people experiencing homelessness and mental illness. We compared daily substance use (DSU) between HF and treatment as usual (TAU).

DESIGN

Two concurrent randomized controlled trials with 24-month follow-up.

SETTING

Market rental apartments with support provided by Assertive Community Treatment (ACT) or Intensive Case Management (ICM); a single building with on-site supports (CONG); TAU in Vancouver, Canada.

PARTICIPANTS

Inclusion criteria were current homelessness and mental illness. Participants were assessed as having either 'high needs' (HN; n = 297) or 'moderate needs' (MN; n = 200). MN participants were randomized to ICM (n = 100) or MN-TAU (n = 100). HN participants were randomized to ACT (n = 90), CONG (n = 107) or HN-TAU (n = 100).

INTERVENTIONS AND COMPARATORS

All HF interventions included independent housing with support services, with an emphasis on promoting client choice and harm reduction in relation to substance use. TAU included existing services and support available to homeless adults with mental illness.

MEASUREMENTS

DSU over 24 and 12 months was derived from the Maudsley Addiction Profile. Also measured were demographics, homelessness history, psychiatric diagnoses, symptom severity, comorbid illnesses and duration of stable housing.

FINDINGS

Compared with HN-TAU, neither CONG [adjusted odds (AOR) ratio = 0.73, 95% confidence interval (CI) = 0.39-1.37] nor ACT (AOR = 1.22, 95% CI = 0.61-2.45) differed on DSU at 24 months, and MN-TAU did not differ from ICM (AOR = 0.78, 95% CI = 0.37-1.63). There were no differences at 12 months, when analyses were restricted to participants who indicated substance use at baseline, or when considering the duration of stable housing.

CONCLUSIONS

Housing First, an intervention to support recovery for homeless people who have co-occurring mental illness and substance use disorders, did not reduce daily substance use compared with treatment as usual after 12 or 24 months.

Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre

OBJECTIVE

The over-representation of mental illness among homeless people across the globe is well documented. However, there is a dearth of Australian literature on the mental health needs of homeless individuals. Furthermore, longitudinal research examining the factors that contribute to better housing outcomes among this population is sparse. The aim of this research is to describe the mental illness profile of a sample of homeless men in an Australian urban centre (in Sydney) and examine the factors associated with better housing outcomes at 12-month follow-up.

METHODS

A longitudinal survey was administered to 253 homeless men who were involved in the Michael Project: a 3-year initiative which combined existing accommodation support services with assertive case management and access to coordinated additional specialist allied health and support services. A total of 107 participants were followed up 12 months later. The survey examined the demographics of the sample and lifetime mental disorder diagnoses, and also included psychological screeners for current substance use and dependence, psychological distress, psychosis, and post-traumatic stress.

RESULTS

Consistent with existing literature, the prevalence of mental illness was significantly greater amongst this sample than the general Australian population. However, mental illness presentation was not associated with housing situation at 12-month follow-up. Instead, type of support service at baseline was the best predictor of housing outcome, wherein participants who received short to medium-term accommodation and support were significantly more likely to be housed in stable, long-term housing at the 12-month follow-up than participants who received outreach or emergency accommodation support.

CONCLUSIONS

This study provides evidence to support an innovative support model for homeless people in Australia and contributes to the limited Australian research on mental illness in this population.

The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness

BACKGROUND

There is strong evidence that Housing First interventions are effective in improving housing stability and quality of life among homeless people with mental illness and addictions. However, there is very little evidence on the effectiveness of Housing First in improving substance use-related outcomes in this population. This study uses a randomized control design to examine the effects of scatter-site Housing First on substance use outcomes in a large urban centre.

METHODS

Substance use outcomes were compared between a Housing First intervention and treatment as usual group in a sample of 575 individuals experiencing homelessness and mental illness, with or without a co-occurring substance use problem, in the At Home/Chez Soi trial in Toronto, Canada. Generalized linear models were used to compare study arms with respect to change in substance use outcomes over time (baseline, 6, 12, 18 and 24 month).

RESULTS

At 24 months, participants in the Housing First intervention had significantly greater reductions in number of days experiencing alcohol problems and amount of money spent on alcohol than participants in the Treatment as Usual group. No differences between the study arms in illicit drug outcomes were found at 24 months.

CONCLUSIONS

These findings show that a Housing First intervention can contribute to reductions in alcohol problems over time. However, the lack of effect of the intervention on illicit drug problems suggests that individuals experiencing homelessness, mental illness and drug problems may need additional supports to reduce use.

TRIAL REGISTRATION

Current controlled trials ISRCTN42520374.

Aging in place within permanent supportive housing

OBJECTIVES

This study examined whether and how permanent supportive housing (PSH) programs are able to support aging in place among tenants with serious mental illness.

DESIGN

Investigators used a mixed-method approach known as a convergent parallel design in which quantitative and qualitative data are analyzed separately and findings are merged during interpretation. Quantitative analysis compared 1-year pre-residential and post-residential outcomes for PSH program enrollees, comparing adults aged 35-49 years (n = 3990) with those aged 50 years or older (n = 3086). Case study analysis using qualitative interviews with staff of a PSH program that exclusively served older adults identified challenges to providing support services.

RESULTS

Substantial declines in days spent homeless and in justice system settings were found, along with increases in days living independently in apartments and in congregate settings. Homelessness and justice system involvement declined less for older adults than younger adults. Qualitative themes related to working with older adults included increased attention to medical vulnerability, residual effects of institutional care, and perceived preference for congregate living.

CONCLUSIONS

PSH is an effective way to end homelessness, yet little is known about how programs can support housing stability among aging populations. Additional support and training for PSH staff will better promote successful aging in place.

Developing community support for homeless people with mental illness in transition

To facilitate effective transitional services and enhance continuity of care among people with mental illness, this grounded theory study explored the practice of developing community support in critical time intervention (CTI), a time-limited, shortterm psychosocial rehabilitation program designed to facilitate the critical transition from institutional to community settings. Semi-structured, one-on-one interviews with twelve CTI workers were analyzed. Results show that CTI workers self-identified as an "extra support" to develop community ties that will help clients sustain stable housing. Their practice of community support development was represented by a transient triangular relationship model, involving three dyadic relationships (worker-client, worker-primary support, primary support-client) as the building blocks and specific strategies to facilitate the relational transition. Findings also detailed identification of community supports, collaboration and boundary issues in working with primary supports, and engagement with clients in this transitional process. Recommendations were drawn from findings to enhance broad discharge and transitional services.

Risk factors associated with recurrent homelessness after a first homeless episode

Alcohol and drug use are commonly associated with the experience of homelessness. In order to better understand this, we explored the prevalence of drug and alcohol use as it related to successful re-housing within a sample of first-time single homeless adults at municipal shelters. From within this sample, we compared the features of recurrent homelessness with those of chronic homelessness and of being stably housed. We interviewed 344 subjects upon shelter entry and followed each one every six months for 18 months using standardized social and mental health measures. We analyzed baseline assessments relative to housing experiences during follow-up using Chi square and multinomial logistic regression. Eighty-one percent (N = 278) obtained housing over 18 months, of which 23.7 % (N = 66) experienced homelessness again. Recurrent homelessness was more common among those with a high school education and if initially re-housed with family. Bivariate analysis resulted in the observation of the highest rate of alcohol and other drug use among this recurrent group and multinomial logistic regression supported this only with the coupling of arrest history and diagnosed antisocial personality disorder. With relatively high rates of recurrent homelessness, there were differences between subjects who experienced recurrent homelessness compared to those who were stably housed and with chronic homelessness. That alcohol and other substance use disorders were associated with recurrent homelessness only if they were linked to other risk factors highlights the complexity of causes for homelessness and a resultant need to organize them into constellations of causal risk factors. Consistent with this, there should be initiatives that span bureaucratic boundaries so as to flexibly meet multiple complex service needs, thus improving outcomes concerning episodes of recurrent homelessness.

Understanding Housing Delays and Relocations Within the Housing First Model

This study explores factors contributing to delays and relocations during the implementation of the Housing First model in Toronto, Ontario. While interruptions in housing tenure are expected en route to recovery and housing stability, consumer and service provider views on finding and keeping housing remain largely unknown. In-person interviews and focus groups were conducted with 48 study participants, including 23 case managers or housing workers and 25 consumers. The following three factors contributed to housing delays and transfers: (1) the effectiveness of communication and collaboration among consumers and service providers, (2) consumer-driven preferences and ambivalence, and (3) provider prioritization of consumer choice over immediate housing access. Two strategies--targeted communications and consumer engagement in housing searches--supported the housing process. Several factors affect the timing and stability of housing. Communication between and among providers and consumers, and a shared understanding of consumer choice, can further support choice and recovery.

Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes

This study examines the prevalence of alcohol and drug disorders among homeless veterans entering the Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program and its association with both housing and clinical outcomes. A total of 29,143 homeless veterans were categorized as either having: no substance use disorder, only an alcohol use disorder, only a drug use disorder, or both alcohol and drug use disorders. Veterans were compared on housing and clinical status prior to admission to HUD-VASH and a smaller sample of 14,086 HUD-VASH clients were compared on their outcomes 6 months after program entry. Prior to HUD-VASH, 60% of program entrants had a substance use disorder and 54% of those with a substance use disorder had both alcohol and drug use disorders. Homeless veterans with both alcohol and drug use disorders had more extensive homeless histories than others, and those with any substance use disorder stayed more nights in transitional housing or residential treatment in the previous month. After six months in HUD-VASH, clients with substance use disorders continued to report more problems with substance use, even after adjusting for baseline differences, but there were no differences in housing outcomes. These findings suggest that despite strong associations between substance use disorders and homelessness, the HUD-VASH program is able to successfully house homeless veterans with substance use disorders although additional services may be needed to address their substance abuse after they become housed.

Measuring community integration using Geographic Information Systems (GIS) and participatory mapping for people who were once homeless

Measures of community integration rely on self-report assessments that often quantify physical or social participation, but fail to capture the individual׳s spatial presence in the community. The current study documents the activity space, or area of daily experiences, of 37 individuals who were once homeless through participatory mapping and Geographic Information Systems (GIS). Contrary to expectations, there was no significant relationship between activity space size and community integration measures, except a negative association with physical integration. Further analysis revealed, however, that continued use of homeless services, geographically spread throughout the city, was associated with larger activity space size, but may be counterproductive to social and psychological integration efforts. Analysis of the types of locations identified revealed high importance given to leisure locations and ongoing involvement with medical and mental health locations. Finally, community integration outcomes did not differ significantly by demographics or housing type, but rather degree of family involvement and feeling like home, factors that may have more potential for change.

Housing retention in single-site housing first for chronically homeless individuals with severe alcohol problems

OBJECTIVES

We studied housing retention and its predictors in the single-site Housing First model.

METHODS

Participants (n = 111) were chronically homeless people with severe alcohol problems who lived in a single-site Housing First program and participated in a larger nonrandomized controlled trial (2005-2008) conducted in Seattle, Washington. At baseline, participants responded to self-report questionnaires assessing demographic, illness burden, alcohol and other drug use, and psychiatric variables. Housing status was recorded over 2 years.

RESULTS

Participants were interested in housing, although a sizable minority did not believe they would be able to maintain abstinence-based housing. Only 23% of participants returned to homelessness during the 2-year follow-up. Commonly cited risk factors--alcohol and other drug use, illness burden, psychiatric symptoms, and homelessness history--did not predict resumed homelessness. Active drinkers were more likely to stay in this housing project than nondrinkers.

CONCLUSIONS

We found that single-site Housing First programming fills a gap in housing options for chronically homeless people with severe alcohol problems.

Vancouver At Home: pragmatic randomized trials investigating Housing First for homeless and mentally ill adults

BACKGROUND

Individuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented.

METHODS

Eligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data.

RESULTS

Participants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data.

CONCLUSION

The study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).

Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders

OBJECTIVES

We examined the relationship between substance dependence and residential stability in homeless adults with current mental disorders 12 months after randomization to Housing First programs or treatment as usual (no housing or support through the study).

METHODS

The Vancouver At Home study in Canada included 2 randomized controlled trials of Housing First interventions. Eligible participants met the criteria for homelessness or precarious housing, as well as a current mental disorder. Residential stability was defined as the number of days in stable residences 12 months after randomization. We used negative binomial regression modeling to examine the independent association between residential stability and substance dependence.

RESULTS

We recruited 497 participants, and 58% (n = 288) met the criteria for substance dependence. We found no significant association between substance dependence and residential stability (adjusted incidence rate ratio = 0.97; 95% confidence interval = 0.69, 1.35) after adjusting for housing intervention, employment, sociodemographics, chronic health conditions, mental disorder severity, psychiatric symptoms, and lifetime duration of homelessness.

CONCLUSIONS

People with mental disorders might achieve similar levels of housing stability from Housing First regardless of whether they experience concurrent substance dependence.

Impact of a housing first program on health utilization outcomes among chronically homeless persons

The authors examined the impact of a Housing First program on the use of specific health services, detoxification services, and criminal activity of long-term homeless individuals. The study sample consisted of eligible members of the inception cohort (18 enrollees) in the Single Adults Residential Assistance program (SARA) in Minneapolis, Minnesota. Analyses examined participant housing stability after enrollment in SARA and compared the use of a county medical center, detoxification programs, and criminal activity in the 2 years before and after enrollment in SARA. Only 1 of the 18 enrollees studied experienced homelessness during the 2-year follow-up after enrollment in SARA. There was a significant reduction in the amount of criminal activity in the 2-year period after SARA enrollment. The direction of association observed for other service uses remained consistent with expectations in existing literature, but were not statistically significant. Supportive housing for chronically homeless individuals may be successful at decreasing homelessness among this fragile population and may help reduce criminal activity.

A domains-based taxonomy of supported accommodation for people with severe and persistent mental illness

PURPOSE

A lack of definitional clarity in supported accommodation and the absence of a widely accepted system for classifying supported accommodation models creates barriers to service planning and evaluation.

METHODS

We undertook a systematic review of existing supported accommodation classification systems. Using a structured system for qualitative data analysis, we reviewed the stratification features in these classification systems, identified the key elements of supported accommodation and arranged them into domains and dimensions to create a new taxonomy. The existing classification systems were mapped onto the new taxonomy to verify the domains and dimensions.

RESULTS

Existing classification systems used either a service-level characteristic or programmatic approach. We proposed a taxonomy based around four domains: duration of tenure; patient characteristics; housing characteristics; and service characteristics. All of the domains in the taxonomy were drawn from the existing classification structures; however, none of the existing classification structures covered all of the domains in the taxonomy.

CONCLUSIONS

Existing classification systems are regionally based, limited in scope and lack flexibility. A domains-based taxonomy can allow more accurate description of supported accommodation services, aid in identifying the service elements likely to improve outcomes for specific patient populations, and assist in service planning.

Subjective Experiences of Clients in a Voluntary Money Management Program

A large proportion of people diagnosed with mental illnesses have difficulty managing their money, and therefore many psychiatric treatments involve providing money management assistance. However, little is known about the subjective experience of having a money manager, and extant literature is restricted to people forced to work with a representative payee or conservator. In this study, fifteen people were interviewed about their experience receiving a voluntary money management intervention designed to minimize substance use. Clients emphasized the importance of trusting the money manager, financial mindfulness (an enhanced awareness of the financial transactions in clients' day-to-day lives), agency over their own affairs, and addiction. In contrast to evaluations of people assigned representative payees and/or conservators, there was little mention of feeling coerced. These findings suggest that money management programs can address client concerns by building trust, relating budgeting to clients' day-to-day lives, and encouraging clients' control over their own affairs.

Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

Background

The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.

Methods

Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.

Results

The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.

Conclusions

Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

"I hope I can make it out there": perceptions of women with severe mental illness on the transition from hospital to community

This study explores the experience of women with severe mental illness in transition from psychiatric hospital care to the community. Three focus groups were conducted among women with severe mental illness from transitional residences at two state psychiatric hospitals. Focus group transcripts and notes were coded according to women's perceived challenges and facilitators of transition. Participants described several challenges including fear of insufficient treatment support, safety concerns, social isolation, stigma, and lack of resources to meet daily needs. The supports that women described as important were an orientation to the neighborhood and residence, access to treatment support with flexibility, and connection to social supports.

Housing satisfaction among chronically homeless adults: identification of its major domains, changes over time, and relation to subjective well-being and functional outcomes

There is limited consensus on the critical domains of housing satisfaction among chronically homeless adults and little information on changes in housing satisfaction over time or whether housing satisfaction at initial entry into housing is correlated with subsequent subjective well-being or other outcomes. The current study tracked housing satisfaction over a 2-year period in a multi-site supported housing initiative and examined the predictive value of clients' housing satisfaction when they were first housed on various subjective and functional outcomes. A total of 756 participants from 11 sites were enrolled in the study. Six domains of housing satisfaction were identified: good environment, control and consumer choice, physical quality, geographic proximity to desirable resources, positive case manager contact, and frequency of landlord interaction. Over 2 years, there were slight declines in housing satisfaction on physical quality of housing and satisfaction with case manager contact, and an increase in satisfaction with landlord interaction. Consistent with some previous research, housing satisfaction was not predictive of housing tenure, clinical outcomes, or duration of program participation. While becoming housed is a significant gain for chronically homeless people, their satisfaction with housing did not predict functional outcomes.

Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories

OBJECTIVES

Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use.

METHODS

A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records.

RESULTS

Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes.

CONCLUSIONS

Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.

Helping homeless individuals with co-occurring disorders: the four components

Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

The 'check effect' reconsidered

AIMS

The 'check effect' refers to the use of disability payments to purchase illegal drugs or alcohol. This paper describes subsequent research concerning three interrelated issues: the check effect, whether receipt of disability payments is associated with more overall substance use, and potential policy responses to misuse of disability payments for substances.

METHODS

Review and synthesis of published papers.

RESULTS

Increased substance use at the beginning of the month has been described in a variety of settings. The tendency to purchase substances at the beginning of the month is impacted by household wealth, the tendency to discount future rewards and cyclical economic activity. However, in naturalistic observational cohort studies, beneficiaries who receive disability payments had no greater substance use than those without disability payments. Potential policy responses to mis-spending of disability checks include financial counseling that discourages spending on drugs and the assignment of a representative payee to prevent misuse of benefits for substances. Assignment of a representative payee per se has not been associated with reduced substance use, but payeeship administered by agencies that integrate payee practice into treatment has been.

CONCLUSION

Disability payments impact the timing of substance use, but receipt of disability payments is not associated with more overall substance use than unalleviated poverty. Money management-based clinical interventions, which may involve assignment of a representative payee, can minimize the purchase of substances with disability payments.

Studies of "supported" and "supportive" housing: a comprehensive review of model descriptions and measurement

Supported housing is a service model that couples provision of independent housing with provision of community-based supports for individuals with psychiatric disabilities at risk of homelessness. Despite its promise as an alternative to traditional sequential residential rehabilitation programs, supported housing has not been evaluated to an extent that supports firm conclusions concerning the efficacy of specific program elements. We conducted a comprehensive review of the literature on supported housing and similarly labeled programs, to determine the degree of clarity in the supported housing model and the degree of fidelity to that model within the empirical literature, and to determine whether lack of clarity or fidelity are barriers to widespread, systematic program implementation and evaluation. We encountered a number of limitations in the literature, including conflicting use of program labels, inconsistent definitions of supported housing and its elements, and use of inadequate measurement indices in assessing adherence to program elements. Our findings suggest that greater model clarity, better specification of model elements, and greater standardization in measurement of program dimensions would aid in supported housing program implementation and evaluation. We present a number of recommendations for the field and suggestions for future research.

Enabling or Engaging? The Role of Recovery Support Services in Addiction Recovery

Recovery capital-the quantity and quality of internal and external resources to initiate and maintain recovery-is explored with suggestions for how recovery support services (RSS) (nontraditional, and often nonprofessional support) can be utilized within a context of comprehensive addiction services. This article includes a brief history of RSS, conceptual and operational definitions of RSS, a framework for evaluating RSS, along with a review of recent empirical evidence that suggests that rather than enabling continued addiction, recovery supports are effective at engaging people into care, especially those who have little recovery capital, and/or who otherwise would likely have little to no "access to recovery."

Housing preferences and choices among adults with mental illness and substance use disorders: a qualitative study

Housing is a crucial issue for adults with severe mental illness and co-occurring substance use disorders, as this population is particularly susceptible to housing instability and homelessness. We interviewed 40 adults with dual disorders, living in either supervised or independent housing arrangements, to examine housing preferences, decision making processes surrounding housing choices, and perceived barriers to housing. We found that many clients indicated their housing preferences had changed over time, and some clients related housing preferences to recovery. Although the majority of clients preferred independent housing, many also described benefits of supervised housing. Clients' current living situations appeared to be driven primarily by treatment provider recommendations and availability of housing. Common barriers to obtaining desired housing were lack of income and information. These findings have implications for supported housing models and approaches to providing housing for clients.