Effect of Housing First on Suicidal Behaviour: A Randomised Controlled Trial of Homeless Adults with Mental Disorders

Programmatic and Organizational Barriers and Facilitators to Addressing High-Risk Issues in Supportive Housing and Housing First Programs

Risk management is an important component of service delivery in supportive housing and Housing First programs. However, there is no evidence on the implementation of risk management approaches in these settings. This qualitative study examined what service providers working in supportive housing and Housing First programs in Canada identify as the programmatic and organizational factors that affect the prevention and management of high-risk behaviours and challenges (e.g., overdose, suicide attempts, non-suicidal self-injury, falls and fall-related injuries, fire-setting, hoarding, apartment takeovers, violence, property damage, drug selling) in their programs. In-depth interviews were completed with a purposive sample of 32 service providers. Data were analyzed using an integrative approach that incorporated techniques from qualitative description and thematic analysis. Four thematic factors, which were comprised of various barriers and facilitators, that affected management of high-risk issues in supportive housing and Housing First programs were identified: [1] flexibility in addressing risk issues; [2] early identification of risk issues; [3] built environment and housing location; and [4] resource availability. Overall, the findings underscore how service providers aim to identify high-risk issues promptly, beginning as early as referral, and that their capacity to effectively do this and intervene accordingly is dynamically shaped by various aspects of the program model, environment, and availability of internal and external resources. Yet, the findings also highlight how risk management approaches may conflict with other programmatic goals and values, and the importance of considering these collectively. Systems-level changes to strengthen programs' capacity to prevent risk and implications for future research are discussed.

The Global Prevalence of Non-suicidal Self-injury, Suicide Behaviors, and Associated Risk Factors Among Runaway and Homeless Youth: A Meta-analysis

A meta-analysis was performed to determine pooled prevalence of non-suicidal self-injury (NSSI), suicide behaviors (including ideation, attempts), and associated risk factors among runaway and homeless youth (RHY). The databases PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant studies published from January 1995 to May 2023. Initially, 8465 papers were screened, resulting in 69 included studies. The results showed that among RHY, lifetime prevalence rates were 42% for NSSI, 38% for suicidal ideation, and 27% for suicide attempts. Lifetime prevalence of NSSI and suicide behaviors was higher among adolescent minors (aged 12-17 years) compared to young adults (aged 18-24 years). Also, NSSI and suicide behaviors were associated with having a childhood history of physical and sexual abuse. Developing an impactful community-based suicide prevention campaign tailored for RHY appears warranted. Peer groups and mentorship programs would provide invaluable support for young individuals, as supportive friendships protect against NSSI.

Suicidal Behaviors and Risk Taking Among Homeless Individuals: A Systematic Review and Meta-Analysis

The present systematic review and meta-analysis study aimed to determine sociodemographic characteristics, risky behaviors, mental health disorders, and substance use disorders associated with suicide behaviors including suicidal ideation and suicide attempts among homeless individuals. PubMed, Scopus, Web of Science, and Cochrane Library databases were searched to identify the relevant studies published between January 1, 1995 and November 1, 2022. After initial evaluation of 9,094 papers, a total of 23 studies met the eligibility criteria. Results of the present study showed that chronic physical illnesses, violent behaviors, mood and psychotic disorders, and substance use disorders were significantly associated with both suicidal ideation and suicide attempts, while being older, having a history of physical abuse, and having mood and post-traumatic stress disorders were associated with suicide attempts only. The present study's findings suggest a crucial need for facilitating access to mental healthcare plans and promoting mental healthcare seeking among homeless individuals.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Association between serum zinc levels and suicidal ideation in US adults: A population-based cross-sectional study

BACKGROUND

Evidence suggests that the homeostatic disruption of zinc, copper, and selenium might contribute to the pathophysiology of mental disorders. However, the specific relationship between the serum levels of these trace elements with suicidal ideation remains poorly understood. This study aimed to investigated the association among suicidal ideation on serum levels of zinc, copper, and selenium.

METHODS

The cross-sectional study was conducted using data from a nationally representative sample of the National Health and Nutrition Examination Survey (NHANES) 2011-2016. Suicidal ideation was assessed using Item #9 of the Patient Health Questionnaire-9 Items. Multivariate regression models and restricted cubic splines were performed and E-value was calculated.

RESULTS

A total of 4561 participants aged 20 years and older were analyzed, of whom 4.08 % had suicidal ideation. The serum zinc levels were lower in the suicidal ideation group than in the non-suicidal ideation group (P = 0.021). In Crude Model, the serum zinc levels were associated with a higher suicidal ideation risk in the second quartile compared with the highest quartile [odds ratio (OR) = 2.63; 95 % confidence interval (CI): 1.53-4.53]. The association persisted (OR = 2.35; 95 % CI: 1.20-4.58) after full adjustment, with E-value 2.44. A nonlinear relationship was observed between serum zinc levels and suicidal ideation (P = 0.028). No relationship was observed between suicidal ideation and serum copper or selenium levels (all P > 0.05).

CONCLUSIONS

Decreased serum zinc levels may increase susceptibility to suicidal ideation. Future studies are needed to validate the findings of this study.

Women experiencing homelessness and mental illness in a Housing First multi-site trial: Looking beyond housing to social outcomes and well-being

OBJECTIVE

There is scant research on the effectiveness of permanent supportive housing for homeless women with mental illness. This study examines the effectiveness of Housing First with an unprecedentedly large sample of homeless women from five Canadian cities, and explore baseline risk factors that predict social, health and well-being outcomes over a 24 month-period.

METHODS

The At Home/Chez Soi multi-site randomized controlled Housing First trial recruited over 600 women between October 2009 and July 2011. This is a post-hoc subgroup exploratory analysis of self-identified women with at least one follow-up interview who were randomized to Housing First (HF) (n = 374) or treatment-as-usual (TAU) (n = 279) and had at least one follow-up interview. Linear mixed models and generalized estimating equations were used after multiple imputation was applied to address missing data.

RESULTS

At the end of follow-up, the mean percentage of days spent stably housed was higher for women in the intervention 74.8% (95%CI = 71.7%-77.8%) compared with women in the treatment-as-usual group, 37.9% (95%CI = 34.4%-41.3%), p<0.001. With few exceptions, social and mental health outcomes were similar for both groups at 6-, 12-, 18- and 24-months post-enrollment. Suicidality was a consistent predictor of increased mental health symptoms (beta = 2.85, 95% CI 1.59-4.11, p<0.001), decreased quality of life (beta = -3.99, 95% CI -6.49 to -1.49, p<0.001), decreased community functioning (beta = -1.16, 95% CI -2.10 to -0.22, p = 0.015) and more emergency department visits (rate ratio = 1.44, 95% CI 1.10-1.87, p<0.001) over the study period. Lower education was a predictor of lower community functioning (beta = -1.32, 95% CI -2.27 to -0.37, p = 0.006) and higher substance use problems (rate ratio = 1.27, 95% CI 1.06-1.52, p = 0.009) during the study.

CONCLUSIONS

Housing First interventions ensured that women experiencing homelessness are quickly and consistently stably housed. However, they did not differentially impact health and social measures compared to treatment as usual. Ensuring positive health and social outcomes may require greater supports at enrolment for subgroups such as those with low educational attainment, and additional attention to severity of baseline mental health challenges, such as suicidality.

TRIAL REGISTRATION

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374.

A Longitudinal Study of Suicidality in a Homeless Population Sample

OBJECTIVE

Little research has been conducted on the timing of the onset and course of suicidality relative to the timing of the onset and temporal status of homelessness. Therefore, this longitudinal study investigated suicidal ideation and plans and suicide attempts in a homeless population in relation to housing attainment, psychiatric disorders, and substance use/disorders.

METHOD

Prospective longitudinal follow-up data were collected from a representative sample of literally homeless adults in St. Louis (N = 255) using the Diagnostic Interview Schedule/Homeless Supplement, the Composite International Diagnostic Interview-Substance Abuse Module, and urine drug screens. Associations among suicidal symptom variables, housing status, psychiatric/substance use disorders, and substance use were examined at baseline and longitudinally.

RESULTS

Lifetime prevalence of suicidal ideation/plan and suicide attempts in this homeless population were much higher than in the general population. Onset of suicidal symptoms had typically preceded onset of homelessness. Few individuals experienced suicidal ideation/plans or attempted suicide during this study, and even fewer experienced new suicidal symptoms after baseline. Securing stable housing during the study follow-up was associated with lower rates of suicidal ideation/plans.

CONCLUSIONS

This study's findings contradict assumptions that the high prevalence of suicidal symptoms in homeless populations can be explained by the difficulties and miseries of homelessness. Psychiatric illness, substance abuse, and psychosocial factors associated with homelessness may be direct contributors to suicidal symptoms and thus represent strategic intervention targets.HIGHLIGHTSMost suicidality reported at baseline first emerged long before first homelessnessAfter baseline, few reported new suicidal symptoms or had active suicidal symptomsSignificantly fewer reports of suicidal ideation/plans over time were found in those with the most stable housing outcome.

Post-housing first outcomes amongst a cohort of formerly homeless youth in Aotearoa New Zealand

This paper explores the government service interactions for a cohort of formerly homeless youth in Aotearoa New Zealand, using linked administrative data. We report the rates of service interactions pre- and post-housing for a cohort of 69 youth, aged 18-25 years old, who received housing and support from a Housing First provider. 60.9% were women, and 69.6% were Māori. Very high rates of service interactions were seen both before and after they were housed. The evidence shows promising potential improvements in young people's lives when housed. The most significant changes we saw in the one and two years post-housing were in incomes from both wages/salaries and social welfare benefits; there was a significant increase in total income for our cohort. There was also a promising reduction in hospitalisations and emergency deparment admissions. Overall, Housing First shows promising outcomes for youth.

The physical and mental health effects of housing homeless people: A systematic review

Housing is a significant determinant of health and is widely accepted as a key solution to address some of the health disparities that exist among the homeless. It is estimated that 150 million people worldwide are homeless, and approximately 1.8 billion lack adequate housing. However, understanding of how housing has a positive impact on the health of the homeless remains unclear and underdeveloped. This systematic review investigates intervention studies that report on the physical and mental health effects of housing homeless persons. A search of PubMed, PsycINFO, EBSCOHost-Academic Search Complete and the Cochrane Library was conducted for peer-reviewed articles published in English from 1999 to 2020 that had a combination of at least one housing intervention and health outcome, with a homeless sample. Three previous reviews and 24 studies were included for analysis. Most of the studies (n = 20) encompassed permanent supportive housing interventions that emphasised placing homeless people with mental illness directly into affordable housing with access to support services. The primary health outcomes reported were general physical and mental health, well-being, and quality of life. Despite inconsistent findings and significant issues identified in the reviewed literature, housing (in the short term) improves some aspects of health in homeless populations with human immunodeficiency virus, anxiety and depression.

Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review

BACKGROUND

Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First.

METHODS

A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use.

RESULTS

A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work.

CONCLUSIONS

Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.

Scoping Review: Suicide Specific Intervention Programmes for People Experiencing Homelessness

Background: The homeless population are among the most vulnerable groups to experience suicide ideation and behavior. Several studies have shown that people who are homeless experience more significant suicidal ideation and behavior than the general population. However, there is limited information about what suicide interventions exist, to what extent they are grounded in robust research, and which intervention components effectively reduce suicidal ideation and behavior in the homeless community. This research aimed to characterise the current evidence base in the area of suicide prevention for homeless individuals. Methods: A scoping review guided by Arksey and O’Malley’s five-stage framework was conducted and a narrative synthesis was performed. Pubmed, EMBASE, PsychInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, and Bielefeld Academic Search Engine were searched up to 8 May 2020. Results: A total of 3209 records were identified through database and grey literature searching. Three studies are included in this review. Key outcomes identify suicide intervention prevention programmes; similarities and differences across interventions, and examples of staff training. A quality review of the studies was completed. Conclusion: A stark gap in the evidence of suicide specific prevention interventions targeted at homeless populations.

Housing First Combined with Suicide Treatment Education and Prevention (HOME + STEP): study protocol for a randomized controlled trial

BACKGROUND

Youth experiencing homelessness are at high risk for suicide, yet few studies have evaluated risk reduction interventions targeting suicidal ideation in this vulnerable population. A comprehensive approach to risk-reduction is needed that addresses basic needs and provides targeted interventions for those at highest risk. The protocol described builds on the design of the first randomized trial of Housing First (HF) for homeless youth. The primary objective is to determine whether housing combined with supportive services that include suicide screening and targeted psychotherapy (Cognitive Therapy for Suicide Prevention) is effective for reducing suicidal ideation and other secondary outcomes (depression and suicide attempts). Additionally, we will explore mediators of the treatment effect (housing stability and substance use) and determinants of implementation.

METHODS

Youth recruited to the HF trial will be randomized to HF + supportive services (n = 120), or supportive services alone (n = 120). The "Suicide Treatment Education and Prevention" (STEP) protocol will additionally screen youth in both arms at baseline and 3 months for suicidal ideation (SSI-W). Those who screen as moderate risk for suicide (SSI-W ≥ 10) will be offered CTSP, which includes up to 9 sessions over the first 6 months following enrollment. CTSP will be delivered in one-on-one sessions by a trained advocate. Research assessments will be collected to assess outcomes (including suicidal ideation) at baseline, 3, 6, 9 and 12 months. Qualitative interviews with subjects receiving CTSP and other stakeholders will explore implementation determinants.

DISCUSSION

The study will fill an important gap in the literature about the added benefit of HF combined with supportive services including suicide screening and treatment for reducing suicidal ideation in homeless youth. With the urgent need to address both homelessness and suicide risk, evidence is needed about services that can be integrated into delivery settings for youth experiencing homelessness.

TRIAL REGISTRATION

NCT04135703 . Date of registration: October 23, 2019.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

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.

Lifetime prevalence of suicidal attempt among homeless individuals in North America: a meta-analysis

BACKGROUND

Homelessness is a compelling public health problem, and homeless individuals are at increased risk for attempting suicide. However, the reported lifetime prevalence of suicidal attempt among homeless individuals in North America varied considerably. Therefore, this meta-analysis aimed to estimate the pooled lifetime prevalence of suicidal attempt among homeless individuals in North America and explore factors that may moderate this estimation.

METHODS

The protocol was registered in PROSPERO database (CRD42018102593). A systematic literature search was conducted in the electronic databases of PubMed, Embase, Web of Science, PsycINFO, and Google Scholar. Observational studies exploring the lifetime prevalence of suicidal attempt among homeless individuals in North America were included. Heterogeneity across studies was evaluated using the Cochran Q test and quantified using the I² statistic. Subgroup analyses were performed to identify possible sources of heterogeneity.

RESULTS

Twenty-two eligible studies with a total of 9,727 homeless individuals were included, of which 2,986 reported having attempted suicide in their lifetime. A high degree of heterogeneity (I²=96.4%, P<0.001) was observed, and the pooled lifetime prevalence was 31.83% (95% confidence interval: 26.87%-36.99%). Subgroup analyses showed that the heterogeneity was quite low when estimating the pooled lifetime prevalence of suicidal attempt among heterosexual (I²=0.0, P=0.401) and non-heterosexual homeless individuals (I²=0.0, P=0.405).

LIMITATIONS

All eligible studies were exclusively conducted in the US and Canada.

CONCLUSIONS

Nearly three tenths of homeless individuals in North America have attempted suicide in their lifetime, and the differences in sexual orientation might have contributed to the heterogeneity.

Determinants of suicidal ideation and suicide attempt among former and currently homeless individuals

PURPOSES

This study identified determinants associated with suicidal ideation, suicide attempt and no suicidal behavior in a 12-month period among 455 former or currently homeless individuals in Quebec (Canada).

METHODS

Study recruitment took place in 27 organizations located in two major Quebec urban areas, where services for homelessness are offered. Independent variables including clinical, socio-demographic, and service use/outcome variables were measured with eight standardized instruments. Significant associations between these variables and suicidal ideation or attempt in bivariate analyses were produced to build a multinomial logistic regression model using a block approach.

RESULTS

Of 455 participants, 72 (15.8%) reported suicidal ideation and 30 (6.6%) suicide attempt, while 353 (77.6%) had not experienced suicidal behavior. Suicide ideation was particularly high among those with generalized anxiety disorder and substance use disorders, and suicide attempt even higher. Participants with higher functional disability and hospitalizations had a higher incidence of suicide attempt, whereas participants with schizophrenia spectrum and other psychotic disorders, those placed in foster care during childhood and with higher stigma scores experienced more suicidal ideation.

CONCLUSIONS

Suicidal ideation and suicide attempt among currently or recently homeless individuals were both strongly associated with clinical variables. Based on the study results, specific interventions may be promoted to improve screening of homeless individuals with suicidal behavior and prevent hospitalization such as training programs and brief care management interventions, addiction liaison nurses, improved access to primary or specialized ambulatory services, and further development of case management and outreach programs for homeless individuals, especially those with functional disabilities.

Relative accuracy of social and medical determinants of suicide in electronic health records

OBJECTIVE

This paper compares the accuracy of predicting suicide from Social Determinants of Health (SDoH) or history of illness.

POPULATION STUDIED

5 313 965 Veterans who at least had two primary care visits between 2008 and 2016.

STUDY DESIGN

The dependent variable was suicide or intentional self-injury. The independent variables were 10 495 International Classification of Disease (ICD) Version 9 codes, age, and gender. The ICD codes included 40 V-codes used for measuring SDoH, such as family disruption, family history of substance abuse, lack of education, legal impediments, social isolation, unemployment, and homelessness. The sample was randomly divided into training (90 percent) and validation (10 percent) sets. Area under the receiver operating characteristic (AROC) was used to measure accuracy of predictions in the validation set.

PRINCIPAL FINDINGS

Separate analyses were done for inpatient and outpatient codes; the results were similar. In the hospitalized group, the mean age was 67.2 years, and 92.1 percent were male. The mean number of medical diagnostic codes during the study period was 37; and 12.9 percent had at least one SDoH V-code. At least one episode of suicide or intentional self-injury occurred in 1.89 percent of cases. SDoH V-codes, on average, elevated the risk of suicide or intentional self-injury by 24-fold (ranging from 4- to 86-fold). An index of 40 SDoH codes predicted suicide or intentional self-injury with an AROC of 0.64. An index of 10 445 medical diagnoses, without SDoH V-codes, had AROC of 0.77. The combined SDoH and medical diagnoses codes also had AROC of 0.77.

CONCLUSION

In predicting suicide or intentional self-harm, SDoH V-codes add negligible information beyond what is already available in medical diagnosis codes.

IMPLICATIONS FOR PRACTICE

Policies that affect SDoH (eg, housing policies, resilience training) may not have an impact on suicide rates, if they do not change the underlying medical causes of SDoH.

Scoping review protocol on non-pharmacological interventions for interpersonal and self-directed violence in adults with severe mental illness

INTRODUCTION

Violence committed by people with mental illness has implications for mental health policy and clinical practice. Several strategies to reduce the risk of aggressive and violent behaviour have been proposed, and these include non-pharmacological interventions. There is, however, a need to identify which of these interventions are effective, and as a first step, we will conduct a scoping review to identify non-pharmacological interventions for self-directed or interpersonal violence in adults with severe mental illness across different conditions and settings.

METHODS AND ANALYSIS

This is a scoping review protocol. The review will include any randomised controlled trials (RCTs) and cluster RCTs that assess the efficacy of interventions on self-directed or interpersonal violence with no restrictions on the control treatment in people with severe mental illness in any setting. No restrictions will be applied in terms of language or date of publication. To identify studies, a search will be performed in the following databases: Embase, MEDLINE (via PubMed), PsycINFO, CINAHL, LILACS, SciELO, Cochrane Library, Web of Science, Scopus, ProQuest, Epistemonikos and databases of clinical trials. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement will be followed for reporting the findings, including the use of a PRISMA flow diagram. A standardised form will be used to extract data from studies. The findings will be classified using conceptual categories that will be specified in detail and a descriptive summary of the main results will be created. Moreover, it will be assessed whether the studies identified have been included in systematic reviews or meta-analyses and the results will be used to generate a conceptual map.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. We will prepare a manuscript for publication in a peer-reviewed journal and the results will be presented at mental health conferences.

Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review

BACKGROUND

Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries.

METHODS

We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

FINDINGS

Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01-1·26]) and high support needs (RR 1·42 [1·19-1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear.

INTERPRETATION

Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes.

FUNDING

Inner City Health Associates.

Predictive Validity of the MINI Suicidality Subscale for Suicide Attempts in a Homeless Population With Mental Illness

OBJECTIVE

Suicide is a leading cause of death, yet the accurate prediction of suicidal behavior is an elusive target for clinicians and researchers. The current paper examines the predictive validity of the Mini Neuropsychiatric Interview (MINI) Suicidality subscale for suicide attempts (SAs) for a homeless population with mental illness.

METHODS

Two thousand two hundred and fifty-five homeless individuals with mental illness across five Canadian cities enrolled in the At Home/Chez Soi Housing First trial interviewed at baseline using the MINI Suicidality subscale with 2-year follow-up of self-reported SAs.

RESULTS

Two thousand two hundred and twenty-one participants were included in the analysis. High rates of mood and substance use disorders were present (56.5% and 67.4%, respectively). The mean MINI Suicidality subscale score was 7.71. Among 1,700 participants with follow-up data, 11.4% reported a SA over the 2-year study period. MINI Suicidality subscale scores were predictive of SAs (AUC ≥ 0.70) among those with and without a history of SAs, even among those with missing answers. A positive predictive value of 0.20 and a negative predictive value of 0.95 were demonstrated, with a relatively low number needed to assess of 4.5-5.

CONCLUSION

The MINI Suicidal subscale shows promise as an easy to use and accurate suicide risk prediction tool among homeless individuals with mental illness.

Treatments for the Prevention and Management of Suicide: A Systematic Review

BACKGROUND

Suicide is a growing public health problem, with the national rate in the United States increasing by 30% from 2000 to 2016.

PURPOSE

To assess the benefits and harms of nonpharmacologic and pharmacologic interventions to prevent suicide and reduce suicide behaviors in at-risk adults.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, and other databases from November 2011 through May 2018.

STUDY SELECTION

Systematic reviews (SRs) and randomized controlled trials (RCTs) that assessed nonpharmacologic or pharmacologic therapies for adults at risk for suicide.

DATA EXTRACTION

One investigator abstracted data and assessed study quality, and a second investigator checked abstractions and assessments for accuracy.

DATA SYNTHESIS

Eight SRs and 15 RCTs were included. The evidence for psychological interventions suggests that cognitive behavioral therapy (CBT) reduces suicide attempts, suicidal ideation, and hopelessness compared with treatment as usual (TAU). Limited evidence suggests that dialectical behavior therapy (DBT) reduces suicidal ideation compared with wait-list control or crisis planning. The evidence for pharmacologic treatments suggests that ketamine reduces suicidal ideation with minimal adverse events compared with placebo or midazolam. Lithium reduces rates of suicide among patients with unipolar or bipolar mood disorders compared with placebo. However, no differences were observed between lithium and other medications in reducing suicide.

LIMITATION

Qualitative synthesis of new evidence with existing meta-analyses, methodological shortcomings of studies, heterogeneity of nonpharmacologic interventions, and limited evidence for pharmacologic treatments and harms.

CONCLUSION

Both CBT and DBT showed modest benefit in reducing suicidal ideation compared with TAU or wait-list control, and CBT also reduced suicide attempts compared with TAU. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Limited data are available to support the efficacy of other nonpharmacologic or pharmacologic interventions.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs Veterans Health Administration. (PROSPERO: CRD42018104978).