Evaluation of the Housing First program in patients with severe mental disorders in France: study protocol for a randomized controlled trial

[Stigma in homelessness and health care: reflections from a Housing First program in Barcelona, Spain]

The experience of homelessness is associated with strong stigmatization processes, which are often reflected in the treatment received from professionals and the healthcare system itself. This article aims to analyze the experiences of participants in a program for homeless individuals in Barcelona called Primer la Llar within the healthcare system, and how the stigma they suffer affects the care processes. This program follows the Housing First model, a social intervention that proposes providing housing without preconditions to individuals with long histories of street living, who suffer from severe mental disorders and/or addictions. Based on individual interviews with 20 participants conducted between 2016 and 2020, it is observed that in certain cases, entering the program, having housing availability, support from professionals, and the development of their own strategies had positive effects on improving their health, although they continue to perceive discriminatory attitudes in some medical settings. It is suggested that the transformation regarding stigmatization be understood broadly, affecting individuals, institutions, and society as a whole.

Using a modified version of photovoice in a European cross-national study on homelessness

This study proposes an innovative use of a modified version of photovoice for cross-national qualitative research that allows participants to express their ideas, experiences, and emotions about a topic through photographic language. We examine factors affecting social service providers' work on people experiencing homelessness in Europe. We highlight five advantages of using photovoice in cross-national research: visual language, methodological flexibility, participatory data analysis, the bottom-up process, and the promotion of social change. Moreover, we identify key stages of the process: writing a detailed protocol for the implementation and fidelity of the projects, using two levels of data analysis, and disseminating the results. This study provides lessons learned for others who may want to use photovoice in cross-national research.

Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d'Abord trial

AIMS

Housing First (HF), a recovery-oriented approach, was proven effective in stabilising housing situations of homeless individuals with severe mental disorders, yet had limited effectiveness on recovery outcomes on a short-term basis compared to standard treatment. The objective was to assess the effects of the HF model among homeless people with high support needs for mental and physical health services on recovery, housing stability, quality of life, health care use, mental symptoms and addiction issues on 4 years of data from the Un Chez Soi d'Abord trial.

METHODS

A multicentre randomised controlled trial was conducted from August 2011 to April 2018 with intent-to-treat analysis in four French cities: Lille, Marseille, Paris and Toulouse. Participants were homeless or precariously-housed patients with a DSM-IV-TR diagnosis of bipolar disorder or schizophrenia. Two groups were compared: the HF group (n = 353) had immediate access to independent housing and support from the assertive community treatment team; the Treatment-As-Usual (TAU) group (n = 350) had access to existing support and services. Main outcomes were personal recovery (Recovery Assessment Scale (RAS) scale), housing stability, quality of life (S-QoL), global physical and mental status (Medical Outcomes Study 36-item Short Form Health Survey (SF-36)), inpatient days, mental symptoms (Modified Colorado Symptom Index (MCSI)) and addictions (Mini International Neuropsychiatric Interview (MINI) and Alcohol Use Disorders Identification Test (AUDIT)). Mixed models using longitudinal and cluster designs were performed and adjusted to first age on the street, gender and mental disorder diagnosis. Models were tested for time × group and site × time interactions.

RESULTS

The 703 participants [123 (18%) female] had a mean age of 39 years (95% CI 38.0-39.5 years). Both groups improved RAS index from baseline to 48 months, with no statistically significant changes found between the HF and TAU groups over time. HF patients exhibited better autonomy (adjusted β = 2.6, 95% CI 1.2-4.1) and sentimental life (2.3, 95% CI 0.5-4.1), higher housing stability (28.6, 95% CI 25.1-32.1), lower inpatient days (-3.14, 95% CI -5.2 to -1.1) and improved SF-36 mental composite score (-0.8, 95% CI -1.6 to -0.1) over the 4-year follow-up. HF participants experienced higher alcohol consumption between baseline and 48 months. No significant differences were observed for self-reported mental symptoms or substance dependence.

CONCLUSION

Data at 4 years were consistent with 2-year follow-up data: similar improvement in personal recovery outcomes but higher housing stability, autonomy and lower use of hospital services in the HF group compared to the TAU group, with the exception of an ongoing alcohol issue. These sustained benefits support HF as a valuable intervention for the homeless patients with severe mental illness.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01570712.

Mortality in homeless people enrolled in the French housing first randomized controlled trial: a secondary outcome analysis of predictors and causes of death

Background

Homeless people face large excess mortality in comparison with the general population, but little is known about the effect of housing interventions like Housing First (HF) on their mortality.

Aims of the study

1) to explore 2-years mortality among homeless people with severe mental illness (SMI) included in French HF randomized controlled trial (RCT). 2) To examine causes of death among homeless participants.

Methods

For 703 participants of HF RCT: 353 in experimental group (HF) and 350 in control group (Treatment As Usual - TAU), any proof of life or death and causes of death were collected with a thorough retrospective investigation among relatives, institutions and administrative databases. Data collection took place from March to June 2017.

Results

4.8% (n = 34) of the study participants died over the study period. Mean age of death was 40.9 (+/− 11.4) years. The overall 2-years mortality rate was 0.065 in the HF group (n = 23) versus 0.034 in the TAU group (n = 11). Mortality was associated with medications for opioid use disorder in multivariate Cox analysis (HR: 2.37, 95%CI 1.15–5.04, p = 0.025). Those in HF group seem to be more at risk of death compared to TAU group, mainly during the first 6 months of being housed, although the difference did not reach significance (HR: 0.49, 95%CI 0.24–1.01, p = 0.054). Violent deaths occurred in 52.2% of HF group’s deaths versus 18.2% of TAU group’s deaths, this excess being explained by 34.8% (n = 8) deaths by overdoses in HF group versus none in TAU group.

Limitations

1) 8.7% (n = 2) people in HF group died before HF intervention but were analyzed in intention-to-treat. 2) No proof of life or death has been found for only 0.6% in HF group (n = 2) but for 9.5% people in TAU group (n = 33) that could be anonymous deaths. 3) Undetermined causes represented 8.7% of deaths in HF group versus 36.4% in TAU group. 4) The small number of events (deaths) in the study population is a limitation for statistical analysis.

Conclusions

Due to important limitations, we cannot conclude on HF effect on mortality, but our results nevertheless confirm that the vulnerability of long-term homeless people with SMI persists after accessing independent housing. Earlier intervention in the pathways of homelessness should be considered, alongside active specific support for addictions.

Trial registration

Ethics Committee Sud Mediterrannée V n° 11.050: trial number 2011-A00668–33: 28/07/2011. Clinicaltrials ID NCT01570712: 4/4/2012.

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.

Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial

AIMS

Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use.

METHODS

We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed.

RESULTS

Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)).

CONCLUSION

An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

Homeless Adults' Recovery Experiences in Housing First and Traditional Services Programs in Seven European Countries

Across Europe, as governments turn to housing-led strategies in attempts to reverse rising rates of homelessness, increasing numbers of Housing First (HF) programs are being implemented. As HF programs become more widespread, it is important to understand how service users experience them compared to the more prevalent traditional treatment-first approach to addressing long-term homelessness. Although there is a large body of research on service users' experiences of Housing First compared to treatment-first in North American contexts, comparatively less is known about how these two categories of homeless services are experienced in the European context. In a correlational and cross-sectional study, part of a larger examination of homelessness in Europe, participants (n = 520) engaged with either HF (n = 245) or traditional services (TS; n = 275) programs in seven countries completed measures of their experiences of services (consumer choice, housing quality, and service satisfaction) and recovery (time in independent housing, psychiatric symptoms, and community integration). Across the seven countries, participants engaged with HF programs reported experiencing more consumer choice, better perceived housing quality, and more satisfaction with services than participants engaged in TS programs. Participants in HF programs also reported a greater proportion of time in independent accommodation, fewer psychiatric symptoms, and more community integration. Varying patterns of association between experiences of services and recovery outcomes were observed. Findings indicate HF consistently predicts greater recovery than TS across diverse sociopolitical and economic contexts. Implications of findings for configurations of homeless services and homeless services policy are discussed.

Improving the treatment and remission of major depression in homeless people with severe mental illness: The multicentric French Housing First (FHF) program

AIMS

The objectives of the present study were to determine the rates and associated factors of (i) MDD, (ii) antidepressant prescription and (iii) MDD non-remission in homeless subjects with bipolar disorder (BD) or schizophrenia (SZ).

METHODS

This multicenter study was conducted in 4 French cities. MDD was defined with the section L of the MINI. Unremitted MDD was defined by current antidepressant treatment and current MDD.

RESULTS

700 subjects, mean aged 38 years and 82.5% men were included: 55.4% were diagnosed with MDD but only 10.4% were administered antidepressants. Violent victimization in the past 6 months, alcohol use disorder and current substance abuse disorder were associated with increased rates of MDD. 71.2% antidepressant-treated subjects were unremitted. BD diagnosis and substance abuse disorder were found to be associated with increased risk of unremitted MDD. BD-MDD patients were found to be twice more frequently administered antidepressants than SZ-MDD ones, however the non-remission rates were higher in BD subjects compared to SZ. No antidepressant class and no specific antipsychotic or mood stabilizer has been associated with higher or lower rates of remitted MDD.

CONCLUSION

MDD seems to be highly prevalent, underdiagnosed and undertreated in BD and SZ homeless subjects. Beyond antidepressants, add-on strategies including complementary agents, lithium, lamotrigine/carbamazepine or anti-inflammatory drugs and the specific care of alcohol and substance use disorders may be recommended to improve the prognosis of this specific population in addition to other interventions including housing and resocialization. Violent victimization is also frequent and should be specifically prevented in this vulnerable population.

Comparison of Housing First and Traditional Homeless Service Users in Eight European Countries: Protocol for a Mixed Methods, Multi-Site Study

BACKGROUND

Homeless services expend considerable resources to provide for service users' most basic needs, such as food and shelter, but their track record for ending homelessness is disappointing. An alternative model, Housing First, reversed the order of services so that homeless individuals are offered immediate access to independent housing, with wraparound supports but no treatment or abstinence requirements. Although the evidence base for Housing First's effectiveness in ending homelessness is robust, less is known about its effectiveness in promoting recovery.

OBJECTIVE

The objective of this research is to compare rehabilitation- and recovery-related outcomes of homeless services users who are engaged in either Housing First or traditional staircase services in eight European countries: France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden.

METHODS

A mixed methods, multi-site investigation of Housing First and traditional services will compare quantitative outcomes at two time points. Key rehabilitation outcomes include stable housing and psychiatric symptoms. Key growth outcomes include community integration and acquired capabilities. Semistructured interviews will be used to examine service users' experiences of environmental constraints and affordances on acquired capabilities to identify features of homeless services that enhance service users' capabilities sets. Multi-level modelling will be used to test for group differences-Housing First versus traditional services-on key outcome variables. Thematic analysis will be used to understand the ways in which service users make sense of internal and external affordances and constraints on capabilities.

RESULTS

The study is registered with the European Commission (registration number: H2020-SC6-REVINEQUAL-2016/ GA726997). Two press releases, a research report to the funding body, two peer-reviewed articles, and an e-book chapter are planned for dissemination of the final results. The project was funded from September 2016 through September 2019. Expected results will be disseminated in 2019 and 2020.

CONCLUSIONS

We will use the findings from this research to formulate recommendations for European social policy on the configuration of homeless services and the scaling up and scaling out of Housing First programs. From our findings, we will draw conclusions about the setting features that promote individuals' exits from homelessness, rehabilitation, and recovery.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/14584.

Europeans' willingness to pay for ending homelessness: A contingent valuation study

The purpose of this study is to assess the utility value European citizens put on an innovative social program aimed at reducing homelessness. The Housing First (HF) model involves access to regular, scattered, independent and integrated housing in the community with the support of a multidisciplinary team. Currently, HF is not implemented by most European countries or funded by healthcare or social plans, but randomised controlled trials have stressed significant results for improved housing stability, recovery and healthcare services use. The broader implementation of HF across Europe would benefit from a better understanding of citizens' preferences and "willingness to pay" (WTP) for medico-social interventions like HF. We conducted a representative telephone survey between March and December 2017 in eight European countries (France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden). Respondent's WTP for HF (N = 5631) was assessed through a contingent valuation method with a bidding algorithm. 42.3% of respondents were willing to pay more taxes to reduce homelessness through the HF model, and significant differences were found between countries (p < 0.001); 30.4% of respondents who did not value the HF model were protest zeros (either contested the payment vehicle-taxes- or the survey instrument). Respondents were willing to pay €28.2 (±11) through annual taxation for the HF model. Respondents with higher educational attainment, who paid national taxes, reported positive attitudes about homelessness, or reported practices to reduce homelessness (donations, volunteering) were more likely to value the HF model, with some countries' differences also related to factors at the environmental level. These findings inform key stakeholders that European citizens are aware of the issue of homelessness in their countries and that scaling up the HF model across Europe is both feasible and likely to have public support.

Interventions for drug-using offenders with co-occurring mental health problems

BACKGROUND

This review represents one from a family of three reviews focusing on interventions for drug-using offenders. Many people under the care of the criminal justice system have co-occurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems in reducing criminal activity or drug use, or both.This review addresses the following questions.• Does any treatment for drug-using offenders with co-occurring mental health problems reduce drug use?• Does any treatment for drug-using offenders with co-occurring mental health problems reduce criminal activity?• Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)?• Does the type of treatment affect treatment outcome(s)?

SEARCH METHODS

We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drug-using offenders with co-occurring mental health problems.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane .

MAIN RESULTS

We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias.Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderate-certainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitive-behavioural therapy (one study; 314 participants), reporting no significant reduction in self-reported drug use (RR 0.78, 95% CI 0.46 to 1.32), re-arrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drug-related crime (RR 0.87, 95% CI 0.56 to 1.36), yielding low-certainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderate-certainty evidence.One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' follow-up on an Addictive Severity Index (ASI) self-report of drug use (mean difference (MD) 0.00, 95% CI -0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or re-incarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing low-certainty evidence.Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at three-month follow-up assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderate-certainty evidence. In comparison to a waiting list control, one study reported no significant reduction in self-reported drug use based on the ASI (MD -0.04, 95% CI -0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting low-certainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD -1.05, 95% CI -2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI -0.12 to 1.86), along with a small reduction in frequency of re-arrest (MD -0.66, 95% CI -1.31 to -0.01) up to 36 months, yielding low-certainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD -0.7, 95% CI -3.5 to 2.1), providing very low-certainty evidence.Two studies reported on the use of multi-systemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD -0.22, 95% CI -2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing low-certainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in re-arrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on low-certainty evidence.One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in self-reported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very low-certainty evidence. The final study (29 participants) compared legal defence service and wrap-around social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very low-certainty evidence.

AUTHORS' CONCLUSIONS

Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multi-systemic therapy, legal defence wrap-around services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes.

The Price of Substitute Technologies

BACKGROUND

Only a small share of new drugs is truly innovative; 85% to 90% of all new health technologies have little or no advantage over existing therapeutic alternatives. Health economic evaluations can be used to induce acceptable prices for new technologies through threshold pricing.

OBJECTIVE

This work discusses a cost-effectiveness threshold (λ) to be applied to the price regulation of substitute technologies.

METHODS

Considering that substitute technologies add only small marginal benefits in terms of innovation or ethical considerations to the system, it does not make sense to allow a loss of efficiency to list them. It has been postulated that the threshold calculated from opportunity costs (κ) represents its maximum possible value and that there must be a threshold (β) that maximizes consumer surplus. For a substitute technology to be listed, the cost of treatment associated with it must be lower than the cost of treatment of the incumbent technology added to the difference in effectiveness priced at the threshold.

RESULTS

There is no reason for us to believe that the oligopolistic pharmaceutical market is currently charging prices at the cost of production. That way, the cost-effectiveness ratio of the incumbent technology, when lower than κ, is shown through a deductive process to be a plausible estimate for λ that fulfills the objective of maximizing consumer benefit, granting producers a part of the combined surplus to stimulate research and development; that is, it would be between β and κ.

CONCLUSION

In conclusion, the price of substitute technologies should be limited by the cost-effectiveness ratio of the incumbent technology.

European public perceptions of homelessness: A knowledge, attitudes and practices survey

Background

Addressing Citizen’s perspectives on homelessness is crucial for the design of effective and durable policy responses, and available research in Europe is not yet substantive. We aim to explore citizens’ opinions about homelessness and to explain the differences in attitudes within the general population of eight European countries: France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden.

Methods

A nationally representative telephone survey of European citizens was conducted in 2017. Three domains were investigated: Knowledge, Attitudes, and Practices about homelessness. Based on a multiple correspondence analysis (MCA), a generalized linear model for clustered and weighted samples was used to probe the associations between groups with opposing attitudes.

Results

Response rates ranged from 30.4% to 33.5% (N = 5,295). Most respondents (57%) had poor knowledge about homelessness. Respondents who thought the government spent too much on homelessness, people who are homeless should be responsible for housing, people remain homeless by choice, or homelessness keeps capabilities/empowerment intact (regarding meals, family contact, and access to work) clustered together (negative attitudes, 30%). Respondents who were willing to pay taxes, welcomed a shelter, or acknowledged people who are homeless may lack some capabilities (i.e. agreed on discrimination in hiring) made another cluster (positive attitudes, 58%). Respondents living in semi-urban or urban areas (ORs 1.33 and 1.34) and those engaged in practices to support people who are homeless (ORs > 1.4; p<0.005) were more likely to report positive attitudes, whereas those from France and Poland (p<0.001) were less likely to report positive attitudes.

Conclusion

The majority of European citizens hold positive attitudes towards people who are homeless, however there remain significant differences between and within countries. Although it is clear that there is strong support for increased government action and more effective solutions for Europe’s growing homelessness crisis, there also remain public opinion barriers rooted in enduring negative perceptions.

Homelessness, health and the policy process: A literature review

Homelessness has serious consequences for the health of people experiencing homelessness, and presents a challenge to the provision of quality care by health services. Policymaking to address homelessness, as with other social determinants of health (SDH), is complicated by issues of complex causation, intersectoral working and the dominance of biomedicine within health policy. This paper investigates how policies addressing homelessness have been explored using formal policy process theories (PPT). It also examines how health (as an actor and an idea) has intersected with the issue of homelessness reaching policy agendas and in policy implementation. A systematised search of academic databases for peer-reviewed literature from 1986 to 2018 identified six studies of homelessness policy change from Australia, Canada, France and the United States. PPT were able to articulate the interplay of actors, ideas and structures in homelessness policymaking. When the health sector was involved, it tended to be in terms of healthcare service utilisation rather than a broader public health framework emphasising structural social determinants of homelessness. Tensions between differing the priorities of local homelessness actors and a biomedical evidence-based policy paradigm were noted. Future policy action on homelessness requires new models of intersectoral governance that account for the complexity of health determinants, a health workforce enabled to engage with the SDH, and meaningful inclusion of those with lived and living experience of homelessness in policy formulation.

Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Homelessness is associated with poor health. A policy approach aiming to end homelessness across Europe and North America, the 'Housing First' (HF) model, provides rapid housing, not conditional on abstinence from substance use. We aimed to systematically review the evidence from randomised controlled trials for the effects of HF on health and well-being.

METHODS

We searched seven databases for randomised controlled trials of interventions providing rapid access to non-abstinence-contingent, permanent housing. We extracted data on the following outcomes: mental health; self-reported health and quality of life; substance use; non-routine use of healthcare services; housing stability. We assessed risk of bias and calculated standardised effect sizes.

RESULTS

We included four studies, all with 'high' risk of bias. The impact of HF on most short-term health outcomes was imprecisely estimated, with varying effect directions. No clear difference in substance use was seen. Intervention groups experienced fewer emergency department visits (incidence rate ratio (IRR)=0.63; 95% CI 0.48 to 0.82), fewer hospitalisations (IRR=0.76; 95% CI 0.70 to 0.83) and less time spent hospitalised (standardised mean difference (SMD)=-0.14; 95% CI -0.41 to 0.14) than control groups. In all studies intervention participants spent more days housed (SMD=1.24; 95% CI 0.86 to 1.62) and were more likely to be housed at 18-24 months (risk ratio=2.46; 95% CI 1.58 to 3.84).

CONCLUSION

HF approaches successfully improve housing stability and may improve some aspects of health. Implementation of HF would likely reduce homelessness and non-routine health service use without an increase in problematic substance use. Impacts on long-term health outcomes require further investigation.

TRIAL REGISTRATION NUMBER

CRD42017064457.

Prescription of potentially inappropriate psychotropic drugs in homeless people with schizophrenia and bipolar disorders. Results from the French Housing First (FHF) program

BACKGROUND

Guidelines have been edited for the treatment of schizophrenia (SZ) and bipolar disorders (BD). Background regimen is currently recommended for both illnesses (antipsychotic drug for SZ and mood stabilizer for BD). The recommendations are less clear for major depression in these disorders. Long-term anxiolytic and hypnotic prescriptions may have potential side effects and should be withdrawn as soon as possible.

OBJECTIVE

The aim of this study was to investigate the prevalence and associated factors of Potentially Inappropriate Psychotropic drugs (PIP) in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) patients.

METHODS

This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. PIP was defined by at least one item among: (i) absence of background regimen (antipsychotic for SZ or mood stabilizer for BD), (ii) absence of antidepressant for major depressive disorder and (iii) daily long-term anxiolytic or (iv) hypnotic prescription.

RESULTS

Overall, 703 HSB patients, mean aged 38 years and 82.9% men were included, 487 SZ (69.3%) and 216 BD (30.7%). 619 (88.4%) of the patients reported at least one PIP. 386 (54.9%) patients had an inappropriate background regimen prescription (209(43.4%) of SZ had no antipsychotic prescription and 177(81.9%) of BD no mood stabilizer), 336 (48%) had an inappropriate antidepressant prescription (with no significant difference between SZ and BD), 326 (46.4%) had an inappropriate prescription of anxiolytics and 107 (15.2%) had an inappropriate prescription of hypnotics. 388(55%) of the subjects were diagnosed with major depression but only 52(13%) of them were administered antidepressants. In multivariate analysis, PIP was associated with bipolar disorder diagnosis (aOR = 4.67 [1.84-11.89], p = 0.001), current major depressive disorder (aOR = 27.72 [9.53-80.69], p < 0.0001), lower rate of willingness to ask for help (aOR = 0.98[0.96-0.99], p = 0.001). Potentially inappropriate background regimen prescription was associated with bipolar disorder diagnosis (aOR = 6.35 [3.89-10.36], p < 0.0001), lower willingness to ask for help (aOR = 0.99[0.98-0.99], p = 0.01) and lack of lifetime history of psychiatric care (aOR = 0.30[0.12-0.78], p = 0.01). Inappropriate antidepressant prescription was associated with antisocial personality disorder (aOR = 1.58 [1.01-2.48], p = 0.04) and current substance use disorder (aOR = 2.18[1.48-3.20], p < 0.0001).

CONCLUSION

The present findings suggest that almost 9 on 10 HSB subjects may receive a PIP including inappropriate prescriptions or absence of appropriate prescription. Bipolar disorder and/or major depression should be targeted in priority and treated with mood stabilizers and/or antidepressants in this population, while anxiolytics and hypnotics should be withdrawn as much as possible. Major depression should be particularly explored in subjects with comorbid antisocial personality disorder and substance use disorder. The psychiatric care has been associated with better appropriate psychotropic prescriptions and should be reinforced in this population.

Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program

OBJECTIVE

The aim of this study was to investigate the factors associated with violent behavior in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) subjects.

METHODS

This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Violent behavior was defined by at least one episode of verbal or physical violence in the last 6 months.

RESULTS

Overall, 675 HSB patients, mean aged 38 years and 82.5% men were included, 458 SZ (68.4%) and 212 BD (31.6%). During the 6 months before evaluation, 213 (34.3%) committed at least one physical or verbal violence. In multivariate analysis, violence has been associated with younger age (aOR = 0.96[0.94-0.99], p = .001), number of nights in the street (aOR = 1.01[1.01-1.01]), BD diagnosis (aOR = 1.63[1.01-2.65], p = .04), higher current illness severity (CGI score) (aOR = 1.32[1.07-1.64], p = .01), higher rates of current manic episode (aOR = 2.24[1.32-3.81], p = .002), current alcohol use disorder (aOR = 2.05 [1.33-3.15], p = .001), antisocial personality disorder (aOR = 2.51[1.55-4.07], p < .001) and with antidepressant consumption (aOR = 2.01[1.01-4.04], p = .04). No specific antipsychotic or mood stabilizer has been associated with decreased rates of violent behavior, however clozapine, lithium and carbamazepine remained poorly prescribed.

CONCLUSION

In case of violent behavior in HSB subjects, clinicians should focus in priority on the treatment of mania, antidepressant iatrogenic effect and alcohol use disorder by pharmacological and non-pharmacological treatments. Clozapine, lithium and carbamazepine should be chosen as the treatments of reference in this population but may be hard to manage in some cases. The current clinical trial number is NCT01570712.

The need to improve detection and treatment of physical pain of homeless people with schizophrenia and bipolar disorders. Results from the French Housing First Study

OBJECTIVE

The aim of this study was to investigate the prevalence and associated factors of physical pain in a large multicenter sample of Homeless Schizophrenia and Bipolar (HSB) patients.

METHODS

This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Pain was measured by EQ5D-3 L questionnaire with no specified period or location. In addition, sociodemographic information, duration of homelessness, illness severity using the Modified Colorado Symptom Index (MCSI) and drug information were collected.

RESULTS

Overall, 655 HSB patients, mean age 38.8 years and 82.6% men were included, 448 (68.9%) were diagnosed with schizophrenia and 202 (31.1%) with bipolar disorder. More than half patients (N = 337, 51.5%) reported moderate to extreme physical pain while only 2.7% were administered analgesic drugs. In the multivariate analysis, self-reported moderate to extreme physical pain was associated with antidepressant consumption (adjusted odd ratio aOR = 2.56[1.25;5.26], p = .01), female gender (aOR = 1.72[1.03;2.86], p = .04), bipolar disorders (vs. schizophrenia) (aOR = 1.81[1.19;2.77], p = .006), older age (aOR = 1.03 [1.01;1.05], p = .01), with higher MCSI psychotic score (a0R = 1.04[1.01;1.06],p = .002), independently of the number of days in the street during the last 180 days, MCSI depression score, alcohol and substance use disorders, psychotropic drugs and analgesic treatments. No association with education level, antipsychotics, mood stabilizers, anxiolytic, hypnotic or medication adherence was found (all p > .05).

CONCLUSION

Physical pain was highly reported in homeless patients with severe mental illness with insufficient care. Physical pain should be systematically explored and treated in this population. Bipolar disorders, antidepressant consumption and female gender may be targeted in priority. Age and psychotic symptomatology were found to influence self-reported pain in a marginal way.

Knowledge, attitudes, and practices about homelessness and willingness-to-pay for housing-first across 8 European countries: a survey protocol

Background

Most European countries report rising numbers of people experiencing homelessness. For those with mental disorders, interventions are centered on achieving mental health and drug rehabilitation alongside housing readiness, often to the detriment of access to housing. Notwithstanding, more European countries are investing in a new model, Housing First (HF), which postulates immediate access to permanent housing with no initial requirements for treatment. While results of the European HF programs are published on individual-level data, little is known about the opinions of the general population about homelessness and the societal value of the HF model, which can represent barriers to the model's dissemination. Therefore, we present the protocol of a study designed for the following objectives: 1) to explore the knowledge, attitudes, and practices (KAP) about homelessness within the general population of 8 European countries, 2) to assess the valuation of the HF model by European citizens, and 3) to estimate the lifetime prevalence of homelessness in the targeted countries.

Methods

A telephone survey was conducted from March to December 2017 among adults selected from opt-in panels from France, Ireland, Italy, the Netherlands, Portugal, Spain, Poland, and Sweden. A total sample of 5600 interviews was expected, with 700 per country. The interviews included three sections: first, the KAP about homelessness; second, the valuation of the HF model by measuring a respondent's willingness-to-pay (WTP) through the contingent valuation method; and third, an assessment of the lifetime prevalence of homelessness among the general population. Descriptive analyses and comparisons between countries will be conducted. KAP indicators will be created and their psychometric properties assessed. Determinants of WTP will be assessed through regression models.

Discussion

This survey will highlight Europeans' views of homelessness, especially their level of tolerance towards homelessness, potential misconceptions and the most important barriers for the implementation of the HF model. Additionally, the results on the valuation of the HF model by citizens could be instrumental for key stakeholders in understanding the level of support from the general population. Ethics approval has been obtained from the Aix-Marseille University Ethics Committee (n° 2016-01-02-01) for this study, which is part of HOME_EU: Reversing Homelessness in Europe H2O20-SC6-REVINEQUAL-2016/GA726997.

Problems maintaining collaborative approaches with excluded populations in a randomised control trial: lessons learned implementing Housing First in France

Background

In 2006, a local collective combating homelessness set up an ‘experimental squat’ in an abandoned building in Marseille, France’s second largest city. They envisioned the squat as an alternative to conventional health and social services for individuals experiencing long-term homelessness and severe psychiatric disorders. Building on what they learned from the squat, some then joined a larger coalition that succeeded in convincing national government decision-makers to develop a scientific, intervention-based programme based on the Housing First model. This article analyses the political process through which social movement activism gave way to support for a state-funded programme for homeless people with mental disorders.

Methods

A qualitative study of this political process was conducted between 2006 and 2014, using a hybrid theoretical perspective that combines attention to both top-down and bottom-up actions with a modified Advocacy Coalition Framework. In addition to document analysis of published and grey literature linked to the policy process, researchers drew on participant observation and observant participation of the political process. Data analysis consisted primarily of a thematic analysis of field-notes and semi-structured interviews with 65 relevant actors.

Results

A coalition of local activists, state officials and national service providers transformed knowledge about a local innovation (an experimental therapeutic squat) into the rationale for a national, scientifically based project consisting of a randomised controlled trial of four state-supported Housing First sites, costing several million euros. The coalition’s strategy was two-pronged, namely to defend a social cause (the right to housing) and to promote a scientifically validated means of realising positive outcomes (housing tenure) and cost-effectiveness (reduced hospitalisation costs).

Conclusion

Activists’ self-agency, especially that of making themselves audible to public authorities, was enhanced by the coalition’s ability to seize ‘windows of opportunities’ to their advantage. However, in contrast to the United States and Canadian Housing First contexts, which are driven by implementation science and related approaches, it was grassroots activists who promoted a scientific-technical approach among government officials unfamiliar with evidence-based practices in France. The windows of opportunity nevertheless failed to attract participation of those most in need of housing, raising the question of whether and how marginalised and/or subordinate groups can be integrated into collaborative research when a social movement-driven innovation turns into a scientific approach.

Trial registration

The current clinical trial number is NCT01570712. Registered July 17, 2011. First patient enrolled August 18, 2011.

Bread and Shoulders: Reversing the Downward Spiral, a Qualitative Analyses of the Effects of a Housing First-Type Program in France

This paper is a qualitative analysis of the effects of accompagnement, a support framework, on recovery trajectories of people with long-term homelessness and severe psychiatric disorders during 24 months in a Housing First-type program in France. A comprehensive methodology based on grounded theory was used to construct an interview guide, conduct multiple interviews with 35 Housing First participants sampled for heterogeneity, and produce memos on their trajectories before and after entering the program based on interview information. Thematic analysis of a representative subsample (n = 13) of memos identified 12 objective factors and 6 subjective factors key to the recovery process. An in-depth re-analysis of the memos generated four recovery themes: (1) the need for secure space favorable to self-reflexivity; (2) a “honeymoon” effect; (3) the importance of even weak social ties; (4) support from and hope among peers. Three challenges to recovery were identified: (1) finding a balance between protection and risk; (2) breaking downward spirals; (3) bifurcating the trajectory. This study provides new insight into the recovery process, understood as a non-linear transformation of an experience—the relationship between objective life conditions and subjective perception of those conditions—which reinforces protective support over risk elements.

Effectiveness of interventions to reduce homelessness: a systematic review and meta-analysis

This Campbell systematic review examines the effectiveness of interventions to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless. Forty-three studies were included in the review, 37 of which are from the USA. Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.

Plain Language Summary

Interventions to reduce homelessness and improve housing stability are effective: There are large numbers of homeless people around the world. Interventions to address homelessness seem to be effective, though better quality evidence is required.What is this review about?: There are large numbers of homeless people around the world. Recent estimates are over 500,000 people in the USA, 100,000 in Australia and 30,000 in Sweden. Efforts to combat homelessness have been made on national levels as well as at local government levels.This review assesses the effectiveness of interventions combining housing and case management as a means to reduce homelessness and increase residential stability for individuals who are homeless, or at risk of becoming homeless.What studies are included?: Included studies were randomized controlled trials of interventions for individuals who were already, or at-risk of becoming, homeless, and which measured impact on homelessness or housing stability with follow-up of at least one year.A total of 43 studies were included. The majority of the studies (37) were conducted in the United States, with three from the United Kingdom and one each from Australia, Canada, and Denmark.What are the main findings of this review?: Included interventions perform better than the usual services at reducing homelessness or improving housing stability in all comparisons. These interventions are: High intensity case managementHousing FirstCritical time interventionAbstinence-contingent housingNon-abstinence-contingent housing with high intensity case managementHousing vouchersResidential treatment These interventions seem to have similar beneficial effects, so it is unclear which of these is best with respect to reducing homelessness and increasing housing stability.What do the findings of this review mean?: A range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services.However, there is uncertainty in this finding as most the studies have risk of bias due to poor reporting, lack of blinding, or poor randomization or allocation concealment of participants. In addition to the general need for better conducted and reported studies, there are specific gaps in the research with respect to: 1) disadvantaged youth; 2) abstinence-contingent housing with case management or day treatment; 3) non-abstinence contingent housing comparing group vs independent living; 4) Housing First compared to interventions other than usual services, and; 5) studies outside of the USA.How up-to-date is this review?: The review authors searched for studies published up to January 2016. This Campbell systematic review was published in February 2018.

Executive summary

Background: The United Nations Universal Declaration of Human Rights (Article 25) states that everyone has a right to housing. However, this right is far from being realized for many people worldwide. According to the United Nations High Commissioner for Refugees (UNHCR), there are approximately 100 million homeless people worldwide. The aim of this report is to contribute evidence to inform future decision making and practice for preventing and reducing homelessness.Objectives: To identify, appraise and summarize the evidence on the effectiveness of housing programs and case management to improve housing stability and reduce homelessness among people who are homeless or at-risk of becoming homeless.Search methods: We conducted a systematic review in accordance with the Norwegian Knowledge Centre's handbook. We systematically searched for literature in relevant databases and conducted a grey literature search which was last updated in January 2016.Selection criteria: Randomized controlled trials that included individuals who were already, or at-risk of becoming, homeless were included if they examined the effectiveness of relevant interventions on homelessness or housing stability. There were no limitations regarding language, country or length of homelessness. Two reviewers screened 2,918 abstracts and titles for inclusion. They read potentially relevant references in full, and included relevant studies in the review.Data collection and analysis: We pooled the results and conducted meta-analyses when possible. Our certainty in the primary outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation for effectiveness approach (GRADE).Results: We included 43 relevant studies (described in 78 publications) that examined the effectiveness of housing programs and/or case management services on homelessness and/or housing stability. The results are summarized below. Briefly, we found that the included interventions performed better than the usual services in all comparisons. However, certainty in the findings varied from very low to moderate. Most of the studies were assessed as having high risk of bias due to poor reporting, lack of blinding, or poor randomization and/or allocation concealment of participants.Case management: Case management is a process where clients are assigned case managers who assess, plan and facilitate access to health and social services necessary for the client's recovery. The intensity of these services can vary. One specific model is Critical time intervention, which is based on the same principles, but offered in three three-month periods that decrease in intensity.High intensity case management compared to usual services has generally more positive effects: It probably reduces the number of individuals who are homeless after 12-18 months by almost half (RR=0.59, 95%CI=0.41 to 0.87)(moderate certainty evidence); It may increase the number of people living in stable housing after 12-18 months and reduce the number of days an individual spends homeless (low certainty evidence), however; it may have no effect on the number of individuals who experience some homelessness during a two year period (low certainty evidence). When compared to low intensity case management, it may have little or no effect on time spent in stable housing (low certainty evidence).Critical time intervention compared to usual services may 1) have no effect on the number of people who experience homelessness, 2) lead to fewer days spent homeless, 3) lead to more days spent not homeless and, 4) reduce the amount of time it takes to move from shelter to independent housing (low certainty evidence).Abstinence-contingent housing programs: Abstinence-contingent housing is housing provided with the expectation that residents will remain sober. The results showed that abstinence-contingent housing may lead to fewer days spent homeless, compared with usual services (low certainty evidence).Non-abstinence-contingent housing programs: Non-abstinence-contingent housing is housing provided with no expectations regarding sobriety of residents. Housing First is the name of one specific non-abstinence-contingent housing program. When compared to usual services Housing First probably reduces the number of days spent homeless (MD=-62.5, 95%CI=-86.86 to -38.14) and increases the number of days in stable housing (MD=110.1, 95%CI=93.05 to 127.15) (moderate certainty evidence). In addition, it may increase the number of people placed in permanent housing after 20 months (low certainty evidence).Non-abstinence-contingent housing programs (not specified as Housing First) in combination with high intensity case management may reduce homelessness, compared to usual services (low certainty evidence). Group living arrangements may be better than individual apartments at reducing homelessness (low certainty evidence).Housing vouchers with case management: Housing vouchers is a housing allowance given to certain groups of people who qualify. The results showed that it mayreduce homelessness and improve housing stability, compared with usual services or case management (low certainty evidence).Residential treatment with case management: Residential treatment is a type of housing offered to clients who also need treatment for mental illness or substance abuse. We found that it mayreduce homelessness and improve housing stability, compared with usual services (low certainty evidence).Authors' conclusions: We found that a range of housing programs and case management interventions appear to reduce homelessness and improve housing stability, compared to usual services. The findings showed no indication of housing programs or case management resulting in poorer outcomes for homeless or at-risk individuals than usual services.Aside from a general need for better conducted and reported studies, there are specific gaps in the research. We identified research gaps concerning: 1)Disadvantaged youth; 2) Abstinence-contingent housing with case management or day treatment; 3) Non-abstinence contingent housing, specifically different living arrangements (group vs independent living); 4) Housing First compared to interventions other than usual services, and; 5) All interventions from contexts other than the USA.

Victimization and posttraumatic stress disorder in homeless women with mental illness are associated with depression, suicide, and quality of life

OBJECTIVE

This study aimed to determine the following: 1) the proportion of women in the homeless population with schizophrenia (SZ) or bipolar disorder (BD), in addition to the trajectory of their homelessness (ie, homelessness history, number of nights spent without home during the 180 past nights) and the characteristics of their illnesses compared to men (ie, illness severity, suicide risk, physical health status, and quality of life [QoL]); 2) whether these women were victimized more frequently than similarly situated men; 3) the impact of victimization on these women in terms of illness severity, suicide risk, physical health status, and QoL; and lastly 4) the differences and overlap of homeless women with SZ and BD.

METHODS

This study employed data at baseline from a multicenter randomized controlled trial conducted in the following four large French cities: Lille, Marseille, Paris, and Toulouse. Mobile mental health outreach teams recruited SZ/BD homeless patients in the street, emergency shelters, hospitals, and jails from August 2011 to April 2014. Evaluations were performed during face-to-face interviews by psychiatrists and research assistants in the offices of mobile mental health outreach teams that were located in the downtown area of each city. The quantitative data were analyzed using descriptive analyses, chi-square and Student's t-tests, generalized estimating equation regression models, and path analysis.

RESULTS

A total of 703 patients were included in this study. The proportion of women in the SZ/BD homeless population was 123/703 (17.5%). In this population, women were more likely than men to declare that they were subjected to physical or sexual assault during the past 6 months, that they had been diagnosed with posttraumatic stress disorder (PTSD), and that they had experienced more severe depressive symptoms. Moreover, these women presented a higher suicide risk, worse physical health status, and lower QoL than similarly situated men. Homeless women with BD were more vulnerable than women with SZ. A path analysis revealed that PTSD and violent victimization might explain the higher levels of depression and suicide risk and the lower levels of physical health status and QoL in homeless women.

CONCLUSION

SZ/BD homeless women experience more PTSD and victimization than men, which are both associated with poor clinical outcomes. These results confirm the vulnerability of homeless women in this high need population and should be considered by public health policy.

Homeless women with schizophrenia reported lower adherence to their medication than men: results from the French Housing First experience

OBJECTIVE

The aim of this study was to investigate the factors associated with non-adherence to medication in a large multi-center sample of homeless schizophrenia (HSZ) patients.

METHODS

This multi-center study was conducted in four French cities: Lille, Marseille, Paris, and Toulouse. In addition to the Medication Adherence Rating Scale (MARS), sociodemographic information, history of homelessness, illness severity using the Modified Colorado Symptom Index (MCSI) and the Multnomah Community Integration Scale (MCAS), and drug information were collected.

RESULTS

In total, 218 HSZ patients (16.1% women, mean age 36.8 ± 9.3 years) were included in this study. In the multivariate analysis, being a woman and having higher illness severity (MCSI score) and lower "acceptance of illness" (MCAS score) were significantly associated with lower MARS index scores. Compared to men, women had lower MARS dimension 1 ('medication adherence behavior') and dimension 3 ('negative side effects and attitudes toward psychotropic medication') scores. First-generation antipsychotic use was also associated with lower MARS dimension 3 scores.

CONCLUSION

HSZ women reported lower adherence than men, mainly due to having more subjective negative side effects and worse attitudes toward psychotropic medication. Future longitudinal studies should confirm these findings and explore the applicability of specific pharmacological and non-pharmacological treatment strategies for HSZ women, including treatment dose adaptation and psychoeducation. Clinical trial number NCT01570712.

A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats

OBJECTIVE

No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU).

METHODS

Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports.

RESULTS

Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU.

CONCLUSION

HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes.

REGISTRATION

Current Controlled Trials: ISRCTN57595077.

Validation of the Medication Adherence Rating Scale in homeless patients with schizophrenia: Results from the French Housing First experience

The Medication Adherence Rating Scale (MARS) is one of the most widely used measurements of adherence in schizophrenia (SZ), but there is no available data regarding its psychometric properties in homeless SZ patients (HSZ). The aim of this study was therefore to assess the psychometric properties of the MARS in a large multicenter sample of HSZ subjects. This multi-centre prospective study was conducted in the following 4 French cities: Lille, Marseille, Paris and Toulouse. Three hundred and fifty-three patients were included. The 3-factor structure of the MARS was confirmed using confirmatory factor analysis: RMSEA = 0.045, CFI = 0.98, TLI = 0.97 and WRMR = 0.76. The unidimensionality of each factor was supported by the satisfactory INFIT statistics. Item internal consistencies were all higher than 0.20 and the Kuder–Richardson were higher than to 0.6, except for factor 2, which was closed to 0.5. Significant associations with symptoms, functioning and quality of life showed satisfactory external validity. The acceptability was satisfactory with missing data lower than 5% for each dimension. The MARS is a short self-administered instrument with acceptable psychometric properties in homeless SZ patients that yields interesting information about medication adherence.

Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill

BACKGROUND

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

METHODS

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

RESULTS

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations (PABAK: 0.77; 95 % confidence interval (CI) = 0.71, 0.83), multiple psychiatric hospitalizations (PABAK = 0.50, 95 % CI = 0.41, 0.59), emergency department visits (PABAK: 0.77; 95 % CI = 0.71, 0.83), jail (PABAK: 0.74; 95 % CI = 0.68, 0.81), and income assistance (PABAK: 0.82; 95 % CI = 0.76, 0.87). Significant differences in under versus over reporting were also found.

CONCLUSIONS

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions. ISRCTN registry: 57595077 (Vancouver at Home Study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual); and 66721740 (Vancouver at Home study: Housing First plus Intensive Case management versus treatment as usual).

Psychometric properties of the recovery measurement in homeless people with severe mental illness

OBJECTIVE

The Recovery Assessment Scale (RAS) is one of the most widely used measurements of recovery in mental health research. To date, no data have been available concerning the psychometric characteristics of the RAS in homeless people with severe mental illness. The aim of this study was to provide new data regarding the psychometric properties of the RAS in homeless people with schizophrenia and bipolar disorder.

METHODS

This multi-center study was conducted in 4 French cities. In addition to the RAS, data on sociodemographic information, disease severity using the Modified Colorado Symptom Index - MCSI, and the number of mental health comorbidities, care characteristics and quality of life (S-QoL-18) were collected. The RAS was tested for construct validity, reliability, external validity, sensitivity to change and acceptability.

RESULTS

Six hundred fifty-eight homeless patients participated in this study. The five-factor structure was confirmed by confirmatory factor analysis (RMSEA = 0.043, CFI = 0.95, NFI = 0.94 and SRMR = 0.063). The internal item consistency (from 0.40 to 0.80) and reliability (Cronbach's alpha from 0.79 to 0.87) were satisfactory for all dimensions. External validity testing revealed that the dimension scores were correlated significantly with the MCSI and S-QoL 18 scores. Significant associations with age, disease severity, psychiatric comorbidities and care characteristics showed good discriminant validity. The percentage of missing data (< 14.4%) and sensitivity to change were satisfactory.

CONCLUSIONS

Our study demonstrated the satisfactory acceptability and psychometric properties of the RAS, supporting its use as a mean of recovery measurement for homeless patients.

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.

The role of stable housing as a determinant of poverty-related quality of life in vulnerable individuals

OBJECTIVE

The aim of this study was to identify potential socio-demographic and socio-economic determinants associated with quality of life (QoL) in impoverished individuals admitted in emergency departments (EDs) using a self-administered multidimensional poverty-related QoL questionnaire (PQoL) and a generic QoL questionnaire (Duke).

DESIGN

cross-sectional study.

SETTING

Ten EDs in France.

PARTICIPANTS

All participants included in this study lived in impoverished conditions.

INTERVENTION AND OUTCOME MEASURES

We collected socio-demographic information, economic data, and data related to the ED visit. Multiple linear regressions were performed to determine which variables were linked to QoL scores.

RESULTS

Three-hundred and eighty-seven individuals were enrolled, and 378 (98%) responded to the QoL questionnaires. PQoL was significantly lower for single individuals (β from -0.15 to -0.23), without a stable home (β from -0.17 to -0.34) and individuals without general health coverage (β = 0.20). Compared with men, women reported lower scores in the psychological well-being dimension (β = -0.19) and higher scores in the relationships with friends dimension (β = 0.17).

CONCLUSIONS

Not having stable housing was the most important factor associated with low QoL in impoverished people. This finding demonstrates the need for support from policymakers at the national and local levels for these vulnerable populations.