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Fearn-Smith EM, Scanlan JN, Hancock N. Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3440. [PMID: 36834133 PMCID: PMC9966671 DOI: 10.3390/ijerph20043440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.
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Affiliation(s)
- Erin M. Fearn-Smith
- Faculty of Medicine and Health, Centre for Disability Research and Policy, The University of Sydney, Camperdown, NSW 2050, Australia
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Gutwinski S, Schreiter S, Deutscher K, Fazel S. The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis. PLoS Med 2021; 18:e1003750. [PMID: 34424908 PMCID: PMC8423293 DOI: 10.1371/journal.pmed.1003750] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/07/2021] [Accepted: 08/02/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Homelessness continues to be a pressing public health concern in many countries, and mental disorders in homeless persons contribute to their high rates of morbidity and mortality. Many primary studies have estimated prevalence rates for mental disorders in homeless individuals. We conducted a systematic review and meta-analysis of studies on the prevalence of any mental disorder and major psychiatric diagnoses in clearly defined homeless populations in any high-income country. METHODS AND FINDINGS We systematically searched for observational studies that estimated prevalence rates of mental disorders in samples of homeless individuals, using Medline, Embase, PsycInfo, and Google Scholar. We updated a previous systematic review and meta-analysis conducted in 2007, and searched until 1 April 2021. Studies were included if they sampled exclusively homeless persons, diagnosed mental disorders by standardized criteria using validated methods, provided point or up to 12-month prevalence rates, and were conducted in high-income countries. We identified 39 publications with a total of 8,049 participants. Study quality was assessed using the JBI critical appraisal tool for prevalence studies and a risk of bias tool. Random effects meta-analyses of prevalence rates were conducted, and heterogeneity was assessed by meta-regression analyses. The mean prevalence of any current mental disorder was estimated at 76.2% (95% CI 64.0% to 86.6%). The most common diagnostic categories were alcohol use disorders, at 36.7% (95% CI 27.7% to 46.2%), and drug use disorders, at 21.7% (95% CI 13.1% to 31.7%), followed by schizophrenia spectrum disorders (12.4% [95% CI 9.5% to 15.7%]) and major depression (12.6% [95% CI 8.0% to 18.2%]). We found substantial heterogeneity in prevalence rates between studies, which was partially explained by sampling method, study location, and the sex distribution of participants. Limitations included lack of information on certain subpopulations (e.g., women and immigrants) and unmet healthcare needs. CONCLUSIONS Public health and policy interventions to improve the health of homeless persons should consider the pattern and extent of psychiatric morbidity. Our findings suggest that the burden of psychiatric morbidity in homeless persons is substantial, and should lead to regular reviews of how healthcare services assess, treat, and follow up homeless people. The high burden of substance use disorders and schizophrenia spectrum disorders need particular attention in service development. This systematic review and meta-analysis has been registered with PROSPERO (CRD42018085216). TRIAL REGISTRATION PROSPERO CRD42018085216.
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Affiliation(s)
- Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefanie Schreiter
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Biomedical Innovation Academy, Berlin Institute of Health, Berlin, Germany
| | - Karl Deutscher
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- * E-mail:
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Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry 2019; 19:370. [PMID: 31775786 PMCID: PMC6880407 DOI: 10.1186/s12888-019-2361-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/15/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Schizophrenia and other psychotic disorders constitute a huge global burden of disease and they are major contributors to disability as well as premature mortality among homeless people. This systematic review and meta-analysis aimed to estimate the pooled prevalence of schizophrenia and other psychotic disorders among homeless people. METHODS PubMed, Embase, and Scopus were searched to identify pertinent studies. We used a fixed- or random-effect meta-analysis to pool data from the included studies depending on the anticipated heterogeneity. A predesigned search strategy, as well as inclusion and exclusion criteria, were used. We also performed subgroup and sensitivity analysis and Cochran's Q- and the I2 test was employed to compute heterogeneity. Egger's test and visual inspection of the symmetry in funnel plots were used to assess publication bias. RESULTS Thirty-one studies involving 51,925 homeless people were included in the final analysis. The meta-analysis showed a remarkably higher prevalence of psychosis [21.21% (95% CI:13.73, 31.29), I2 = 99.43%], schizophrenia [10.29% (95%, CI: 6.44, 16.02), I2 = 98.76%], schizophreniform disorder [2.48% (95% CI: 6.16, 28.11), I2 = 88.84%] schizoaffective disorder [3.53% (95% CI: 1.33, 9.05), I2 = 31.63%,] as well as psychotic disorders not otherwise specified [9% (95% CI: 6.92, 11.62), I2 = 33.38%] among homeless people. The prevalence estimate of psychosis was higher in developing (29.16%) as compared to developed (18.80%) countries. Similarly, the prevalence of schizophrenia was highest in developing (22.15%) than developed (8.83%) countries. CONCLUSION This systematic review and meta-analysis revealed that schizophrenia and other psychotic disorders are highly prevalent among homeless people, indicating an urgent need for studies to help develop better mechanisms of prevention, detection as well as treatment of those disorders among homeless people.
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Affiliation(s)
- Getinet Ayano
- Research and Training Department, Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.
| | - Getachew Tesfaw
- 0000 0000 8539 4635grid.59547.3aDepartment of Psychiatry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Shegaye Shumet
- 0000 0000 8539 4635grid.59547.3aDepartment of Psychiatry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Manthorpe J, Samsi K, Joly L, Crane M, Gage H, Bowling A, Nilforooshan R. Service provision for older homeless people with memory problems: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Early or timely recognition of dementia is a key policy goal of the National Dementia Strategy. However, older people who are homeless are not considered in this policy and practice imperative, despite their high risk of developing dementia.
Objectives and study design
This 24-month study was designed to (1) determine the prevalence of memory problems among hostel-dwelling homeless older people and the extent to which staff are aware of these problems; (2) identify help and support received, current care and support pathways; (3) explore quality of life among older homeless people with memory problems; (4) investigate service costs for older homeless people with memory problems, compared with services costs for those without; and (5) identify unmet needs or gaps in services.
Participants
Following two literature reviews to help study development, we recruited eight hostels – four in London and four in North England. From these, we first interviewed 62 older homeless people, exploring current health, lifestyle and memory. Memory assessment was also conducted with these participants. Of these participants, 47 were included in the case study groups – 23 had ‘memory problems’, 17 had ‘no memory problems’ and 7 were ‘borderline’. We interviewed 43 hostel staff who were participants’ key workers. We went back 3 and 6 months later to ask further about residents’ support, service costs and any unmet needs.
Findings
Overall, the general system of memory assessment for this group was found to be difficult to access and not patient-centred. Older people living in hostels are likely to have several long-term conditions including mental health needs, which remain largely unacknowledged. Participants frequently reported experiences of declining abilities and hostel staff were often undertaking substantial care for residents.
Limitations
The hostels that were accessed were mainly in urban areas, and the needs of homeless people in rural areas were not specifically captured. For many residents, we were unable to access NHS data. Many hostel staff referred to this study as ‘dementia’ focused when introducing it to residents, which may have deterred recruitment.
Conclusions
To the best of our knowledge, no other study and no policy acknowledges hostels as ‘dementia communities’ or questions the appropriateness of hostel accommodation for people with dementia. Given the declining number of hostels in England, the limits of NHS engagement with this sector and growing homelessness, this group of people with dementia are under-recognised and excluded from other initiatives.
Future work
A longitudinal study could follow hostel dwellers and outcomes. Ways of improving clinical assessment, record-keeping and treatment could be investigated. A dementia diagnosis could trigger sustained care co-ordination for this vulnerable group.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jill Manthorpe
- National Institute for Health Research Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Kritika Samsi
- National Institute for Health Research Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Louise Joly
- National Institute for Health Research Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Maureen Crane
- National Institute for Health Research Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Heather Gage
- Surrey Health Economics Centre, School of Economics, University of Surrey, Guildford, UK
| | - Ann Bowling
- Health Sciences, University of Southampton, Southampton, UK
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Abstract
Homeless families are defined as all adults with dependent children who are statutorily accepted by local authorities (housing departments) in the UK, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period varies from a few days to several months, although the target for rehousing is usually around 4 to 6 weeks. Some housing departments, particularly in London, also use bed and breakfast accommodation.
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Durbin A, Lunsky Y, Wang R, Nisenbaum R, Hwang SW, O’Campo P, Stergiopoulos V. The Effect of Housing First on Housing Stability for People with Mental Illness and Low Intellectual Functioning. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:706743718782940. [PMID: 29916270 PMCID: PMC6299190 DOI: 10.1177/0706743718782940] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Housing First (HF) has been linked to increased tenure in housing for homeless people with mental illness, but the effect of HF on housing stability for people with borderline or lower intellectual functioning has not been examined. This study of homeless adults with mental illness in Toronto, Ontario assessed whether the association between housing stability and HF differed for adults with borderline or lower intellectual functioning, compared to adults with above borderline intellectual functioning. METHOD This study included 172 homeless adults with mental illness from the Toronto site of the At Home-Chez Soi randomized trial that compared receiving HF relative to treatment as usual. This sample was divided into two intellectual functioning groups: 1) adults with borderline or lower intellectual functioning (IQ < 85, 16%), and 2) adults with above borderline intellectual functioning (IQ ≥ 85, 84%). We compared these groups by modelling the percentage of days stably housed using a linear multivariable generalized estimating equation and included interaction between treatment and intellectual functioning. An interaction between treatment and time was also included. RESULTS There were no overall differences in housing stability for individuals with borderline or lower intellectual functioning compared to people with higher than borderline intellectual functioning in either the HF or the treatment as usual groups. CONCLUSION This study is the first to demonstrate that for homeless adults with mental illness, borderline or lower intellectual functioning did not significantly affect housing stability. This accentuates the need for more research and potentially wider consideration of their inclusion in housing interventions, such as HF.
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Affiliation(s)
- Anna Durbin
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Yona Lunsky
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
- Centre for Addiction and Mental Health, Toronto, Ontario
| | - Ri Wang
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
| | - Rosane Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Stephen W. Hwang
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario
| | - Patricia O’Campo
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Vicky Stergiopoulos
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Psychiatry, University of Toronto, Toronto, Ontario
- Centre for Addiction and Mental Health, Toronto, Ontario
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Abstract
Homelessness is associated with multiple adversities that might impact upon brain function. We performed a review of published work to assess evidence of cognitive dysfunction among adults who are homeless. Despite liberal inclusion criteria only seventeen publications were identified, these describing eighteen samples mainly from the USA. Although the total number of individuals studied is small (about 3300) and the samples are heterogeneous, most studies indicate a considerable burden of cognitive dysfunction among homeless people. Such dysfunction might be expected to impact upon their ability to reintegrate into society, thereby undermining policies of inclusiveness. In clinical practice, assessment of homeless adults should include their cognitive state.
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Affiliation(s)
- Sean Spence
- Academic Clinical Psychiatry, Division of Genomic Medicine, University of Sheffield, The Longley Centre, Norwood Grange Drive, Sheffield S5 7JT, UK.
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Abstract
Homeless people experience elevated rates of risk factors for cognitive impairment. We reviewed available peer-reviewed studies reporting data from objective measures of cognition in samples identified as homeless. Pooled sample-weighted estimates of global cognitive screening measures, full-scale intelligence quotient (IQ), and premorbid IQ were calculated, in addition to pooled sample characteristics, to understand the representativeness of available studies. A total of 24 unique studies were identified, with 2969 subjects. The pooled estimate for the frequency of cognitive impairment was 25%, and the mean full-scale IQ score was 85, 1 standard deviation below the mean of the normal population. Cognitive impairment was found to be common among homeless adults and may be a transdiagnostic problem that impedes rehabilitative efforts in this population. Comparatively little data are available about cognition in homeless women and unsheltered persons.
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Abstract
AbstractObjectives: To examine the mental health status of homeless children and their families living in a supported temporary housing project.Method: The assessment measures used: (i) the 28-item General Health Questionnaire (GHQ); (ii) the Child Behaviour Checklist (CBCL); and (iii) the Parenting Stress Index (PSI). The population studied consisted of 14 families and 31 children. Children aged two to 16 years were eligible for the study. Most of the families (12/14) assessed were single parent (mother only) family units.Results: The General Health Questionnaire was completed by the 14 mothers and two fathers. Of the mothers 28% (4/14) indicated the presence of psychiatric ‘caseness’. The Child Behaviour Checklist (CBCL) was completed on 31 children by the mothers. More than a third of the children (12/31) had a Total Problem Score above the ‘clinical’ threshold, indicating the presence of mental health problems of sufficient severity to merit referral for treatment. Of the children 45% (14/31) manifested externalising problems in the ‘deviant’ range, while 29% of the children (9/31) manifested internalising problems in the ‘clinical’ range. In all, when the CBCL scores were examined within each family, 78% (11/14) had at least one child with a CBCL dimension of clinical significance. The Parenting Stress Index was completed by each mother. Of the mothers 70% (10/14) obtained scores in the critical range. They reported feeling incompetent in their parenting role, being dominated by their children's needs and feeling social isolated from their relatives and peers. Their scores also indicated poor self-esteem and significant depressive symptoms. Of note the peak score was the lack of emotional and active support from the other parent.Conclusion: This study revealed a high level of stress and clinical morbidity in this group of homeless mothers and their children and the need to provide appropriate mental health supports and services for them.
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Keller C, Goering P, Hume C, Macnaughton E, O'Campo P, Sarang A, Thomson M, Vallée C, Watson A, Tsemberis S. Initial Implementation of Housing First in Five Canadian Cities: How Do You Make the Shoe Fit, When One Size Does Not Fit All? AMERICAN JOURNAL OF PSYCHIATRIC REHABILITATION 2013. [DOI: 10.1080/15487768.2013.847761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The impact of mental illness, comorbid substance abuse, and medication nonadherence, coupled with disjointed psychiatric and social services, conspires to a disproportionately high rate of psychiatric disorders among people who are homeless in the United States. This article reviews the prevalence of homeless among the mentally ill as well as the prevalence of mental illness among the homeless and details barriers in access to care and the solutions that have been attempted. The need and solutions to introduce a new generation of physicians and allied health care workers to the unique health care needs of the homeless population are highlighted.
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Affiliation(s)
- Adriana Foster
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Georgia Health Sciences University, 997 Saint Sebastian Way, Augusta, GA 30912, USA.
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12
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Abstract
PURPOSE This study assessed lifetime and current prevalence rates of mental disorders and concurrent mental and substance use disorders in a sample of homeless women. Current suicide risk and recent health service utilization were also examined in order to understand the complex mental health issues of this population and to inform the development of new treatment strategies that better meet their specific needs. METHODS A cross-sectional survey of 196 adult homeless women in three different Canadian cities was done. Participants were assessed using DSM-IV-based structured clinical interviews. Current diagnoses were compared to available mental health prevalence rates in the Canadian female general population. RESULTS Current prevalence rates were 63% for any mental disorder, excluding substance use disorders; 17% for depressive episode; 10% for manic episode; 7% for psychotic disorder; 39% for anxiety disorders, 28% for posttraumatic stress disorder; and 19% for obsessive-compulsive disorder; 58% had concurrent substance dependence and mental disorders. Lifetime prevalence rates were notably higher. Current moderate or high suicide risk was found in 22% of the women. Participants used a variety of health services, especially emergency rooms, general practitioners, and walk-in clinics. CONCLUSION Prevalence rates of mental disorders among homeless participants were substantially higher than among women from the general Canadian population. The percentage of participants with moderate or high suicide risk and concurrent disorders indicates a high severity of mental health symptomatology. Treatment and housing programs need to be accompanied by multidisciplinary, specialized interventions that account for high rates of complex mental health conditions.
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Mercier C, Picard S. Intellectual disability and homelessness. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2011; 55:441-449. [PMID: 21241395 DOI: 10.1111/j.1365-2788.2010.01366.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The association between poverty and intellectual disability (ID) has been well documented. However, little is known about persons with ID who face circumstances of extreme poverty, such as homelessness. This paper describes the situation of persons with ID who were or are homeless in Montreal and are currently receiving services from a team dedicated to homeless persons. AIMS (1) To describe the characteristics, history and current situation of these persons; and (2) to report within-group differences as a function of gender and current residential status. METHODS The data were collected from files using an anonymous chart summary. Descriptive statistics on the whole sample (n = 68) and inferential statistics on cross-tabulations by gender and residential status were performed. RESULTS Persons with ID exhibited several related problems. Some of these persons, primarily women, experienced relatively short periods of homelessness and their situations stabilised once they were identified and followed up. Other persons with ID experienced chronic homelessness that appeared to parallel the number and severity of their other problems. When compared with a previous epidemiological study of the homeless in Montreal, the population of homeless persons with ID differed from the overall homeless population in a number of respects. CONCLUSION The results suggest prevention and intervention targets. The need for epidemiological research appears particularly clear in light of the fact that below-average intellectual functioning has been identified as a risk factor for homelessness and a predisposing factor for vulnerability among street people.
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Affiliation(s)
- C Mercier
- Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada.
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Burra TA, Stergiopoulos V, Rourke SB. A systematic review of cognitive deficits in homeless adults: implications for service delivery. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2009; 54:123-33. [PMID: 19254443 DOI: 10.1177/070674370905400210] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The primary goals of this systematic review were to assess studies of homeless adults and cognitive functioning, and to explore the clinical implications and potential impacts on social functioning of these cognitive deficits. METHOD The MEDLINE, CINAHL, EMBASE, PsycINFO, Applied Social Sciences Index and Abstracts, ERIC, Social Sciences Abstracts, Social Sciences Citation Index, Social Services Abstracts, and Sociological Abstracts databases were searched from 1970 (or their inception) to October 2007. Abstracts from 582 studies were screened and 22 studies were found to meet inclusion criteria (published in the English language, reported results of neuropsychological tests, or screening tests for cognitive dysfunction in homeless people aged 18 years or older). Two investigators independently reviewed each study and rated its quality based on well-defined criteria. RESULTS Ten studies were of good or fair quality. Studies that administered the Mini Mental State Examination indicate about 4% to 7% of homeless people exhibit global cognitive deficits. Focal deficits in verbal and visual memory, attention, speed of cognitive processing, and executive function were also apparent. No studies of the functional implications of cognitive deficits were found. CONCLUSIONS Cognitive deficits in homeless people likely have a significant mediating impact on the effectiveness of skills training and rehabilitation programs. Clinicians should be cognizant that cognitive deficits probably impair homeless patients' ability to maintain housing stability and follow treatment recommendations. Implications for housing options and health service delivery should also be considered. Research is lacking on interventions to improve cognitive functioning in the homeless.
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Affiliation(s)
- Tara A Burra
- Department of Psychiatry, University of Toronto, Toronto, Ontario.
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Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med 2008; 5:e225. [PMID: 19053169 PMCID: PMC2592351 DOI: 10.1371/journal.pmed.0050225] [Citation(s) in RCA: 588] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 10/03/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There are well over a million homeless people in Western Europe and North America, but reliable estimates of the prevalence of major mental disorders among this population are lacking. We undertook a systematic review of surveys of such disorders in homeless people. METHODS AND FINDINGS We searched for surveys of the prevalence of psychotic illness, major depression, alcohol and drug dependence, and personality disorder that were based on interviews of samples of unselected homeless people. We searched bibliographic indexes, scanned reference lists, and corresponded with authors. We explored potential sources of any observed heterogeneity in the estimates by meta-regression analysis, including geographical region, sample size, and diagnostic method. Twenty-nine eligible surveys provided estimates obtained from 5,684 homeless individuals from seven countries. Substantial heterogeneity was observed in prevalence estimates for mental disorders among the studies (all Cochran's chi(2) significant at p < 0.001 and all I(2) > 85%). The most common mental disorders were alcohol dependence, which ranged from 8.1% to 58.5%, and drug dependence, which ranged from 4.5% to 54.2%. For psychotic illness, the prevalence ranged from 2.8% to 42.3%, with similar findings for major depression. The prevalence of alcohol dependence was found to have increased over recent decades. CONCLUSIONS Homeless people in Western countries are substantially more likely to have alcohol and drug dependence than the age-matched general population in those countries, and the prevalences of psychotic illnesses and personality disorders are higher. Models of psychiatric and social care that can best meet these mental health needs requires further investigation.
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Affiliation(s)
- Seena Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom.
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16
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Oakes PM, Davies RC. Intellectual disability in homeless adults: a prevalence study. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2008; 12:325-334. [PMID: 19074937 DOI: 10.1177/1744629508100496] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
There has been considerable recent interest in the health and associated socio-economic inequalities faced by adults with learning disabilities. A serious and so far under-reported aspect of this is homelessness. This study sought to determine the prevalence of intellectual disability in a homeless population. Fifty people registered at a general practice in north-east England for socially excluded groups, and staying in temporary accommodation for the homeless during 2006-7, were assessed for learning disability. Full-scale and verbal IQ scores for the group were significantly lower than would be expected in the general population, but there was no significant difference in performance IQ. Homeless people are significantly more likely to have an intellectual disability than the general population. The implications for practice and policy development are far reaching. Further work is required to confirm these findings and to explore the experience of homeless people with intellectual disability.
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Haw C, Hawton K, Casey D. Deliberate self-harm patients of no fixed abode: a study of characteristics and subsequent deaths in patients presenting to a general hospital. Soc Psychiatry Psychiatr Epidemiol 2006; 41:918-25. [PMID: 16902733 DOI: 10.1007/s00127-006-0106-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND International studies report high rates of deliberate self-harm (DSH) and suicide in the homeless. Little is known about DSH among homeless people in the UK and their subsequent risk of death from suicide and non-suicidal causes. METHOD We have carried out a study of no fixed abode (NFA) patients using data collected through the Oxford Monitoring System for Attempted Suicide. We describe the demographic and clinical characteristics of NFA DSH patients and the findings of a mortality follow-up study of a cohort of these patients. RESULTS Between July 1988 and December 2002, 10,346 persons presented following 17,352 DSH episodes. Of these persons, 374 (3.6%) were of NFA. Compared with domiciled DSH patients, NFA patients were more likely to be male, single, unemployed, to have been a recent victim of violence and violent towards others, to have a criminal record and to have a personality disorder. More NFA patients faced problems with drugs and alcohol, social isolation, finances, the law and housing and had received psychiatric treatment within the previous 12 months. Substantially more NFA patients had a past history of DSH and re-presented with a further episode of DSH within 12 months. In the cohort of DSH patients who presented between January 1978 and December 1997 and who were followed up until December 2000, mortality from probable suicide and from all causes was approximately double that of domiciled patients. CONCLUSIONS NFA DSH patients are a vulnerable group of patients at high risk of DSH repetition and with increased mortality from all causes. Good liaison between medical and psychiatric services is important. Specialist services may need to be developed to meet the particular needs of this patient group.
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Affiliation(s)
- Camilla Haw
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Headington, Oxford, OX3 7JX, UK
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Spence S, Stevens R, Parks R. Cognitive dysfunction in homeless adults: a systematic review. J R Soc Med 2004. [PMID: 15286189 DOI: 10.1258/jrsm.97.8.375] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Homelessness is associated with multiple adversities that might impact upon brain function. We performed a review of published work to assess evidence of cognitive dysfunction among adults who are homeless. Despite liberal inclusion criteria only seventeen publications were identified, these describing eighteen samples mainly from the USA. Although the total number of individuals studied is small (about 3300) and the samples are heterogeneous, most studies indicate a considerable burden of cognitive dysfunction among homeless people. Such dysfunction might be expected to impact upon their ability to reintegrate into society, thereby undermining policies of inclusiveness. In clinical practice, assessment of homeless adults should include their cognitive state.
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Affiliation(s)
- Sean Spence
- Academic Clinical Psychiatry, Division of Genomic Medicine, University of Sheffield, The Longley Centre, Norwood Grange Drive, Sheffield S5 7JT, UK.
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Graham-Jones S, Reilly S, Gaulton E. Tackling the needs of the homeless: a controlled trial of health advocacy. HEALTH & SOCIAL CARE IN THE COMMUNITY 2004; 12:221-232. [PMID: 19777712 DOI: 10.1111/j.1365-2524.2004.00491.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The objective of the present study was to assess the effectiveness of a health advocate's casework with homeless people in a primary care setting in terms of improvements in health-related quality of life (QoL). The impact of the health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless people moving into hostels or other temporary accommodation in the Liverpool 8 area of the UK and patients registering at an inner-city health centre as temporary residents were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. Health-related QoL outcomes were assessed using three independent self-report measures: the Life Fulfilment Scale; the Delighted-Terrible Faces Scale; and the Nottingham Health Profile. Out of the 326 homeless people who were given baseline questionnaires at registration, 222 (68%) returned usable questionnaires. Out of these individuals, 171 (77.0%) were traceable at follow-up, and 117 (68.4%) follow-up questionnaires were returned. The majority of respondents (n = 117) were women (72%) who were under 30 years of age (74%), white British (91%), and single (63%) or separated (23%), many of whom were living with their children (41%) in either women's refuges (30%) or family hostels (25%). Improvements in health-related QoL were greatest in people recruited and supported by a health advocate early in their stay in temporary housing, in comparison with those in the control group given 'usual care' at the health centre. The model of streamlined care for patients with complex psycho-social needs is shown to be a worthwhile and effective option for primary healthcare providers.
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Affiliation(s)
- S Graham-Jones
- Institute of Health Sciences, University of Oxford, Oxford OX3 7LF, UK.
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Abstract
Since 1980s there is a noticeable change in the homeless population in Western countries. Some researchers titled the change as the "new" homeless that are distinctly different than the "skid row" population described in the past. Among the "new" homeless there are increasing numbers of elderly subjects. The elderly homeless are a fragile and vulnerable group that suffers from high rates of physical and mental problems as well as increased mortality. The aim of the present study was to characterize the "new" elderly homeless. Over a 10-year period each homeless 65 years of age and older was assessed by a psychiatrist. The project was undertaken in Tel-Aviv, Israel, and was feasible due to close co-operation between the Municipal Welfare Department and mental health consultants. The Structured Clinical Interview for DSM-IV (SCID) was the main diagnostic tool. Ninety-eight subjects of 2567 homeless persons located and contacted were elderly (3.8%). Mean age for the elderly sub-group was 71.7+/-5.3 years and the great majority were male 94/98 (95.9%). In 44/98 (44.9%), a formal DSM-IV axis I psychiatric disorder was diagnosed, most common being dementia (15/44) and schizophrenia (15/44). A significant minority of 13/44 (29.5%) were diagnosed and treated prior to becoming homeless. Physical co-morbidity was found in nearly 2/3 subjects. Following intensive case-management by social workers, 35/44 (79.5%) subjects were successfully placed in permanent housing. The main conclusion is that the "new" elderly homeless are typically males suffering from frequent psychiatric morbidity and physical co-morbidity. Intensive case-management succeeded in achieving return to permanent housing in the majority of subjects.
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Affiliation(s)
- Yoram Barak
- Department of Psychogeriatric, Abarbanel Mental Health Center, 59100 Bat-Yam, Israel.
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22
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Abstract
OBJECTIVE This article systematically reviews studies of prevalence of schizophrenia in homeless persons. METHOD Medline and PsychInfo were searched using the key words: homeless person, mental illness, psychosis, and schizophrenia. The bibliographies of identified articles were also reviewed. RESULTS Study designs varied considerably. The rate of schizophrenia in homeless persons reported in the 33 published reports, representing eight different countries, ranged from 2 to 45%. In the 10 methodologically superior studies, the prevalence range was 4-16% and the weighted average prevalence was 11%. In addition, rates were higher in younger persons, women and the chronically homeless. Slightly less than half of the homeless persons with schizophrenia were not currently receiving treatment. CONCLUSION Schizophrenia is much more prevalent among homeless persons than in the population at large. Future research should focus on better ways of meeting the mental health care needs of homeless people with schizophrenia.
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Affiliation(s)
- D Folsom
- Department of Psychiatry and Neurosciences, University of California, San Diego, CA 92161, USA
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Hassiotis A, Ukoumunne O, Tyrer P, Piachaud J, Gilvarry C, Harvey K, Fraser J. Prevalence and characteristics of patients with severe mental illness and borderline intellectual functioning. Report from the UK700 randomised controlled trial of case management. Br J Psychiatry 1999; 175:135-40. [PMID: 10627795 DOI: 10.1192/bjp.175.2.135] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Low cognitive ability and developmental delays have been implicated in the causation of mental illness. AIMS To examine the prevalence, socio-demographic characteristics, psychopathology and social functioning profiles of people with low intelligence and recurrent psychotic illness. METHOD A multi-centre randomised controlled trial of case management provided the opportunity to explore associations between mental illness and borderline intellectual functioning (assessed using the National Adult Reading test). RESULTS Overall prevalence of borderline intelligence was 18%. Significant positive associations were shown with: being Black Caribbean; having a father who worked in a manual occupation; lower educational achievement; having had special education; longer course of illness. Those with borderline intelligence had greater disability and were more likely to suffer extrapyramidal side-effects and show evidence of negative symptoms. Educational achievement, history of special education and social class were the best socio-demographic predictors of intellectual level. CONCLUSIONS Many patients who attend generic psychiatric services have considerable intellectual deficits. This may lead to difficulties in other domains of adaptive functioning, and merits further investigation as well as clinical vigilance.
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Affiliation(s)
- A Hassiotis
- Academic Department of Psychiatry and Behavioural Sciences, University College, London.
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Abstract
OBJECTIVE To investigate the psychosocial characteristics of homeless children and their parents. METHOD Homeless families were assessed within 2 weeks of admission to seven hostels and were compared with a group of housed families matched for socioeconomic status. Measures included a semistructured interview, the General Health Questionnaire (GHQ), the interview Schedule for Social Interaction, the Child Behavior Checklist (CBCL), the Communication domain of the Vineland Adaptive Behavior Scales, and height and weight percentiles. The sample consisted of 113 homeless families (249 children aged 2 through 16 years) and 29 comparison families (83 children). RESULTS Homeless families primarily consisted of single mothers and an average of two children, who had become homeless because of domestic violence (56%) or violence from neighbors (29%). Homeless mothers reported high rates of previous abuse (45%) and current psychiatric morbidity (49% caseness on the GHQ) and poor social support networks compared with housed controls. Homeless children were more likely to have histories of abuse, living in care, and being on the at-risk child protection register and less likely to have attended school or a preschool/day-care center since admission to the hostel. They also had delayed communication and higher CBCL scores. Maternal GHQ scores best predicted CBCL caseness. CONCLUSIONS Homeless mothers and children have high rates of psychosocial morbidity, which are related to multiple risk factors and chronic adversities. Their complex needs should be best met by specialized and coordinated health, social, and educational services.
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Affiliation(s)
- P Vostanis
- Department of Child and Adolescent Psychiatry, University of Birmingham, U.K.
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Bremner AJ, Duke PJ, Nelson HE, Pantelis C, Barnes TR. Cognitive function and duration of rooflessness in entrants to a hostel for homeless men. Br J Psychiatry 1996; 169:434-9. [PMID: 8894193 DOI: 10.1192/bjp.169.4.434] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Four previous studies of homeless adults have yielded conflicting results regarding the presence of cognitive impairment. METHOD A consecutive series of 80 roofless entrants to a hostel for homeless men were sampled and 62 (76%) completed a range of assessments, including measures of mental state, cognitive functions and substance use. RESULTS Estimated premorbid IQ (mean = 96), current IQ (mean = 84) and cognitive speed were significantly lower than the norm. There was a significant IQ drop in all diagnostic groups. IQ drop, but not current IQ, correlated with duration of rooflessness. Those with schizophrenia or alcohol problems were roofless for longest. Alcohol misuse did not correlate with IQ drop, excepting alcohol withdrawal symptoms in those with schizophrenia. CONCLUSION The hypothesis that low IQ is a risk factor for rooflessness is supported. However, length of rooflessness was more closely related to IQ drop than to current IQ, suggesting that some third factor may be affecting both rooflessness and intellectual functioning. Roofless men with schizophrenia or alcohol problems may be especially at risk of long-term rooflessness.
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Affiliation(s)
- A J Bremner
- Department of Psychiatry, Charing Cross and Westminster Medical School, London
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