Intellectual disability among Dutch homeless people: prevalence and related psychosocial problems

"The System Tends to Scoop You Up and Spit You Out and They're Done With You": The Intersection of Intellectual/Developmental Disability and Homelessness From the Perspectives of Service Providers

People with intellectual and developmental disabilities (IDD) experience elevated risk for poor health and social outcomes in adulthood and are at risk for experiencing homelessness and housing instability. Although the exact prevalence of IDD among homeless populations is unknown, a small body of literature related to the intersection of IDD and homelessness suggests differential health needs and service use patterns, with a need for targeted health and social services. In this study, we explore the perceptions and experiences of 18 homeless or disability service providers about (a) their clients at the intersection of IDD and homelessness and (b) their role and the services provided at the intersection of IDD and homelessness. Participants struggled to provide appropriate, accessible services for this population, owing to lack of training and awareness of specific needs, fragmented systems, and inadequately funded healthcare and housing support. Our findings also reveal that clients at this intersection have high contact with public systems, which places them at risk for losing their right to self-determination. Recommendations center on systems transformation to facilitate the ability of providers to collaborate and to make data-driven decisions to deliver person-centered care.

Implementation of a threefold intervention to improve palliative care for persons experiencing homelessness: a process evaluation using the RE-AIM framework

Background

Palliative care provision for persons experiencing homelessness is often poor. A threefold consultation service intervention was expected to increase knowledge of palliative care and multidisciplinary collaboration, and improve palliative care for this population. This intervention comprised: 1) consultation of social service professionals by palliative care specialists and vice versa; 2) multidisciplinary meetings with these professionals; and 3) training and education of these professionals. We aimed to evaluate the implementation process and its barriers and facilitators of this service implemented within social services and healthcare organizations in three Dutch regions.

Methods

A process evaluation using structured questionnaires among consultants, semi-structured individual and group interviews among professionals involved, and (research) diaries. Qualitative data were analysed using thematic analysis. The process evaluation was structured using the Reach, Adoption, Implementation and Maintenance dimensions of the RE-AIM framework.

Results

All three regions adopted all three activities of the intervention, with differences between the three regions in the start, timing and frequency. During the 21-month implementation period there were 34 consultations, 22 multidisciplinary meetings and 9 training sessions. The professionals reached were mainly social service professionals. Facilitators for adoption of the service were a perceived need for improving palliative care provision and previous acquaintance with other professionals involved, while professionals’ limited skills in recognizing, discussing and prioritizing palliative care hindered adoption. Implementation was facilitated by a consultant’s expertise in advising professionals and working with persons experiencing homelessness, and hindered by COVID-19 circumstances, staff shortages and lack of knowledge of palliative care in social service facilities. Embedding the service in regular, properly funded meetings was expected to facilitate maintenance, while the limited number of persons involved in this small-scale service was expected to be an obstacle.

Conclusions

A threefold intervention aimed at improving palliative care for persons experiencing homelessness is evaluated as being most usable when tailored to specific regions, with bedside and telephone consultations and a combination of palliative care consultants and teams of social service professionals. It is recommended to further implement this region-tailored intervention with palliative care consultants in the lead, and to raise awareness and to remove fear of palliative care provision.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01083-3.

Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes?

Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.

Systematic review and meta-analysis of the prevalence of depressive symptoms, dysthymia and major depressive disorders among homeless people

OBJECTIVES

To assess the global prevalence estimates of depressive symptoms, dysthymia and major depressive disorders (MDDs) among homeless people.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Databases including PubMed, Scopus and Web of Science were systematically searched up to February 2020 to identify relevant studies that have reported data on the prevalence of depressive symptoms, dysthymia and MDDs among homeless people.

ELIGIBILITY CRITERIA

Original epidemiological studies written in English that addressed the prevalence of depressive problems among homeless people.

DATA EXTRACTION AND SYNTHESIS

A random-effect meta-analysis was performed to pool the prevalence estimated from individual studies. Subgroup and sensitivity analyses were employed to compare the prevalence across the groups as well as to identify the source of heterogeneities. The Joanna Briggs Institute's quality assessment checklist was used to measure the study quality. Cochran's Q and the I² test were used to assess heterogeneity between the studies.

RESULTS

Forty publications, including 17 215 participants, were included in the final analysis. This meta-analysis demonstrated considerably higher prevalence rates of depressive symptoms 46.72% (95% CI 37.77% to 55.90%), dysthymia 8.25% (95% CI 4.79% to 11.86%), as well as MDDs 26.24% (95% CI 21.02% to 32.22%) among homeless people. Our subgroup analysis showed that the prevalence of depressive symptoms was high among younger homeless people (<25 years of age), whereas the prevalence of MDD was high among older homeless people (>50 years of age) when compared with adults (25-50 years).

CONCLUSION

This review showed that nearly half, one-fourth and one-tenth of homeless people are suffering from depressive symptoms, dysthymia and MDDs, respectively, which are notably higher than the reported prevalence rates in the general population. The findings suggest the need for appropriate mental health prevention and treatment strategies for this population group.

Health Patterns Reveal Interdependent Needs of Dutch Homeless Service Users

Background: Homelessness is an increasing problem in Western European countries. Dutch local authorities initiated cross-sectional reviews to obtain accurate health and needs information on Homeless Service (HS) users. Methods: The Homeless People Treatment and Recovery (HOP-TR) study uses a comprehensive assessment strategy to obtain health data. Using a naturalistic meta-snowball sampling in 2015-2017, 436 Dutch HS users were assessed. The lived experience of HS users was the primary data source and was enriched with professional assessments. The InterRAI Community Mental Health questionnaire and "Homelessness Supplement" provided information in different areas of life. The approach for mental health assessments was transdiagnostic. Raw interview data were recoded to assess health and needs. The positive health framework structured symptomatic, social, and personal health domains relevant to recovery. Results: Most subjects were males, low educated, with a migration background. The majority were long-term or intermittently homeless. Concurrent health problems were present in two domains or more in most (95.0%) subjects. Almost all participants showed mental health problems (98.6%); for a significant share severe (72.5%). Frequent comorbid conditions were addiction (78%), chronic physical conditions (59.2%), and intellectual impairments (39.9%). Conclusion: The HOP-TR study reveals significant concurrent health problems among Dutch HS users. The interdependent character of different needs requires an integrated 3-D public health approach to comprehensively serve symptomatic, social, and personal dimensions, required to facilitate recovery.

Psychometric Properties of the QoL-ME: A Visual and Personalized Quality of Life Assessment App for People With Severe Mental Health Problems

Background: Quality of Life (QoL) assessment in people with severe mental health problems may benefit from improved personalization and accessibility. Therefore, an innovative, digital, visual, and personalized QoL assessment app for people with severe mental health problems was recently developed: the QoL-ME. The aim of this study was to evaluate the psychometric quality of the QoL-ME by assessing its reliability, validity, and responsiveness. Methods: To examine the reliability of the QoL-ME, the internal consistency of its subscales was assessed using Cronbach's Alpha. Correlations between the QoL-ME and the MANSA were computed to appraise the construct validity of the QoL-ME. Internal responsiveness was evaluated using the standardized response mean and external responsiveness was investigated using hierarchical regression. Results: Cronbach's Alpha's of the subscales of the QoL-ME ranged between 0.5 and 0.84. In accordance with expectations, the language-based core version of the QoL-ME correlated strongly (r = between 0.55 and 0.76) with the MANSA, whilst the picture-based additional modules of the QoL-ME correlated moderately (r = 0.3) with the MANSA. The standardized response mean was 0.23 and the regression model revealed a coefficient β of -0.01. Conclusions: The QoL-ME has adequate psychometric properties. In comparison with similar pictorial instruments, both the QoL-ME's reliability and validity can be considered as sufficient. The results indicate that the responsiveness of the QoL-ME is insufficient. Additional research is needed to evaluate and potentially modify the instrument to improve its responsiveness.

Visual and Personalized Quality of Life Assessment App for People With Severe Mental Health Problems: Qualitative Evaluation

BACKGROUND

QoL-ME is a digital visual personalized quality of life assessment app for people with severe mental health problems. Research reveals that e-mental health apps frequently suffer from low engagement and fall short of expectations regarding their impact on patients' daily lives. Studies often indicate that e-mental health apps ought to respect the needs and preferences of end users to achieve optimal user engagement.

OBJECTIVE

The aim of this study was to explore the experiences of users regarding the usability and functionality of QoL-ME and whether the app is actionable and beneficial for patients.

METHODS

End users (n=8) of QoL-ME contributed to semistructured interviews. An interview guide was used to direct the interviews. All interviews were audiorecorded and transcribed verbatim. Transcriptions were analyzed and coded thematically.

RESULTS

Analysis revealed 3 main themes: (1) benefit, (2) actionability, and (3) characteristics of the QoL-ME. The first theme reveals that the QoL-ME app was beneficial for the majority of respondents, primarily by prompting them to reflect on their quality of life. The current version is not yet actionable; the actionability of the QoL-ME app may be improved by enabling users to view their scores over time and by supplying practical advice for quality of life improvements. Overall, participants had positive experiences with the usability, design, and content of the app.

CONCLUSIONS

The QoL-ME app can be beneficial to users as it provides them with insight into their quality of life and elicits reflection. Incorporating more functionalities that facilitate self-management, such as advice and strategies for improving areas that are lacking, will likely make the app actionable. Patients positively regarded the usability, design, and contents of the QoL-ME app.

End-of-life care for homeless people in shelter-based nursing care settings: A retrospective record study

BACKGROUND

Homeless people experience multiple health problems and early mortality. In the Netherlands, they can get shelter-based end-of-life care, but shelters are predominantly focused on temporary accommodation and recovery.

AIM

To examine the characteristics of homeless people who reside at the end-of-life in shelter-based nursing care settings and the challenges in the end-of-life care provided to them.

DESIGN

A retrospective record study using both quantitative and qualitative analysis methods.

SETTING/PARTICIPANTS

Two Dutch shelter-based nursing care settings. We included 61 homeless patients who died between 2009 and 2016.

RESULTS

Most patients had somatic (98%), psychiatric (84%) and addiction problems (90%). For 75% of the patients, the end of life was recognised and documented; this occurred 0-1253 days before death. For 26%, a palliative care team was consulted in the year before death. In the three months before death, 45% had at least three transitions, mainly to hospitals. Sixty-five percent of the patients died in the shelter, 27% in a hospital and 3% in a hospice. A quarter of all patients were known to have died alone. Documented care difficulties concerned continuity of care, social and environmental safety, patient-professional communication and medical-pharmacological alleviation of suffering.

CONCLUSIONS

End-of-life care for homeless persons residing in shelter-based nursing care settings is characterised and challenged by comorbidities, uncertain prognoses, complicated social circumstances and many transitions to other settings. Multilevel end-of-life care improvements, including increased interdisciplinary collaboration, are needed to reduce transitions and suffering of this vulnerable population at the end of life.

Homelessness and people with intellectual disabilities: A systematic review of the international research evidence

BACKGROUND

People with intellectual disabilities can experience homelessness, and some of the reasons differ from the general homeless population. Specific policy and practice responses are required.

METHOD

A systematic review of studies examining homelessness among people with intellectual disabilities utilizing CINAHL, MEDLINE, PsycINFO and Sociological Abstracts databases from inception to November 2019.

RESULTS

The search produced 259 papers, and following screening, a total of 13 papers were included in the review. The themes identified were (i) pathways into homelessness, (ii) experiencing homelessness and (iii) routes out of homelessness.

CONCLUSIONS

People with ID become homeless due to multifactorial issues. The identification of people within homeless services and their care and support concerns remains challenging, impacting upon the provision of assessments, interventions, care and supports. Psychosocial assessments, interventions and supports are necessary to assist people with ID to leave homelessness.

Building Bridges to Housing for homeless adults with intellectual and developmental disabilities: outcomes of a cross-sector intervention

BACKGROUND

Adults with intellectual and developmental disabilities (IDD) have high rates of homelessness. This observational study evaluates Bridges to Housing, a cross-sector intervention offering immediate access to housing and supports to this population in Toronto, Canada.

METHODS

Twenty-six participants, enrolled between April 2016 and December 2017, were assessed at baseline, six and 12 months post-enrolment. Descriptive statistics and generalized linear modelling evaluated quality of life (QOL) and service needs outcomes. Twenty-one service users and providers participated in semi-structured interviews between August 2017 and June 2018 to elicit their experiences of the intervention, which were analysed thematically.

RESULTS

Twelve months post-enrolment, 24 participants were successfully housed and reported increased QOL scores (F(2,43) = 13.73, p = <.001) and decreased perceived unmet service needs (Wald χ² (2) = 12.93, p = .002). Individual-, intervention- and system-level characteristics facilitated housing stability in this population.

CONCLUSIONS

Cross-sector approaches can improve outcomes for homeless adults with IDD and may have an important role in supporting this marginalized population.

Risk factors for homelessness: A structural equation approach

This study aims to assess the pathway relationships between adolescent adversities, adult addictive behaviours, divorce, conviction, long-standing unemployment, disability, and homelessness. A structural equation model was estimated using data on n₁  = 677 homeless men and n₂  = 651 housed men of the same age and educational distribution, living in Warsaw, Poland. Retrospective adolescent adversities were found to be significantly related to the occurrence of adult homelessness (p ≤ .01). This relationship was mainly indirect and largely mediated by addictive behaviours, divorce, conviction, and unemployment. Addiction, divorce, and conviction were the three most frequent events preceding homelessness and were likely to coincide. The first job experience did not differentiate the two groups from each other. However, homeless individuals were more likely to currently prefer self-employment over wage employment. Low perceived importance of family life and preference for self-employment over wage employment were hypothesised to be related to the severity of homelessness.

Accuracy of case managers in estimating intelligence quotients and functional status of people experiencing homelessness

Adults who are homeless experience high rates of health conditions and psychological distress, including low IQ and functional status. Resources are available to help these individuals, but provision of support is often contingent upon the identification of a known disability. In this context, we examined case managers' (CMs') subjective estimates of IQ and functional status in 77 adult residents of an urban homeless shelter. Participants completed objective measures of IQ and functional capacity. CMs overestimated IQs of lower IQ (IQ < 90) participants, correctly estimated IQs of average IQ (IQ = 90-110) participants, and underestimated IQs of higher IQ (IQ > 110) participants. CMs correctly identified 2 out of 8 participants meeting criteria for intellectual disability and 4 out of 16 participants with impaired functional status. These findings suggest that subjective evaluations of IQ and functional status are prone to a central tendency bias, leading CMs to overlook clients who are in need of assistance. Consequently, the objective measurement of IQ and functional status in homeless shelters is highly recommended. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Supporting Efforts by Intellectually Disabled Adults to Exit Homelessness: Key Ingredients of a Cross-Sector Partnership

This column describes the development of a partnership between health care, housing, and intellectual disability services to support efforts by homeless adults with intellectual disabilities to exit homelessness. Applying a Housing First approach and philosophy, the partners launched a pilot intervention, which at its first phase engaged 26 homeless adults with intellectual disabilities in Toronto. This cross-sector service model was acceptable to service users, who reported positive experiences and good program engagement. Key enablers of success included the program's capacity to address complexity, stakeholders' approach to choice and compromise, and fulsome collaboration and communication at every level.

Multimorbidity and emergency department visits by a homeless population: a database study in specialist general practice

BACKGROUND

Estimating healthcare needs of the homeless is associated with challenges in identifying the eligible population.

AIM

To explore the demographic characteristics, disease prevalence, multimorbidity, and emergency department visits of the homeless population.

DESIGN AND SETTING

EMIS electronic database of patient medical records and Quality and Outcomes Framework (QOF) data of all 928 patients registered with a major specialist homeless primary healthcare centre based in the West Midlands in England, from the period of October 2016 to 11 October 2017.

METHOD

Prevalence data on 21 health conditions, multimorbidity, and visits to emergency departments were explored and compared with the general population datasets.

RESULTS

Most homeless people identified were male (89.5%), with a mean age of 38.3 (SD = 11.5) years, and of white British origin (22.1%). Prevalence of substance (13.5%) and alcohol dependence (21.3%), hepatitis C (6.3%), and multimorbidity (21.3%) were markedly higher than in the general population. A third (32.5%) had visited the emergency department in the preceding 12 months. Emergency department visits were associated with a patient history of substance (odds ratio [OR] = 2.69) and alcohol dependence (OR = 3.14).

CONCLUSION

A high prevalence of substance and alcohol dependence, and hepatitis C, exists among the homeless population. Their emergency department visit rate is 60 times that of the general population and the extent of multimorbidity, despite their lower mean age, is comparable with that of 60-69-year-olds in the general population. Because of multimorbidity, homeless people are at risk of fragmentation of care. Diversification of services under one roof, preventive services, and multidisciplinary care are imperative.

Cognitive impairment and homelessness: A scoping review

This paper reports the findings of a scoping review designed to identify research which has explored the relationship between cognitive impairment and homelessness. A systematic search of databases for articles published between 2007 and 2017 was conducted using keywords relating to cognitive impairments and homelessness. Sources were expanded using manual searches of citations and grey literature. Forty studies represented in 45 papers were selected for review using predefined inclusion criteria. Sources were subject to quality appraisal and data were extracted in line with review questions. Prevalence studies were over-represented in the review, while qualitative data were lacking. Aetiology of impairments was delineated by acquired and developmental causes. A variety of measures were employed by studies which were not validated in homeless populations. Studies did not give sufficient consideration to co-occurring disorders and overlapping symptoms between aetiologies. Because of these factors, it was difficult to conclude that all studies had accurately measured what they set out to; however, the evidence suggested that cognitive impairment was disproportionately over-represented in homeless populations. Cognitive impairment was found to be both a risk factor to and perpetuator of homelessness. Risk factors for homelessness were similar to those of the general population, though exaggerated by sequelae of certain cognitive impairments. The results of this review suggest that more attention needs to be paid to the underlying socioeconomic disadvantages, persons with cognitive impairments face which may lead to homelessness. Further research should prioritise the voice of homeless persons with cognitive impairments, to better understand both causes of homelessness and effective methods of rehabilitation.

Borderline Intellectual Functioning and Lifetime Duration of Homelessness among Homeless Adults with Mental Illness

This paper reports on the association between intellectual functioning and lifetime homelessness duration among 172 homeless adults with mental illness in Toronto, Canada. Using a standardized test of intellectual functioning, we created two groups: individuals with borderline or lower intellectual functioning (16%) and individuals with above borderline intellectual functioning (84%). Lifetime homelessness duration was approximately three years longer, or almost twice as long, for individuals with borderline or lower intellectual functioning. Implementing more systematic strategies for identifying and supporting individuals with cognitive impairments may hasten transitions out of homelessness for this population. Brief intellectual functioning assessment tools are available.

Cocreative Development of the QoL-ME: A Visual and Personalized Quality of Life Assessment App for People With Severe Mental Health Problems

BACKGROUND

Quality of life (QoL) is a prominent outcome measure in mental health. However, conventional methods for QoL assessment rely heavily on language-based communication and therefore may not be optimal for all individuals with severe mental health problems. In addition, QoL assessment is usually based on a fixed number of life domains. This approach conflicts with the notion that QoL is influenced by individual values and preferences. A digital assessment app facilitates both the accessibility and personalization of QoL assessment and may, therefore, help to further advance QoL assessment among individuals with severe mental health problems.

OBJECTIVE

This study focused on the development of an innovative, visual, and personalized QoL assessment app for people with severe mental health problems: the QoL-ME.

METHODS

This study targeted 3 groups of individuals with severe mental health problems: (1) people with psychiatric problems, (2) people treated in forensic psychiatry, and (3) people who are homeless. A group of 59 participants contributed to the 6 iterations of the cocreative development of the QoL-ME. In the brainstorming stage, consisting of the first iteration, participants' previous experiences with questionnaires and mobile apps were explored. Participants gave their feedback on initial designs and wireframes in the second to fourth iterations that made up the design stage. In the usability stage that comprised the final 2 iterations, the usability of the QoL-ME was evaluated.

RESULTS

In the brainstorming stage, participants stressed the importance of privacy and data security and of receiving feedback when answering questionnaires. Participants in the design stage indicated a preference for paging over scrolling, linear navigation, a clean and minimalist layout, the use of touchscreen functionality in various modes of interaction, and the use of visual analog scales. The usability evaluation in the usability stage revealed good to excellent usability.

CONCLUSIONS

The cocreative development of the QoL-ME resulted in an app that corresponds to the preferences of participants and has strong usability. Further research is needed to evaluate the psychometric quality of the QoL-ME and to investigate its usefulness in practice.

A Systematic Review of Substance Use (Disorder) in Individuals with Mild to Borderline Intellectual Disability

Although the attention for substance use (SU) and SU disorders (SUD) among individuals with mild to borderline intellectual disability (MBID) has been growing exponentially, this form of dual diagnosis has largely been ignored by addiction medicine. In this article, we systematically review the research between January 2000 and June 2018 on the prevalence, assessment, and treatment of SU(D) among children, adolescents, and adults with MBID. A total of 138 articles were included. It is concluded that individuals with MBID are likely to be at a higher risk for developing SUD compared to those without MBID. Future research should focus on the detection of MBID among patients being treated in addiction medicine, the development and implementation of systematic assessment methods of SU(D) among individuals with MBID, and the development and evaluation of prevention and treatment interventions. System integration, interdisciplinary collaboration, and the development of tailored treatment for individuals with MBID are advised to improve treatment access and outcome for those who have developed SUD.

Care avoidance among homeless people and access to care: an interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people

BACKGROUND

Because of their poor health and social vulnerability, homeless people require specific care. However, due to care avoidance, homeless people are often not involved in care. This study aims to get insights into reasons for and kinds of care avoidance among homeless people and to provide suggestions to reach this target group.

METHODS

Semi-structured individual interviews were conducted among street pastors (n = 9), spiritual caregivers (n = 9), homeless outreach workers (n = 7) and formerly homeless people (n = 3). Participants were recruited by purposive sampling in the four major cities in the Netherlands (Amsterdam, Utrecht, Rotterdam, The Hague). The verbatim transcripts were analysed using thematic analysis.

RESULTS

The term care avoidance was perceived as stigmatizing. Care avoidance is found to be related to characteristics of the homeless person (e.g. having complex problems, other priorities) as well as of the system (e.g. complex system, conditions and requirements of organizations). The person-related characteristics suggestions to involve homeless persons include tailoring care and building relationships, which might even be prioritised over starting care interventions. Setting limits on behaviour without rejecting the person, and an attitude reflecting humanity, dignity and equality were also important factors in making care more accessible and lasting. As regards system-related characteristics, the suggestions include clear information and communication to homeless people who avoid care as being crucial in order to make care more accessible. Other suggestions include quiet and less busy shelters, a non-threatening attitude and treatment by professionals, self-reflection by professionals and finally a change of policy and legislation regarding available time.

CONCLUSIONS

Reasons for care avoidance can be found in the interplay between both the individual and the system; measures to reduce care avoidance should be taken at both levels. These measures are centred on lowering the barriers to care inter alia by incorporating building trust and understanding into the care provided.

The Views of Homeless People and Health Care Professionals on Palliative Care and the Desirability of Setting Up a Consultation Service: A Focus Group Study

CONTEXT

Palliative care for homeless people is often given late, if at all. Professionals in both palliative care and shelter care are often insufficiently equipped to provide this complex care.

OBJECTIVES

To provide insights into the palliative care experiences of professionals and homeless people, including barriers and facilitators to care, and to investigate whether a consultative function can help improve palliative care for homeless people.

METHODS

Six focus groups were included; four with professionals (n = 19) and two with severely ill homeless people (n = 15). Professionals were sampled purposively in organizations providing (palliative) care to the homeless. Homeless people were recruited by opportunity sampling.

RESULTS

Palliative care for homeless people is especially complex and differs substantially from regular palliative care. It differs greatly among professionals, institutions, and cities. Homeless people get less autonomy than they would like. Homeless people and professionals have different perceptions of the care provided. Trusting relationships between professionals and homeless people is essential and easily accessible, and flexible care is needed. Consultation, in particular involving exchange of expertise between professionals, can provide added value to professionals. Homeless people consider consultation primarily as an opportunity to train professionals to show more understanding, provide tailored palliative care, and enhance professional collaboration. The local situation, characteristics of a consultant, and role of a consultant in providing information and education must be considered when developing the consultation process.

CONCLUSION

Consultation can play an important role in improving palliative care by linking disciplines, providing support to professionals and appropriate palliative care to homeless people.

Worth a thousand words? Visual concept mapping of the quality of life of people with severe mental health problems

OBJECTIVES

Conventional approaches to quality of life (QoL) measurement rely heavily on verbal, language-based communication. They require respondents to have significant cognitive and verbal ability, making them potentially unsuitable for people with severe mental health problems. To facilitate an alternative approach to QoL assessment, the current study aims to develop an alternative, visual representation of QoL for people with severe mental health problems.

METHODS

An alternative, visual adaptation of the concept mapping method was used to construct this visual representation of QoL. Eighty-two participants (i.e., patients, care professionals, and family members) contributed to this study. Results were processed statistically to construct the concept map.

RESULTS

The concept map contains 160 unique visual statements, grouped into 8 clusters labelled (1) Support and Attention, (2) Social Contacts, (3) Happiness and Love, (4) Relaxation and Harmony, (5) Leisure, (6) Lifestyle, (7) Finances, and (8) Health and Living. Examples of visual statements are pictures of family silhouettes, romantic couples, natural scenes, houses, sports activities, wallets and coins, smiley faces, and heart shapes. The clusters were interpreted and labelled by participants.

CONCLUSIONS

Almost all of the statements correspond to clusters found in previous (non-visual) QoL research. Hence, QoL domains can also be presented visually.

Alcohol use disorders in people with intellectual disability

This article initially highlights that although the prevalence of alcohol use disorders in people with intellectual disability (PWID) appears to be low, it is a significant issue. This group can be more vulnerable to the adverse effects of alcohol and it is likely that many PWID who have alcohol use disorders are not being identified. We go on to review the limited existing literature on treatment for PWID who have alcohol use disorders and the challenges in meeting the needs of this patient group. We explore how assessment and treatment of alcohol use disorders in this population can be and needs to be tailored to the needs of PWID on an individual basis. There is also discussion about the use of incapacity legislation to treat this group.

LEARNING OBJECTIVES

•

DECLARATION OF INTEREST

None.

The Effect of Housing First on Housing Stability for People with Mental Illness and Low Intellectual Functioning

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.

Causes of homelessness prevalence: Relationship between homelessness and disability

AIM

Many studies have reported that the prevalence of mental illness and cognitive disability is higher among homeless individuals compared to the general population, and the rates of mental illness among the homeless population have recently increased. This study: (i) compares causes of homelessness or barriers to escaping homelessness for people with/without mental illness/cognitive disability; (ii) reveals problems with the Japanese homeless policy; and (iii) proposes an effective and necessary support system.

METHODS

The participants were 114 homeless individuals. A psychiatric diagnostic interview and the Wechsler Adult Intelligence Scale, version III were used to measure participants' mental health and cognitive abilities. A questionnaire was administered comprising 17 items related to the causes of their homelessness and barriers to escaping from it. Participants were divided into four groups - with/without mental illness or cognitive disability - and Fisher's exact test was used to compare the questionnaire results.

RESULTS

Individuals with cognitive disabilities considered bad relationships with their family members to be the cause of their homelessness. Conversely, normal individuals considered their homelessness to be the result of debt more so than did individuals with mental problems. Individuals with mental illness had more difficulties escaping homelessness than did either normal individuals or individuals with cognitive disability. This tendency was observed most strongly among individuals with both mental illness and cognitive disability.

CONCLUSION

Most homeless individuals considered economic problems to be the cause of their homelessness; however, difficulties with human relationships were also important factors and were more difficult for participants to acknowledge. Furthermore, these difficulties were exacerbated among those individuals with mental problems.

Self-reported care needs of Dutch homeless people with and without a suspected intellectual disability: a 1.5-year follow-up study

Cognitive impairment is a prevalent problem among the homeless and seems related to more psychosocial problems. However, little is known about the care needs of the subgroup of homeless people with an intellectual disability compared to those without an intellectual disability and how their care needs develop over time. This study explores self-reported care needs within a broad range of life domains among Dutch homeless people with and without a suspected intellectual disability to gain insight into the transition of self-reported care needs from baseline to follow-up in both subgroups. This longitudinal study is part of a cohort study among homeless people who had been accepted for an individual programme plan in four major Dutch cities. The initial cohort consisted of 513 participants who were interviewed in 2011. At 1.5-year follow-up, 336 participants (65.5%) were also interviewed and screened for intellectual disability. Of these participants, 31% (95% CI 26.2-36.1) had a suspected intellectual disability. For both groups, between baseline and follow-up, the number of 'unmet care needs' decreased significantly and the number of 'no care needs' increased significantly, while at follow-up, participants with a suspected intellectual disability reported 'no care needs' on significantly fewer life domains than those without a suspected intellectual disability (mean numbers 16.4 vs. 17.5). Between baseline and follow-up, 'met care needs' decreased significantly on housing for both groups, and increased on finances and dental care for participants with a suspected intellectual disability. At follow-up, participants with a suspected intellectual disability more often preferred housing support available by appointment than those without a suspected intellectual disability. These findings suggest that homeless people who had been accepted for an individual programme plan with a suspected intellectual disability have care needs for a longer period of time than those without a suspected intellectual disability. Providing care to homeless people with a suspected intellectual disability might require ongoing care and support, also after exiting homelessness. Support services should take this into account when considering their care provision and planning of services.

Prevalence of Mental Illness, Cognitive Disability, and Their Overlap among the Homeless in Nagoya, Japan

BACKGROUND

While the prevalence of mental illness or cognitive disability is higher among homeless people than the general population in Western countries, few studies have investigated its prevalence in Japan or other Asian countries. The present study conducted a survey to comprehensively assess prevalence of mental illness, cognitive disability, and their overlap among homeless individuals living in Nagoya, Japan.

METHODS

Participants were 114 homeless individuals. Mental illness was diagnosed based on semi-structured interviews conducted by psychiatrists. The Wechsler Adult Intelligence Scale-III (WAIS-III, simplified version) was used to diagnose intellectual/ cognitive disability.

RESULTS

Among all participants, 42.1% (95% CI 33.4-51.3%) were diagnosed with a mental illness: 4.4% (95% CI 1.9-9.9%) with schizophrenia or other psychotic disorder, 17.5% (95% CI 11.6-25.6%) with a mood disorder, 2.6% (95% CI 0.9-7.5%) with an anxiety disorder, 14.0% (95% CI 8.8-21.6%) with a substance-related disorder, and 3.5% (95% CI 1.4-8.8%) with a personality disorder. Additionally, 34.2% (95% CI 26.1-43.3%) demonstrated cognitive disability: 20.2% (95% CI 13.8-28.5%) had mild and 14.0% (95% CI 8.8-21.6%) had moderate or severe disability. The percent overlap between mental illness and cognitive disability was 15.8% (95% CI 10.2-23.6%). Only 39.5% (95% CI 26.1-43.3%) of the participants were considered to have no psychological or cognitive dysfunction. Participants were divided into four groups based on the presence or absence of mental illness and/or cognitive disability. Only individuals with a cognitive disability reported a significant tendency toward not wanting to leave their homeless life.

CONCLUSION

This is the first report showing that the prevalence of mental illness and/or cognitive disability among homeless individuals is much higher than in the general Japanese population. Appropriate support strategies should be devised and executed based on the specificities of an individual's psychological and cognitive condition.

Prevalence of mental illness, intellectual disability, and developmental disability among homeless people in Nagoya, Japan: A case series study

AIM

While it has been reported that the prevalence of mental illness is higher in homeless people than in the national population, few studies have investigated the prevalence of intellectual and developmental disability among the homeless. In this study, we conducted a survey to comprehensively assess these mental problems among homeless people in Nagoya, Japan.

METHODS

The subjects were 18 homeless men. Mental illness was diagnosed with semi-structured interviews conducted by psychiatrists. We used the Wechsler Adult Intelligence Scale III to diagnose intellectual disability. Discrepancies between Wechsler Adult Intelligence Scale III subtest scores were used as criteria for developmental disability.

RESULTS

Eleven of the 18 participants were diagnosed with mental illness: six with mood disorder, two with psychotic disorder, and six with alcohol problems. The mean IQ of all subjects was 83.4 ± 27.4. The 95% confidence interval (CI) was 96.2-69.1. Seven participants were found to have intellectual disability. Three men showed discrepancies of more than 10 between subtest scores, and all of them were diagnosed with a mental illness. We divided the participants into four groups: those with mental illness only; those with intellectual disability only; those with both problems; and those without diagnosis. The men with intellectual disability only were significantly younger and had been homeless since a younger age than the other groups. Participants diagnosed with a mental illness had been homeless for longer than those without mental health problems.

CONCLUSION

Although the sample size was limited, this study revealed the high prevalence of mental illness and intellectual disability, 61% (95%CI, 35-83%) and 39% (95%CI, 17-64%), respectively, in homeless people in Nagoya, Japan.