*Bernice Prinsloo, Registrar, Child and Adolescent Psychiatry, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland. E-mail: email@example.com
Catherine Parr, Registrar in Psychiatry, James Connolly Memorial Hospital, Blanchardstown, Dublin 15, Ireland.
Joanne Fenton, Consultant Psychiatrist, ACCES Team, Dublin 8, Ireland
Submitted December 15th 2010 / Accepted March 21st 2011
Objective: To determine the prevalence of mental illness among the residents of a homeless hostel in inner city Dublin.
Method: A cross-sectional survey was carried out among hostel residents, as previous studies have indicated that homeless hostel-dwelling men in Dublin constitute the largest single grouping of homeless Irish people. All agreeable residents were interviewed by the authors over an eight-week period using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For each disorder, the current (30-day) and past prevalence was determined.
Results: A total of 38 residents were interviewed, resulting in a response rate of 39.2% for the study. A total of 81.6% of residents had a current Axis I diagnosis; this number increased to 89.5% when combining current and past diagnoses. Only four residents had no diagnosis. There was considerable comorbidity between disorders, with a significant number of residents experiencing both mental illness and substance use problems. When considering lifetime diagnoses, 31.6% had a single diagnosis only; 57.9% had two/more diagnoses. Twelve residents (31.6%) had been admitted to a psychiatric hospital during their lifetime. The most prevalent disorders during the past month were Alcohol Dependence (23.7%), Opioid Dependence and Major Depressive Disorder (both 18.4%), Opioid Abuse and Alcohol-Induced Depression (both 7.9%). Only 23.7% of interviewed residents were attending psychiatric or addiction services. A significant number of residents who did not wish to participate in the study were identified by hostel staff as having a confirmed psychiatric diagnosis.
Conclusion: The survey demonstrated a very high prevalence of mental disorders among homeless hostel residents. The high prevalence of dual diagnosis highlights the need for greater collaboration between psychiatric services and addiction services. The outcome also points to the importance of providing mental health training to emergency shelter/hostel staff. Research into the mental health status of the homeless should be undertaken regularly if services are to be planned to meet the needs of this vulnerable group.
Key words: homeless, hostel, mental illness, dual diagnosis
Prevalence of mental illness among the homeless
Studies have consistently demonstrated high rates of mental disorders among people who are homeless.1 The rates of psychiatric morbidity among homeless adults will vary according to the type of homelessness: sleeping rough, using a night shelter, staying in special hostels, and using temporary leased accommodation.2 International comparisons also demonstrated significant cross-cultural differences in the prevalence of mental disorders among the homeless.1
In an Australian study 73% of homeless men and 81% of homeless women in inner Sydney met criteria for at least one mental disorder in the past year and 40% of the men and 50% of the women had at least two mental disorders.1 Among the homeless population in Utrecht, The Netherlands, 32% of people had depression, 15% a schizophrenic disorder and 52% an antisocial personality disorder.3 In Madrid, Spain, 67% of homeless people had some type of mental disorder.4 In Stockholm, Sweden, 47% of the homeless suffered from mental illness.5 A survey in Belfast indicated that approximately 25% of the homeless in Belfast hostels have a diagnosed mental disorder.6
The most prominent mental disorders among the homeless are depression, affective disorders, substance abuse, psychotic disorders, schizophrenia, and personality disorders.7 Significant numbers of homeless people experience the coexistence of mental health issues and substance use problems (dual diagnosis).8
The relationship between homelessness and mental illness
The causal link between homelessness and mental ill-health is the subject of an ongoing debate. Some argue that the psychiatric problems of many of the homeless may result directly from their poverty and associated lack of accommodation. Others contend that the majority first experienced their symptoms of mental disorder before becoming homeless.2
According to Dr Joe Fernandez, former Director of the Programme for the Homeless in St Brendan’s Hospital in Dublin, a distinction must be drawn between “mental health problems” induced by homelessness, and “mental illness” which may be a factor in becoming or remaining homeless; both of which should be attended to by primary care agents i.e. general practitioners, or by the mental health services.9 Research suggests that the experience of being homeless may contribute to anxiety or depressive illnesses.10 On the other hand, a significant factor in precipitating homelessness is serious mental illness, and alcohol or drug addiction. It is also accepted that homelessness may exacerbate a previous existing mental condition.11
Homelessness amongst the mentally ill is associated with a range of other factors, including substance abuse, younger age at first hospitalisation, and greater severity of symptoms compared to individuals with mental illness who are not homeless.12 Many homeless people with a dual diagnosis of mental illness and drug or alcohol misuse find themselves without a service, since existing services consider themselves to be either psychiatric services or addiction services, with poorly defined collaborative functions.13
The homeless mentally ill also appear to encounter a range of specific, additional problems in relation to housing including, for example, difficulties accessing community care services following discharge from hospital.14 A Crisis survey performed in 2002 found that the homeless people interviewed were almost 40 times more likely not to be registered with a GP than the average person. Poor access to primary care services has a direct impact on other health care services, with an increased likelihood of people attending A&E.15
Social integration and participation, as well as employment and meaningful life activities are compromised by the presence of persistent and untreated psychiatric and physical health problems for individuals who are homeless. The ability to take steps forward may be limited due to a combination of poor life skills, ongoing mental health issues and/or substance use problems, as well as disruptive life events (lack of stable residence, lack of regular income, victimisation related to street life).15 Individuals with mental illness also tend to encounter substantial problems adapting to housing following lengthy periods of homelessness and many of these problems go on to complicate their broader re-integration into society.16
Homelessness and mental illness in Ireland
Holohan conducted the first study to examine the health of the adult homeless population in Dublin in 1997. Sixty six per cent of people had at least one physical or psychiatric problem. Chronic physical disease was reported by 41%. The prevalence of depression in this study was 32.5% and for anxiety disorders 27.6%.17 In 1999 Feeney et al built on this work and examined the health status and perception of health service access of homeless hostel-dwelling men in Dublin. In this study 52% of men suffered from depression, 50% from anxiety and 4% from other mental health problems. Fifty percent of hostel residents were defined as alcohol dependent, with 29% having severe alcohol dependence. More than one third of respondents reported having engaged in illicit use of at least one drug in the previous year.10
O’Neill et al conducted an audit in 2003 to determine the proportion of those attending the Mater Misericodiae Hospital’s psychiatric service that were homeless, including those presenting to accident and emergency who were homeless. Of all the A&E referrals to psychiatry, 34.8% were homeless. The homeless presented most commonly in suicidal crisis (26.6%) compared with 12.5% in the non-homeless group. Substance-abuse disorders were the primary diagnosis in 42.3% of the homeless group, accounting for 14.2% in the housed sample.18
Considerable difficulty arises for homeless people in accessing mental health care due to the sectorisation of services into catchment areas.13 In Dublin this has resulted in increased pressure on the two assertive community mental health teams providing service to the homeless population, based in North Dublin and South Dublin respectively.
The burden resulting from the gaps in statutory service provision for homeless people with, or at risk of mental illness, falls on voluntary homeless service providers and on the wider health and social services, all of which are already under enormous strain. The consequences impact severely on the quality of life for homeless people with mental illness. The Simon Communities of Ireland, a voluntary homeless agency has said: “[we] are extremely concerned at the increase … witnessed in the numbers of people who are homeless who are presenting with mental ill health. The lack of access to assessment and treatment services by people who are homeless further exacerbates the problem – leaving individuals very vulnerable, and homeless services struggling to ensure they meet service users’ needs.”13
In A Vision for Change several recommendations were made in relation to mental health services for homeless individuals.19 There is however still a long way to go towards implementing this policy in the context of homelessness.
The objective of the study was to determine the prevalence of mental illness among the residents of an emergency hostel located in inner city Dublin. The hostel provides direct access, emergency and short term accommodation for 74 single homeless men aged over 26. The hostel is managed in partnership by Depaul Trust and SVP.20 Previous studies have indicated that homeless hostel-dwelling men in Dublin constitute the largest single grouping of homeless Irish people.10
A cross-sectional survey was carried out among hostel residents. Posters were placed on a public notice board at the hostel inviting residents to participate in the study; they were asked to inform their key workers should they wish to participate. All agreeable residents were then interviewed at the hostel by the authors over an eight-week period from June to August 2010. All participants were given €10 as an incentive; this was provided on completion of each interview. This procedure has been used in other studies to maximise response rates.10
Residents were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) Clinical Version. For each disorder, the 30-day (current) and past prevalence was determined. The interviewers were psychiatrically trained and familiar with the DSM-IV diagnoses. Inter-rater reliability was determined between the interviewers.
A total of 38 residents were interviewed. During the study period 128 men used beds at the hostel; of these 31 were emergency bed users, simply occupying rooms with no key worker input. Not taking these 31 men into account, a response rate of 39.2% was achieved for the study. Characteristics of participating residents are displayed in Table 1, with SCID-CV Diagnoses summarised in Table 2.
Click here for Table 1. Demographic profile of study participants
Click here for Table 2. Prevalence of DSM-IV Axis I Disorders among hostel residents
A total of 81.6% of residents had a current Axis I diagnosis; this number increased to 89.5% for lifetime diagnoses (when combining current and past diagnoses). Only four residents had no diagnosis. When considering lifetime diagnoses, 31.6% had a single diagnosis only; 57.9% had two/more diagnoses. Twelve residents (31.6%) had been admitted to a psychiatric hospital during their lifetime. Sixteen residents (42.1%) had a lifetime diagnosis of any depressive disorder, two residents (5.3%) of a psychotic disorder, 30 residents (78.9%) of any substance use disorder, and 7 residents (18.4%) of an anxiety/adjustment disorder.
The most common current and past diagnosis was Alcohol Dependence, with 52.6% of residents meeting the criteria for either current or past dependence. The most prevalent current diagnoses are displayed in Figure 1.
Click here for Figure 1. Most prevalent Axis I Disorders during the past month
Only 23.7% of interviewed residents were attending an outpatient department (either psychiatric or addiction services); in addition one resident was attending a counsellor and one was attending AA. The majority were not linked in with any service.
The Specialist Support Worker at the hostel was able to provide some information on the 59 hostel residents who did not wish to participate in the study. Of these men, 14 (23.7%) had evidence of mental illness. Six of these residents reportedly had a diagnosis of Schizophrenia; five of them were linked in with psychiatric services. An additional eight residents suffered from Depression (one of them having a diagnosis of Bipolar Affective Disorder); of these six were under the care of their GP, one was linked in with psychiatric services and the resident with Bipolar Affective Disorder had been refusing intervention in recent years. Another resident had no clear diagnosis but had previously been admitted to a psychiatric hospital.
The survey demonstrated a very high prevalence of mental disorders among homeless hostel residents. Comparing prevalence rates with other cities and countries is difficult though due to different definitions used for homelessness, differing diagnostic criteria/interview techniques and different timeframes used (e.g. lifetime/12-month/30-day prevalence).
The response rate of 39.2% in this study is low compared to other studies.17,21 A possible explanation for this could be that the interviews were conducted over a period of eight weeks, as opposed to some studies where interviews were conducted together within a few days. It is worth noting that reasons for nonparticipation in research may also be related to severe mental illness.21
There was considerable comorbidity between disorders, with a significant number of residents experiencing both mental illness and substance use problems. Both alcohol and substance use disorders were highly prevalent, as has also been found in other studies. A systematic review of the prevalence of mental disorders among the homeless found that alcohol dependence and drug dependence were the most common disorders in this group.21
Combining depressive disorders (including those that are alcohol and substance-induced) results in a current prevalence of 34.2%. This is similar to the rate found in a previous study examining the health of the adult homeless population in Dublin; in that study 32.5% of homeless individuals reported depression.17 The current prevalence of anxiety disorders was 10.5%, which is much lower than the rate of 27.6% in the previous study.17 This low rate is surprising as many men have been exposed to trauma and violence. A possible explanation for this could be stricter diagnostic criteria used in this study.
Of note only 5.3% of the sample were identified as having a psychotic disorder, which is lower than expected compared to some other studies.1,3,22 The prevalence would increase slightly if one were to take into account those mentioned residents who did not want to participate in the study. The systematic review previously mentioned found that the prevalence rates for psychotic illness among the homeless in western countries ranged from 2.8% to 42.3%. The review found that lower participation in surveys was associated with lower prevalence of psychosis. 21
The low number of residents attending services is cause for concern. There could be various reasons for this, including the differentiation between psychiatric and addiction services, sectorisation of services into catchment areas, stigma of psychiatric care, and shelter/hostel staff having limited experience in assessing for or managing mental illness or addiction. In addition both physical and psychiatric care rank low in homeless people’s list of priorities. The demands of securing immediate needs for survival – food, shelter, money – are more pressing than appointments with doctors or nurses.23
A relatively small sample of residents were interviewed and the study only focused on one particular group of homeless men, thus limiting generalisability. The Specialist Mental Health Worker actively encouraged those men with mental health problems to attend for interview, possibly introducing selection bias. The study was unique though in that, to the best of the authors’ knowledge, it was the first study in Ireland assessing the complete spectrum of Axis I Disorders; previous studies focused primarily on depression and anxiety disorders.10,17 Interviews were conducted by psychiatrically trained raters using a well validated measure.
The study highlights the need to address mental illness in the homeless population, as it is experienced by so many and may be contributing to maintaining homelessness through sustained unemployment and social isolation. The high prevalence of dual diagnosis highlights the need for greater collaboration between psychiatric and addiction services. The outcome further points to the importance of providing mental health training to emergency shelter/hostel staff. Such training offers the potential to significantly improve staff’s ability to respond to the needs of residents with mental illness, and to the behavioural problems some of these individuals may pose for shelter/hostel operation.24 Research into the mental health status of the homeless should be undertaken regularly if services are to be planned to meet the needs of this vulnerable goup.13
Conflict of interest
We would like to thank the following people for their assistance:
• Ms Sharon Harvey, Specialist Support Worker
• Ms Margaret Freeney, Administrative Assistant
• Dr Some Onuoha, Locum Consultant Psychiatrist
1. Teesson M, Hodder T, Buhrich N. Psychiatric disorders in homeless men and women in inner Sydney. Australian and New Zealand Journal of Psychiatry 2004; 38: 162-168.
2. Meltzer H. State-of-Science Review: SR-B6 The Mental Ill-Health of Homeless People. Foresight Mental Capital and Wellbeing Project. The Government Office for Sciences, 2008: 1-8.
3. Reinking DP, Wolf JR, Kroon H. High prevalence of mental disorders and addiction problems among the homeless in Utrecht. Ned Tijdschr Geneeskd. 2001; 145(24): 1161-6.
4. Vázquez C, Muñoz M, Sanz J. Lifetime and 12-month prevalence of DSM-III-R mental disorders among the homeless in Madrid: a European study using the CIDI. Acta Psychiatr Scand. 1997; 95(6): 523-30.
5. Halldin J, Eklöv L, Lundberg C, Åhs S. Mental health problems among homeless people in Sweden: focus on Stockholm. International Journal of Mental Health 2001; 3: 74-83.
6. McAuley A, McKenna HP. Mental disorders among a homeless population in Belfast: an exploratory survey. Journal of Psychiatric and Mental Health Nursing 2008; 2(6): 335-342.
7. Martens WH. A review of physical and mental health in homeless persons. Public Health Rev. 2001; 29(1): 13-33.
8. Holohan T. Health Status, Health Service Utilisation and Barriers to Health Service Utilisation among the Adult Homeless Population of Dublin. Dublin: Eastern Health Board, 1997.
9. Fernandez J. Caring for the Homeless Mentally Ill: Status and Directions. Seminar presentation for the Irish Psychiatric Association at St Patrick’s Hospital, April 2003.
10. Feeney A, McGee HM, Holohan T, Shannon W. Health of Hostel-dwelling Men in Dublin. ERHA & RCSI 2000.
11. Barry S. The Homeless Mentally Ill – discussion document, Apendix A, Cluain Mhuire Adult Mental Health Service Proposal: The Homeless Mentally Ill. Dublin, 2002.
12. Opler LA, White L, Caton CL et al. Gender differences in the relationship of homelessness to symptom severity, substance abuse, and neuroleptic compliance in schizophrenia. J Nerv Ment Dis 2001; 189: 449-556.
13. Crowley F. Mental Illness: The Neglected Quarter – Homelessness. Amnesty International (Irish Section), Dublin, 2003.
14. Melzer D, Hale AS, Malik SJ et al. Community care for patients with schizophrenia one year after hospital discharge. BMJ 1991; 303: 1023-1026.
15. Critical Condition: Vulnerable single homeless people and access to GPs. Crisis UK, London, 2002.
16. Yanos PT, Barrow SM, Tsemberis S. Community integration in the early phase of housing among homeless persons diagnosed with severe mental illness. Community Ment Health J 2004; 40: 133-15.
17. Holohan TW. Health and Homelessness in Dublin. Ir Med J 2000; 93: 41-43.
18. O’Neill A, Casey P, Minton R. The homeless mentally ill: an audit from an inner city hospital. Ir J Psychol Med 2007; 24: 62-66.
19. Expert Group on Mental Health Policy. A Vision for Change: Report of the Expert Group on Mental Health Policy. Dublin: The Stationery Office, 2006.
20. Homelessness Directory 2007/2008. Suffolk: Homeless Agency and Resource Information Centre, 2006: 10.
21. Fazel S, Khosia V, Doll H, Geddes J. The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis. PLoS Medicine 2008; 5(12): 1670-1681.
22. Shanks NJ, Priest RG, Bedford A, Garbett S. Use of the delusions-symptoms-state inventory to detect psychiatric symptoms in a sample of homeless men. British Journal of General Practice 1995; 45: 201-203.
23. Timms P, Balázs J. ABC of mental health: Mental health on the margins. British Medical Journal 1997; 315: 536-539.
24. Vamvakas A, Rowe M. Mental health training in emergency homeless shelters. Community Mental Health J 2001; 37(3): 287-95.