Boanerges Dominguez

Risk Factors for Long-Term Homelessness: Findings From a Longitudinal Study of First-Time Homeless Single Adults

OBJECTIVES We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. METHODS Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, symptoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. RESULTS Eighty-one percent of participants returned to community housing during the follow-up period; the median duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group P<.05) and arrest history (P<.01) were the strongest predictors of a longer duration of homelessness. CONCLUSIONS Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventions.

Risk factors for homelessness among schizophrenic men: A case-control study

OBJECTIVES To identify risk factors for homelessness among the severely mentally ill, we conducted a case-control study of 100 indigent schizophrenic men meeting criteria for literal homelessness and 100 such men with no homeless history. METHODS Subjects were recruited from shelter, clinic, and inpatient psychiatric programs in Upper Manhattan. Clinical interviewers employed standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. RESULTS Homeless subjects showed significantly higher levels of positive symptoms, higher rates of a concurrent diagnosis of drug abuse, and higher rates of antisocial personality disorder. Homeless subjects experienced greater disorganization in family settings from birth to 18 years and less adequate current family support. Fewer homeless subjects than subjects in the never-homeless comparison group had a long-term therapist. These differences remained when demographic variables were adjusted statistically. CONCLUSIONS Homeless schizophrenic men differed from their domiciled counterparts in all three domains we investigated; family background, nature of illness, and service use history. Findings are discussed in relation to policy and programs for the severely mentally ill.

Homelessness, health status, and health care use

OBJECTIVES Little is known about the health status of those who are newly homeless. We sought to describe the health status and health care use of new clients of homeless shelters and observe changes in these health indicators over the study period. METHODS We conducted a longitudinal study of 445 individuals from their entry into the homeless shelter system through the subsequent 18 months. RESULTS Disease was prevalent in the newly homeless. This population accessed health care services at high rates in the year before becoming homeless. Significant improvements in health status were seen over the study period as well as a significant increase in the number who were insured. CONCLUSION Newly homeless persons struggle under the combined burdens of residential instability and significant levels of physical disease and mental illness, but many experience some improvements in their health status and access to care during their time in the homeless shelter system.

Symptom profiles and homelessness in schizophrenia

One hundred homeless schizophrenic men and 100 never homeless schizophrenic men were compared in terms of symptom ratings on the Positive and Negative Syndrome Scale (PANSS), which yields a positive, negative, and general psychopathology scale score, as well as evaluated on a number of other variables. The homeless group obtained significantly higher ratings on the PANSS positive and general psychopathology scales, but the two groups did not differ on the PANSS negative scale score. When symptom patterns for subsets of patients who did not abuse illicit substances or alcohol (N=23 for homeless, N=56 for nonhomeless) and who were compliant with medication (N=63 for homeless, N=82 for nonhomeless) were examined, the higher ratings on the positive and general psychopathology scales failed to achieve statistical significance, while the absence of between-group differences on the negative scale was maintained. Our results suggest that severity of positive and general psychopathology symptoms, but not of negative symptoms, predicts homelessness in schizophrenia and that illicit substance abuse and neuroleptic noncompliance contributed, at least in part, to our higher positive and general psychopathology symptom ratings in the homeless sample. Our findings underscore the need to undertake prospective longitudinal studies to unravel the multifactorial etiology of homelessness in schizophrenia.

Gender differences in the relationship of homelessness to symptom severity, substance abuse, and neuroleptic noncompliance in schizophrenia.

This study examined gender differences in the relationship of homelessness in schizophrenia to symptom severity, risk behaviors, and prognostic features. Four hundred subjects with schizophrenia were studied: 100 homeless men, 100 homeless women, 100 never homeless men, and 100 never homeless women. Assessments included derivation of five symptom factors by using the Positive and Negative Syndrome Scale (PANSS). Homelessness for the entire sample was associated with greater severity of positive, activation, and autistic preoccupation symptoms, younger age at first hospitalization, and substance abuse (SA). For men only, homelessness was associated with neuroleptic noncompliance (NN). When NN and SA were statistically controlled, symptom severity was not different between the homeless and never homeless. Women, independent of residential status, had more severe negative, activation, and autistic preoccupation symptoms that were not associated with prognostic features or risk behaviors. For both men and women, SA was associated with homelessness, but independent of residence, SA was less severe in women. Additionally, SA was less severe in homeless women than never homeless men. Thus, symptom severity in homeless individuals with schizophrenia appears as an interaction of symptom profiles and risk behaviors that are gender specific. Although cross-sectional analyses cannot distinguish cause from effect, these findings suggest gender-specific routes to homelessness among indigent urban adults with schizophrenia.

CATON ET AL. RESPOND

We appreciate Alexander-Eitzman’s interest in our article and welcome the opportunity to respond to his letter. We take issue with his assertion that our approach in this study of risk factors for long-term homelessness is one where the “tools define the problem,”1(pXXX) with the implication that our predictor variables were heavily tilted toward the assessment of psychopathology. Although our assessment battery did include standardized assessments of health and mental health status, the tools did not define the results. Our overall findings underscored the heterogeneity of the contemporary homeless, but a Kaplan–Meier survival analysis showed that participants who were younger and those who had better psychosocial adjustment, recent or current employment, earned income, and adequate family support experienced shorter durations of homelessness than those without these characteristics. In the Discussion section of our article we concluded that these findings suggest that new shelter admissions presenting with such characteristics might be offered assistance with job searches, temporary income support, or other supportive services that might provide a fast track out of homelessness. We reject the argument by Meyer and Schwartz2 that epidemiological analyses of social problems such as homelessness should be avoided. The identification of individual-level risk factors for chronic homelessness has practical implications for service delivery in that it suggests new preventive intervention approaches. Other findings we reported, specifically the characteristics of living arrangements prior to shelter entry and upon exit from homelessness, illustrate the scarcity of housing options available to this economically disadvantaged population. Although not predictive of duration of homelessness, widespread and long-standing mental health and substance abuse problems among our study subjects indicate a substantial unmet need for public health and mental health services in the disadvantaged neighborhoods from which these newly homeless men and women emerged. We agree completely with Alexander-Eitz-man’s recommendation that the longitudinal study of homelessness be broadened to include multiple levels of analysis. A strategy for the prevention of chronic homelessness should encompass interventions at both individual and population levels and should address housing, health, and mental health policy and program development issues.