Carol L. M. Caton

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.

Rehospitalization in chronic schizophrenia.

This report on rehospitalization in chronic schizophrenia is based on a 1-year study of the postdischarge experiences of 119 chronic schizophrenics in New York City. The life table method of analysis identified the important role of discharge planning, community treatment compliance, and interpersonal stress in the patients living environment in determining the number of days postdischarge that the patient remained in the community without further inpatient care. A mathematical model to predict days in hospital over the follow-up period, based on three specific components of time in hospital defined in numerical terms (PR, NR, LSR), was devised and tested. The first component, the experience of rehospitalization (PR), was determined by interpersonal stress, social supports, and aftercare treatment compliance. Adequacy of discharge planning, an intervention designed to link the patient to community treatment services, has its greatest impact in identifying number of rehospitalizations for the rehospitalized group (NR). Aftercare treatment compliance has its greatest effect in relation to length of subsequent rehospitalization episodes (LSR). Test of the model revealed that it can predict time in hospital within less than one half of a standard deviation of observed hospital days in approximately 50% of cases.

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.

Housing change of chronic schizophrenic patients: A consequence of the revolving door

A study of 119 chronic schizophrenics discharged to the community revealed that by 1 year post release, 50% have changed their living arrangement at least once. Housing changes, which typically involved movement from one non-institutional living situation to another, followed rehospitalization episodes and appear to be a consequence of the revolving door phenomenon. By virtue of its impact on rehospitalization, interpersonal stress in the patients living environment has an indirect effect on housing change. The remarkable frequency with which housing changes occur among the mentally ill in both sheltered care and non-institutional living settings deserves consideration in the planning of mental health and social welfare service for this constituency.

When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders.

&NA; Substances such as alcohol, cocaine, amphetamine, and cannabis can produce psychotic reactions in individuals who are otherwise free of serious mental illness. However, persons with primary psychotic disorders, such as schizophrenia and bipolar disorder, who use these substances often present for treatment with signs and symptoms similar to those whose psychosis resulted from the use of drugs alone. While it is often difficult to distinguish substance‐induced from primary psychoses, especially early in the course of treatment, this differential diagnosis has important implications for treatment planning. To help clinicians distinguish these two types of presentations, the authors first review the types of psychotic symptoms that can co‐occur with substance use. They discuss the prevalence and patterns of substance use that have been found in patients with schizophrenia and other primary psychotic disorders and review the negative outcomes associated with substance use in this population. The prevalence of and types of symptoms and problems associated with psychotic symptoms that occur as a result of substance use alone are also reviewed. The authors describe assessment procedures for differentiating substance‐induced and primary psychotic disorders. They stress the importance of accurately establishing the temporal relationship between the substance use and the onset and continuation of psychotic symptoms in making a differential diagnosis, as well as the importance of being familiar with the types of psychological symptoms that can occur with specific substances. The authors review the utility and limitations of a number of diagnostic instruments for assessing patients with co‐occurring psychosis and substance use problems, including The Addiction Severity Index, The Michigan Alcohol Screening Test, and diagnostic interviews such as the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM. They then discuss the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), an instrument that has been developed to address the lack of a diagnostic interview that is suitable for assessing the comorbidity of substance use and psychiatric disorders. The article concludes with a discussion of the importance of an appropriate match between diagnosis and treatment and the current state of our knowledge concerning the most appropriate types of treatment interventions for patients with substance‐induced psychosis and those with dual diagnoses. (Journal of Psychiatric Practice 2000;6:256–266)

A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis.

OBJECTIVE The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis METHOD Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations. RESULTS Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged. CONCLUSIONS Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

Health, Access to Health Care, and Health Care use Among Homeless Women with a History of Intimate Partner Violence

Among a sample of sheltered homeless women, we examined health, access to health care, and health care use overall and among the subgroup of participants with and without intimate partner violence (IPV). We recruited homeless women from a random sampling of shelters in New York City, and queried them on health, access to health care and health care use. Using multivariable logistic regression, we determined whether IPV was associated with past-year use of emergency, primary care and outpatient mental health services. Of the 329 participants, 31.6% reported one or more cardiovascular risk factors, 32.2% one or more sexually transmitted infections, and 32.2% any psychiatric condition. Three-fourths (73.5%) had health insurance. Health care use varied: 55.4% used emergency, 48.9% primary care, and 75.9% outpatient mental health services in the past year. Across all participants, 44.7% reported IPV. Participants with IPV compared to those without were more likely to report medical and psychiatric conditions, and be insured. Participants with IPV reported using emergency (64.4%) more than primary care (55.5%) services. History of IPV was independently associated with use of emergency (Adjusted odds ratio (AOR) 1.7, 95% CI 1.0–2.7), but not primary care (AOR 1.5, 95% CI 0.9–2.6) or outpatient mental health services (AOR 1.9, 95% CI 0.9–4.1). Across the whole sample and among the subgroup with IPV, participants used emergency more than primary care services despite being relatively highly insured. Identifying and eliminating non-financial barriers to primary care may increase reliance on primary care among this high-risk group.