Hunter L. McQuistion

Hepatitis C and Substance Use in a Sample of Homeless People in New York City

Abstract This study examined the prevalence of hepatitis C virus (HCV) antibodies and its association with substance use and sexual behavior among a sample of 139 persons visiting a mobile medical clinic in Manhattan. Ninety percent were unstably housed or were living on the street. The prevalence of HCV antibodies was 32%. Prevalence was also high for hepatitis B core antibodies (47%), HIV antibodies (15%), and syphilis exposure (14%); 76% tested positive for cocaine. Among subjects who reported ever injecting (20%), 86% were HCV positive; 19% of non-injectors were HCV positive. In separate multivariate logistic regression models (with injection controlled), HCV was predicted by quantitative hair assays for cocaine and self-re -ported duration of crack-cocaine use. Alcohol dependence and sexual behavior did not predict HCV. Hepatitis C is a significant public health problem among the urban homeless population, with injection drug use and, to a lesser extent, cocaine use implicated as risk factors.

MEDICAL OUTREACH TO HOMELESS SUBSTANCE USERS IN NEW YORK CITY: PRELIMINARY RESULTS*

An innovative, experimental, medical out-reach initiative, using a fully-equipped mobile medical van with a staff of 2 part-time physicians, a physician assistant, a social worker, and a driver/medical aid serving the needs of 1048, mostly male, minority group, high-level, homeless New York City substance users with infectious diseases is described. The study sample (N = 250) was divided into experimental Ss who received Intensive case management and a control group who could choose to refer themselves to the SW. Biological tests revealed high rates of cocaine use and infectious diseases. Preliminary 4-month outcomes (N=128) showed reductions in drug use, homelessness and health complaints in both groups; experimental subjects compared with controls received more Public Assistance and had fewer emergency room visits.

The association between cocaine use and HIV/STDs among soup kitchen attendees in New York City

We examined the associations of cocaine use with HIV/sexually transmitted diseases (STDs) in a sample of 184 soup kitchen attendees using a mobile medical van in Manhattan (male = 66%; black or Hispanic = 81%; cocaine use, primarily crack = 75%; ever injected drugs = 22%). In addition to confirming the association between years of cocaine use and HIV antibodies in this sample (odds ratio [OR] = 2.11; p <.05) we examined the pattern of associations of cocaine use and non-HIV STDs under the hypothesis that the strength of an association depends on the efficiency of sexually transmitting a particular STD (high, moderate, and low for syphilis, hepatitis B and hepatitis C, respectively). As predicted, years of cocaine use was strongly associated with syphilis (OR = 2.07; p <.05), moderately associated with hepatitis B core antibodies (OR = 1.50; p <.05), and not significantly associated with hepatitis C antibodies (OR = 1.48; p >.05). A reverse pattern of associations between opiate use (injection drug use) and the three STDs points to the singular significance of cocaine use in the sexual transmission of STDs, and by inference, HIV. This conclusion is further bolstered by correlations of biologic (hair assays) and self-reported measurements of cocaine use (but not opiates) with self-reports of high risk sexual behavior among the women (number of partners and selling sex) and men (number of partners and buying sex). These data underscore the need for effective cocaine treatment and HIV interventions tailored to the large numbers of cocaine users in inner cities.

BROADENING PERSPECTIVES ON MOBILE MEDICAL OUTREACH TO HOMELESS PEOPLE

Using data collected by Project Renewals mobile medical services to homeless people in New York City, this paper discusses a tension between an emergency medicine model of outreach and that of primary care. In the former model, clinicians evaluate clients on the basis of presenting complaints and refer them, as necessary, for specialized treatment. The latter is a broader model of comprehensive outreach and/or treatment, where clinicians screen clients and assess them for various conditions offering ongoing evaluation and treatment on site. The model of outreach is applicable for some homeless clients, but the prevalence and overlap of physical complaints, infectious diseases, substance abuse, and psychiatric symptoms among homeless people in New York City has resulted in an evolution toward broader approaches to outreach in this population. Improvements in diagnostic testing and increasingly portable medical technology may make the mobile delivery of medical care to homeless persons increasingly feasible.

Mentally Ill Populations in Jails and Prisons: A Misuse of Resources

The American prison system is intended as a method of incarceration and punishment, but by virtue of its population it is serving as an inadequate and inappropriate method to contain mental illness. National surveys show that between 6 and 15% of all jail inmates and 10 to 15% of prison inmates have a severe mental illness (1). Mentally ill individuals are admitted to jails at approximately eight times the rate at which they are admitted to public psychiatric hospitals, and there are now more people with severe mental illness in U.S. jails than in state hospitals (2). Approximately 70% also have a co-occurring alcohol and or drug abuse problem (5,6). Among this population, the incidence of poverty is high with a disproportionate representation of minority groups. For example, in New York City jails it is estimated that 20% of those arrested are homeless (3), and up to 85% are African American and Latino (4). This national trend has implications for prison services, diversion of the mentally ill from incarceration to the community, coordinated and targeted services after incarceration, and prevention. To address these concerns, the American Association of Community Psychiatrists and the American Association of Psychiatric Administrators organized a conference entitled Successful Transition: From Incarceration to the Community for Mentally Ill Persons. This October 1999 conference was sponsored by New York University’s Ehrenkrantz School of Social Work Institute Against Violence; the New York City Department of Mental Health, Mental Retardation and Alcoholism Services; and the New York State Office of Mental Health. It brought together

Psychosocial rehabilitation : Issues and answers for psychiatry

The American Association of Community Psychiatrists has composed a set of principles to guide psychiatrys relationship with psychosocial rehabilitation. They consist of five basic precepts offering the profession an orientation to rehabilitation, accompanied by seven issues that discuss aspects of how psychiatry must finally adopt psychosocial rehabilitation as a model of practice with people who have severe psychiatric disorders. The authors advance the argument that a confluence of developments, both within and beyond psychiatry, has now created an opportunity for psychiatry to build a mutually productive relationship with rehabilitation.

TRAINING IN COMMUNITY PSYCHIATRY: NEW OPPORTUNITIES

The authors describe the impact on training that accompanied an assignment of senior (PGY-4) residents to work one-half day each week for a six month period at a community-based agency concerned with the care of persons with severe and persistent mental illness who were formerly homeless. As the goals and methods of psychiatric training are rethought and adapt to programmatic shifts and economic pressures, new opportunities open up to move treatment and training to the “front lines” in the community where an innovative therapeutic armamentarium for persons with severe and chronic mental illness is developing.

Heroes in Community Psychiatry: C. Christian Beels and the Evolution of Community Psychiatry in New York City

C. Christian Beels, M.D. occupies a unique role among community psychiatrists in New York City. In this article, we trace this Hero of Community Psychiatry s life as an educator, family therapist, administrator, and scholar, from his early years as a creative force in the Department of Psychiatry at the Albert Einstein College of Medicine (AECOM) to his creation of the Fellowship in Public Psychiatry at the New York State Psychiatric Institute and Columbia University. We will also put a remarkable career into the context of the times, showing how it was shaped by the social and intellectual environments in which he