Stefanie N. Rezansoff

Housing First Reduces Re-offending among Formerly Homeless Adults with Mental Disorders: Results of a Randomized Controlled Trial

Background Homelessness and mental illness have a strong association with public disorder and criminality. Experimental evidence indicates that Housing First (HF) increases housing stability and perceived choice among those experiencing chronic homelessness and mental disorders. HF is also associated with lower residential costs than common alternative approaches. Few studies have examined the effect of HF on criminal behavior. Methods Individuals meeting criteria for homelessness and a current mental disorder were randomized to one of three conditions treatment as usual (reference); scattered site HF; and congregate HF. Administrative data concerning justice system events were linked in order to study prior histories of offending and to test the relationship between housing status and offending following randomization for up to two years. Results The majority of the sample (67%) was involved with the justice system, with a mean of 8.07 convictions per person in the ten years prior to recruitment. The most common category of crime was “property offences” (mean = 4.09). Following randomization, the scattered site HF condition was associated with significantly lower numbers of sentences than treatment as usual (Adjusted IRR = 0.29; 95% CI 0.12–0.72). Congregate HF was associated with a marginally significant reduction in sentences compared to treatment as usual (Adjusted IRR = 0.55; 95% CI: 0.26–1.14). Conclusions This study is the first randomized controlled trial to demonstrate benefits of HF among a homeless sample with mental illness in the domain of public safety and crime. Our sample was frequently involved with the justice system, with great personal and societal costs. Further implementation of HF is strongly indicated, particularly in the scattered site format. Research examining interdependencies between housing, health, and the justice system is indicated. Trial registration ISRCTN57595077

Trajectories of recovery among homeless adults with mental illness who participated in a randomised controlled trial of Housing First: a longitudinal, narrative analysis

Objectives This study used longitudinal, narrative data to identify trajectories of recovery among homeless adults with mental illness alongside the factors that contribute to positive, negative, mixed or neutral trajectories over time. We expected that participants who received Housing First (HF) would describe more positive trajectories of recovery than those who were assigned to Treatment as Usual (TAU; no housing or support provided through the study). Design Narrative interview data were collected from participants at baseline and 18 months after random assignment to HF or TAU. Setting Participants were sampled from the community in Vancouver, British Columbia. Participants Fifty-four participants were randomly and purposively selected from the larger trial; 52 were interviewed at baseline and 43 were reinterviewed 18 months after randomisation. Method Semistructured interviews were conducted at both time points. For each participant, paired baseline and follow-up narratives were classified as positive, negative, mixed or neutral trajectories of recovery, and thematic analysis was used to identify the factors underlying different trajectories. Results Participants assigned to HF (n=28) were generally classified as positive or mixed trajectories; those assigned to TAU (n=15) were generally classified as neutral or negative trajectories. Positive trajectories were characterised by a range of benefits associated with good-quality, stable housing (eg, reduced substance use, greater social support), positive expressions of identity and the willingness to self-reflect. Negative, neutral and mixed trajectories were characterised by hopelessness (‘things will never get better’) related to continued hardship (eg, eviction, substance use problems), perceived failures and loss. Conclusions HF is associated with positive trajectories of recovery among homeless adults with mental illness. Those who did not receive housing or support continued to struggle across a wide range of life domains. Findings are discussed with implications for addressing services and broader social change in order to benefit this marginalised population.

The prevalence and geographic distribution of complex co-occurring disorders: a population study.

AIMS A subset of people with co-occurring substance use and mental disorders require coordinated support from health, social welfare and justice agencies to achieve diversion from homelessness, criminal recidivism and further health and social harms. Integrated models of care are typically concentrated in large urban centres. The present study aimed to empirically measure the prevalence and distribution of complex co-occurring disorders (CCD) in a large geographic region that includes urban as well as rural and remote settings. METHODS Linked data were examined in a population of roughly 3.7 million adults. Inclusion criteria for the CCD subpopulation were: physician diagnosed substance use and mental disorders; psychiatric hospitalisation; shelter assistance; and criminal convictions. Prevalence per 100 000 was calculated in 91 small areas representing urban, rural and remote settings. RESULTS 2202 individuals met our inclusion criteria for CCD. Participants had high rates of hospitalisation (8.2 admissions), criminal convictions (8.6 sentences) and social assistance payments (over

A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats

36 000 CDN) in the past 5 years. There was wide variability in the geographic distribution of people with CCD, with high prevalence rates in rural and remote settings. CONCLUSIONS People with CCD are not restricted to areas with large populations or to urban settings. The highest per capita rates of CCD were observed in relatively remote locations, where mental health and substance use services are typically in limited supply. Empirically supported interventions must be adapted to meet the needs of people living outside of urban settings with high rates of CCD.

Comparative Analysis of Recidivism Outcomes Following Drug Treatment Court in Vancouver, Canada

Objective No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU). Methods Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports. Results Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU. Conclusion HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes. Registration Current Controlled Trials: ISRCTN57595077.

Adherence to Antipsychotic Medication and Criminal Recidivism in a Canadian Provincial Offender Population

Drug Treatment Courts (DTCs) integrate therapeutic interventions for substance using offenders with the administration of justice. Available evidence indicates that DTCs are effective at reducing recidivism, but it is not yet established whether they are equally effective for all subgroups of offenders. The current study investigates the comparative effectiveness of a Canadian DTC among subgroups defined by ethnicity, gender, prior offending, and the presence of a co-occurring mental disorder. Results indicate greater reductions in recidivism among female and Aboriginal participants, and no differences in recidivism associated with the presence or absence of co-occurring mental disorders or the number of prior convictions. Longer duration of involvement with the DTC program was positively associated with reduced recidivism. The effectiveness of DTCs with distinct subpopulations may be related to their composition and inclusion of expertise relevant to the needs of diverse participants.

Migration to the Downtown Eastside neighbourhood of Vancouver and changes in service use in a cohort of mentally ill homeless adults: a 10-year retrospective study

Abstract Preliminary evidence suggests that adherence to antipsychotic medication reduces criminal recidivism among patients diagnosed with schizophrenia. However, existing studies operationalize antipsychotic adherence as a binary variable (usually using a threshold of ≥80%), which does not reflect the prevalence of suboptimal adherence in real-world settings. The purpose of the current analysis was to investigate the association between successive ordinal levels of antipsychotic adherence and criminal recidivism in a well-defined sample of offenders diagnosed with schizophrenia (n = 11462). Adherence was measured using the medication possession ratio (MPR) and analyzed as a time-dependent covariate in multivariable regression models. Data were drawn from linked, comprehensive diagnostic, pharmacy and justice system records, and individuals were followed for an average of 10 years. Adjusted rate ratios (ARR) and confidence intervals (CI) are reported. Overall mean MPR was 0.41. Increasing levels of antipsychotic adherence were not associated with progressively lower rates of offending. However, when compared to the reference group (MPR ≥ 80%) all lower adherence levels were significantly associated (P < .001) with increased risk of violent (ARR = 1.58; 95% CI = 1.46–1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33–1.50) offenses. Significance was replicated in separate sensitivity analyses. Previously published studies reporting reductions in crime may have been influenced by antipsychotic adherence ≥80%. Binary operationalization of adherence is an inaccurate predictor of recidivism. Future research addressing functional outcomes of antipsychotic adherence should conceptualize adherence as an incremental independent variable.

Examining the impact of case management in Vancouver's downtown community court: a quasi-experimental design.

Objectives Little research has investigated the role of migration as a potential contributor to the spatial concentration of homeless people with complex health and social needs. In addition, little is known concerning the relationship between possible migration and changes in levels of service use over time. We hypothesised that homeless, mentally ill individuals living in a concentrated urban setting had migrated from elsewhere over a 10-year period, in association with significant increases in the use of public services. Setting Recruitment was concentrated in the Downtown Eastside neighbourhood of Vancouver, Canada. Participants Participants (n=433) met criteria for chronic homelessness and serious mental illness, and provided consent to access administrative data. Methods Linked administrative data were used to retrospectively examine geographic relocation as well as rates of health, justice, and social welfare service utilisation in each of the 10 years prior to recruitment. Generalised estimating equations were used to estimate the effect of migration on service use. Results Over a 10-year period there was significant movement into Vancouvers Downtown Eastside neighbourhood (from 17% to 52% of the cohort). During the same period, there were significant annual increases in community medical services (adjusted rate ratio (ARR) per year=1.08; 95% CI 1.06 to 1.10), hospital admissions (ARR=1.08; 95% CI 1.04 to 1.11), criminal convictions (ARR=1.08; 95% CI 1.03 to 1.13), and financial assistance payments (ARR=1.04; 95% CI 1.03 to 1.06). Migration was significantly associated with financial assistance, but not with other types of services. Conclusions Significant increases in service use over a 10-year period coincided with significant migration into an urban area where relevant services were concentrated. These results highlight opportunities for early intervention in spatially diverse neighbourhoods to interrupt trajectories marked by worsening health and extremely high service involvement. Further research is urgently needed to investigate the causal relationships between physical migration, health and social welfare, and escalating use of public services. Trial registration numbers ISRCTN57595077 and ISRCTN66721740; Post-results.

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness

Background Problem solving courts (PSC) have been implemented internationally, with a common objective to prevent reoffending by addressing criminogenic needs and strengthening social determinants of health. There has been no empirical research on the effectiveness of community courts, which are a form of PSC designed to harness community resources and inter-disciplinary expertise to reduce recidivism in a geographic catchment area. Method We used the propensity score matching method to examine the effectiveness of Vancouver’s Downtown Community Court (DCC). We focused on the subset of DCC participants who were identified as having the highest criminogenic risk and were assigned to a case management team (CMT). A comparison group was derived using one-to-one matching on a large array variables including static and dynamic criminogenic factors, geography, and time. Reductions in offences (one year pre minus one year post) were compared between CMT and comparison groups. Results Compared to other DCC offenders, those triaged to CMT (9.5% of the DCC population) had significantly higher levels of healthcare, social service use, and justice system involvement over the ten years prior to the index offence. Compared to matched offenders who received traditional court outcomes, those assigned to CMT (n = 249) exhibited significantly greater reductions in overall offending (p<0.001), primarily comprised of significant reductions in property offences (p<0.001). Conclusions Our findings indicate that CMT achieved significantly greater reductions in recidivism than traditional court among offenders with complex needs and high numbers of previous offences. Limitations of this research include a non-experimental design and one year follow up. Strengths include a robust matching process and extensive client level data spanning multiple sectors. Further research is needed to replicate the observed outcomes, to investigate the extension of community courts to settings with divergent offender needs and local resources, and to estimate potential cost avoidance attributable to this intervention.

The effect of Housing First on adherence to methadone maintenance treatment

Background Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. Material and methods Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. Results Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051). Conclusions The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.