Suzanne L. Wenzel

Utilization of Mental Health and Substance Abuse Services Among Homeless Adults in Los Angeles

OBJECTIVES Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

Prevalence and Characteristics of Clients with Co-Occurring Disorders in Outpatient Substance Abuse Treatment

This article reports on the prevalence of probable mental health disorders among clients entering outpatient substance abuse treatment, their clinical characteristics, and past access to substance abuse and mental health care. Four hundred fifteen individuals (74% of those eligible) entering three publicly funded outpatient substance abuse treatment facilities in Los Angeles County were screened for a probable mental health disorder. Of the 210 with a positive screener (just over 50% of those screened), 195 (93%) were interviewed. Depression and anxiety were the most common disorders, and more than a third had two or more probable disorders. Close to 70% reported using alcohol, and almost half reported using crack or cocaine. Half had never received any mental health treatment, and for a third this was their first episode of addiction treatment; 22% were on psychotropic medications. Levels of physical and mental health functioning were lower than the 25th percentile of the U.S. population norms. Our results indicate high rates of co‐occurring mental health disorders among individuals entering these outpatient substance abuse treatment clinics in Los Angeles. Identifying people with probable mental health disorders as they enter treatment has the potential to increase access to care among those with limited prior access.

Trauma, Depression, Coping, and Mental Health Service Seeking Among Impoverished Women

The authors examined the relationship among trauma, coping, depression, and mental health service seeking in a probability sample of sheltered homeless and low-income housed women. Results highlight the diversity of trauma. In a longitudinal analysis, women who lived in shelters or experienced major violence had a twofold increase in their risk of depression over the 6-month follow-up. In a cross-sectional analysis, childhood sexual abuse, living in a shelter, physical violence, childhood physical abuse, and death or injury of a friend or relative predicted avoidant coping and symptoms of depression. Active coping and depression predicted mental health service seeking among traumatized women. Modifying coping strategies may ameliorate some of the negative impact of trauma and potentially enhance mental health service use among at-risk women.

Drug Courts: A Conceptual Framework

Structural and process characteristics of drug courts may have a major influence on offender outcomes. However, despite the existence of dozens of outcome evaluations in the drug court literature, it is impossible to draw clear conclusions regarding variability in outcomes in relation to drug court characteristics. We describe existing approaches to the description of drug court structure and process and argue that a new approach is needed. To address that need, we propose a conceptual framework of five drug court dimensions: leverage, population severity, program intensity, predictability, and rehabilitation emphasis. These dimensions, each scorable on a range from low to high, lend themselves to a systematic set of hypotheses regarding the effects of structure and process on drug court outcomes. Finally, we propose quantitative and qualitative methods for identifying such effects.

Risk Factors for Major Violence Among Homeless Women

Violence against women is a significant public health, criminal, and social problem, but survey research with a focus on homeless womens experiences of violence is limited. Using self-report data from a probability sample of 974 homeless women in Los Angeles County, California, this study examines severity of homelessness, social and family characteristics, subsistence activities, and alcohol and drug abuse or dependence as predictors of major violence (i.e., being kicked, bitten, hit with a fist or object, beaten up, choked, burned, or threatened or harmed with a knife or gun). One third of the women experienced major violence during the year before they were interviewed. Greater severity of homelessness, engaging in subsistence activities, and victimization during childhood were significant predictors of major violence. Analyses suggested that drug dependence might influence victimization risk through sex trade. Major violence against homeless women requires attention from multiple service sectors.

Personal Network Correlates of Alcohol, Cigarette, and Marijuana Use Among Homeless Youth

BACKGROUND Youth who are homeless and on their own are among the most marginalized individuals in the United States and face multiple risks, including use of substances. This study investigates how the use of alcohol, cigarettes, and marijuana among homeless youth may be influenced by characteristics of their social networks. METHODS Homeless youth aged 13-24 were randomly sampled from 41 service and street sites in Los Angeles County (N=419). Predictors of substance use were examined using linear regression analysis (for average number of drinks and average number of cigarettes per day) and negative binomial regression analysis (for frequency of past month marijuana use). RESULTS Youth with more substance users in their networks reported greater alcohol, cigarette, and marijuana consumption regardless of whether these network members provided tangible or emotional support. Marijuana use was more frequent for youth who met more network members through homeless settings, but less frequent among those who met more network members through treatment or AA/NA. Greater alcohol use occurred among youth who met more network members through substance use-related activities. Youth having more adults in positions of responsibility in their networks consumed less alcohol, and those with more school attendees in their networks consumed less alcohol and cigarettes. CONCLUSIONS Findings highlight the importance of social context in understanding substance use among homeless youth. Results also support the relevance of network-based interventions to change social context for substance-using youth, in terms of both enhancing pro-social influences and reducing exposure to substance use.

A DECADE OF DRUG TREATMENT COURT RESEARCH

As drug treatment courts have multiplied over the past decade, so too have research evaluations conducted on their implementation and effectiveness. This article explores the decade of drug treatment court research conducted at RAND, starting with the experimental field evaluation of Maricopas drug testing and treatment options to the most current 14-site national evaluation of courts funded in 1995–96 by the Drug Court Program Office. The article presents summaries of findings, a brief description of a drug treatment court typology, and suggestion of where future research might focus.

Health of homeless women with recent experience of rape.

There is limited understanding of the physical health, mental health, and substance use or abuse correlates of sexual violence against homeless women. This study documents the association of rape with health and substance use or abuse characteristics reported by a probability sample of 974 homeless women in Los Angeles. Controlling for potential confounders, women who reported rape fared worse than those who did not on every physical and mental health measure and were also more likely to have used and abused drugs other than alcohol. Results should serve to alert clinicians about groups of homeless women who may benefit from rape screening and treatment interventions.

The social context of homeless women's alcohol and drug use.

BACKGROUND Substance use poses a significant threat to the health of women, and homeless women are more likely to use alcohol and drugs than other women. Addressing risk factors in this population requires a focus on the social context of substance use among homeless women. METHODS Participants were 445 homeless women who were randomly sampled and interviewed in shelter settings about the characteristics of their personal networks. Binomial logistic regressions predicted days of binge drinking and of using marijuana, crack, cocaine, and methamphetamine or other amphetamines in the past 6 months. RESULTS Homeless women with a greater proportion of heavy alcohol users in their personal networks had greater odds of engaging in binge drinking, and women with a greater proportion of drug users in their networks had greater odds of using marijuana, cocaine, crack, and methamphetamine or other amphetamines. Women with a greater proportion of individuals in their networks that they had met in school or through work had lower odds of marijuana, cocaine, and crack use. CONCLUSIONS Findings suggest the importance of structural solutions in addressing homeless womens alcohol and drug use, including greater access to treatment and recovery support for alcohol and drug problems as well as depression, and enhancing employment and educational opportunities for homeless women.

Access to Inpatient or Residential Substance Abuse Treatment Among Homeless Adults With Alcohol or Other Drug Use Disorders

Objectives.We conducted a theoretically guided study of access to inpatient or residential treatment among a probability sample of homeless adults with alcohol or drug use disorders in Houston, Texas. Methods.This study used a cross-sectional, retrospective design with data collected from a multistage random sample of 797 homeless adults age 18 or older who were living in Houston shelters and streets in 1996. Structured, face-to-face interviews produced screening diagnoses for alcohol and drug use disorders, treatment use data, and candidate predictors of treatment use. Logistic and linear regression analyses were performed on the subset of 326 homeless persons with either alcohol or drug use disorder. Results.27.5% of persons with substance use disorder had accessed inpatient or residential treatment during the past year. Controlling for additional need factors such as comorbidity, persons having public health insurance and a history of treatment for substance problems had greater odds of receiving at least one night of treatment. Contrary to expectation, contact with other service sectors was not predictive of treatment access. Schizophrenia and having a partner appeared to hinder access. Greater need for treatment was associated with fewer nights of treatment, suggesting retention difficulties. Conclusions.This study adds to previous findings on access to health care among homeless persons and highlights a pattern of disparities in substance abuse treatment access. Health insurance is important, but enhancing access to care involves more than economic considerations if homeless persons are to receive the treatment they need. Referral relationships across different service sectors may require strengthening.