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Raphaël Guillot

on 2 June 2015

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Transcript of Homelessness

General Population
Interventions Tackling Vulnerable Populations
Interventions to address Housing
Direct Interventions for Mental Illness & Substance Abuse
Portrait of the situation
In Canada,
-30,000 people are homeless on a given night or 200,000/year
-Either unsheltered or living in emergency shelters, prisons, hospitals or interim housing
-Many people on the edge of homelessness:
-380,600 household live in severe housing needs
-8.2% of households experience moderate or severe food insecurity
-47.5% are single adult males 25-55 y/o
-Some populations particularly at risk:
-Women & Families

Why is this an important health issue?
Mental Health
o Increase resources and therapy services in psychiatric cares in CLSC, both for people who are already suffering and for young people, before symptoms (early 20s)
o Ambulatory services, to avoid hospitalization and rupture with environment.
o Increase resources in communities for support to families

Interventions for Mental Illness:
Assertive Community Treatment (ACT)
Interventions for Mental Illness:
Intensive Case
Management (ICM)
• Similar to ACT: has intensive services and long term
• Different from ACT: services provided by individual case manager

• Improved housing stability and community functioning
• Decrease in hospitalizations

Based on Jim Harvey's speech structures
Plan of the presentation
What is the Logic model?

What are Potential Areas for interventions?
Causes & Opportunities
A Quick Portrait of the Situation

What are the Salient features?

Why is this an important health issue?
The issue
What should we do?
Successful interventions (both upstream and downstream) and outcomes measures

Homelessness & Mental Health
Nour Rached-d'Astous
Lea Restivo
Ashutosh Sharma
Zhuo Shao
Raphaël Morisseau-Guillot

Meet Mr X
Mr X is a 53 y/o man living in downtown Montréal. He experiences both homelessness and mental illness
The Logic Model
Particular health issues
-Psychotic disorders (mostly schizophrenia): 6% (1% in general population)
-Anti-social personality disorder: 29%
-68% reported a lifetime diagnostic of substance abuse/dependence
-Depressive symptoms and MDD
-...not to mention all the physical illnesses
What is homelessness? Homelessness describes the situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it
Source: Canadian Alliance to End Homelessness (2013)
Source: Canadian Alliance to End Homelessness (2013)
Source: Canadian Institute for Health Information (2007)
“All of this suggests that we can no longer justify going down the same road. Morally, ethically and financially, our response to homelessness has failed to achieve the kinds of results that are necessary for Canada to continue to prosper as a leading country internationally”
Source: Stephen et al., (2013)
The Canadian Government’s Homelessness Knowledge Development Program has adopted a housing first strategy
“Provides access to both permanent, independent housing through rent subsidies and to mental health and support services offered by community teams”
5 core components of Housing First are:

- no housing readiness requirements
- choice and self determination
- individualized support services
- harm reduction
- social and community integration

Source: Stephen et al., (2013)
-more housing stability
-68% of participants housed in their first or second unit
-reduces costs due to less health care use
-shift of health care from institutions to the community
-less inpatient days
-reduces emergency visits and hospitalization
-improves health, mental health and addiction symptoms
-housing first is a catalyst to improve health
- there is less police and criminal justice system use
- improves quality of life

At Home/Chez Soi Interim Report
Source: Mental Health Commission of Canada (2012)
• Comprises: psychiatrists, psychologists, social workers, addiction specialists, and other professionals.
• Offer: intensive case management and support services
• How: in client’s home community and on a long term

• improved housing and clinical outcomes
• greater satisfaction with general well being and health
• fewer psychiatric inpatient hospital days and emergency department visits

Source: Hulchanski et al., (2009)
Source: Hulchanski et al., (2009)
Intervention for Homeless People with Substance Abuse
Source: Wang et al. (2005); Podymow et al. (2006)
"The coordinated treatment programs for homeless adults with mental illness or substance abuse normally results in much better health outcomes compared to the usual care"
Source: Wang et al.(2005); Podymow et al. (2006)
Mental Health
Factors causing homelessness in mentally ill individuals:
1. Cognitive problems
- eg: disorganized thinking/actions and poor problem-solving skills
2. Lack of a comprehensive and effective system of mental health care
3. Lack of available jobs that are adapted to their condition
4. Loss of familial and social support
5. Stigmatization towards mental health

Causing factors for mental illness:
1. genetics
2. environment
- eg: stress, lack of social support, and drug use
3. Maternal Health during pregnancy:
- eg: malnutrition, infection, and stress

Factors causing mental illness in homelessness population:
1. Alcohol and/or substance abuse/dependence
2. Social Isolation
3. History of violence
- eg: childhood abuse, police force, and domestic abuse
4. Stigmatization

Causing factors for homelessness:
1. Poverty
2. Lack of Education
3. Insufficient Social Safety
- eg: minimum wage, social well fare, and affordable housing
4. Work Insecurity

Studies have shown a high comorbidity between mental health and homeless individuals
- Does one cause another?

o Not necessarily a bidirectional causal relationship but existence of one disorder increases the risk of another in lack of appropriate supportive environments and interventions .
o Both have many common causes and many interrelated pathways link mental health and homelessness.

Sources: Seena (2008); Jones & Scannell (1997); CPHI Council (2007)
o Homeless leading to mental health: Studies show that homeless people are more likely to experience compromised mental health and develop mental health disorders .
• Among the homeless, the rates of attempted and completed suicide are higher compared to the general population. Most individual committing suicide had psychiatric comorbidity
o Mental health causing Homelessness: Homelessness results from many complex issues including mental health problems.
• Lack or enough resources/services affects more mentally ill people – for example, mentally ill people are more likely to go homeless when housing is scarce.

Sources: Yoram et al. (2004); Crane et al. (2005); Susser et al. (2010); Folsom et al. (2002)
Create stable, secure and comprehensive work opportunities, which provide adequate salary for decent living conditions
In the field of work, governmental action to protect workers in precarious positions by adopting regulating laws acting on the development of:
o Permanent rather than contractual and temporary jobs
o More opportunities for people seeking social reinsertion
o Accountability of employers to assist employees with physical or mental illness by providing adapted working conditions and flexibility
o Raise minimal wage
o Accessible education

Studies show that reservation in which aboriginal people have higher level of self-governance and are under territorial claims tend to have better living conditions.
o So, intervention to increase and enable empowerment. Give more opportunities for self governance
o Give back parts of resources and territory to enable economic independence

o In history class, true coverage of colonization and its implications for aboriginal people, and culture center

o Women center
• More support for single mothers
• Approach oriented on empowerment of women, and not victimization
• Services for children

o Raising salaries in jobs that are traditionally taken women
o More subsidized child are for single mothers (or families in difficulties)

Breaking financial dependency to partner for women experiencing family violence and creating safe and accessible help centers in crisis situations
Creating supporting, stable, geographically accessible and available cares for people suffering form mental illness from the onset of their illness
Working out on traumas caused by four centuries colonization and institutional violence by giving back parts of what was originally taken and working on diminishing racism and stigmatization
Outcome Measurements
3. Mortality rate in mentally ill homeless population
• Goal: Increase life quality and life expectancy of mentally ill homeless population
• Measurement:
•Compare the shelter database to the provincial death certificate records
•Interview / survey on life quality: including housing situation, nutritional level, and life satisfaction.

4. Victimization rate in mentally ill homeless population
• Goal: Reduce victimization rate in mentally ill homeless population
• Measurement:
•Self-reported victimization questionnaires at the appointment of ICM/ACT
•Police report on been the victim of a robbery by force; theft of property; threats with a gun, knife, or other weapon; a beating with fists, club, or other heavy object; or sexual assault

1. Prevalence of homelessness
• Goal: Reduce the prevalence of homelessness especially mentally ill patients
• Measurement:
•Population that uses homeless services such as shelter and daytime meal program for at least 7 out of the past 14 days
•Mental status assessment: addiction severity index (ASI) and neuropsychiatric tests

Sources: Burra et al. (2009); Kushel et al. (2001)
2. Mental illness control
• Goal: Control substance abuse and alleviate the symptoms of mental illness
• Measurement:
•Urine test for substance abuse
•Neuropsychiatric test results
•Frequency and duration of hospitalization/ institutionalization
•ACT/ICM follow-up survey.

Source: Schumacher et al. (2007)
Source: Hwang (2000)
Source: Lam and Rosenheck, (1998)
1) case management
Repeated measures Manova found a significant difference favoring case management partients compared to usual care (p=0.02) for measures of the number of days drinking out of 30 and hte number of nights spent in own home out of 60 nights
2) Abstinence-contingent work
provides work opportunities based on client work perfomrance and health behavior
18% fewer positive cocaine toxicologies at 6 months compared to usual care
8 fewer days of reported alcohol use in 30 days
52 fewer days homeless in 60 days
3) intensive residential treatment
• a 3-step program that requires social detoxification, transitional care, and extended care/independent living
• intensive residential treatment was found to significantly reduce the following measures compared to usual care:
o number of days in the last 30 days where subjects did not consume alcohol
o number of day in conventional housing in the last 30 days

4) harm reduction – managed alcohol program
• decreases the amount of alcohol from 45.6 mean drinks to 8.3 mean drinks

From a strictly financial point of view :
-Average annual cost of an homeless person for society: ~42,484$
-Could lead to significant decrease in spending
-Relieve traditional health care system
From a societal point of view:
-It is not acceptable/ethical in an developed country to have such health inequities
-Negative impact on the rest of the population
Source: Canadian Alliance to End Homelessness (2013)
Adrian Jones & Tony Scannell, Outreach Interventions for the homeless mentally ill, British Journal of Nursing, November 27, 1997, VOL 6, No 21.
Barak Yoram et al, Suicide Among the Homeless: A 9-Year Case-Series Analysis. The Journal of Burra, T.A., Stergiopoulos, V., and Rourke, S.B. (2009). A systematic review of cognitive deficits in homeless adults: implications for service delivery. Canadian journal of psychiatry Revue canadienne de psychiatrie 54, 123-133.
Canadian Institute for Health Information, Improving the Health of Canadians: Mental Health and Homelessness (Ottawa: CIHI, 2007).
Canadian Population Health Initiative of the Canadian Institute for Health Information, Mental Health, Mental Illness, and Homelessness in Canada. In: Hulchanski, J. David; Campsie, Philippa; Chau, Shirley; Hwang, Stephen; Paradis, Emily (eds.) Finding Home: Policy Options for Addressing Homelessness in Canada (e-book), Chapter 2.3. Toronto: Cities Centre, University of Toronto. www.homelesshub.ca/FindingHome
Charity Intelligence Canada. Homelessness in Canada. 2009. King City, Ontario.
Crisis Intervention and Suicide Prevention, Vol 25(2), 2004, 51-53.
CPHI Council, Mental Health and Homelessness Improving Health of Canadians 2007-2008
David P. Folsom et al, Medical Comorbidity and Reciept of Medical care by Older Homeless people with Schizophrenia or Depression. Psychiatric services November 2002 Vol. 53 No. 11.
Devine, J., Brody, C., & Wright, J. (1997). Evaluating an alcohol and drug treatment program for the homeless: an econometric approach. Elsevier Science , 20 (2), 205-215
Ezra Susser et el, Risk Factors for Homelessness, American Journal of Epidemiology, Vol 15, No 2
Hwang, S. W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to Improve the Health of the Homeless: A Systematic Review. American Journal of Preventative Medecine , 29 (4), 311-319.
Hwang, S.W. (2000). Mortality among men using homeless shelters in Toronto, Ontario. JAMA : the journal of the American Medical Association 283, 2152-2157.
Kirmayer, Laurence, S. Dandeneau, E. Marshall, M. Phillips, and K. Williamson (2011). Rethinking Resilience from Indigenous Perspectives. Canadian Journal of Psychiatry, 56, no 2, 84-91.
Kushel, M.B., Vittinghoff, E., and Haas, J.S. (2001). Factors associated with the health care utilization of homeless persons. JAMA : the journal of the American Medical Association 285, 200-206.
Lam, J.A., and Rosenheck, R. (1998). The effect of victimization on clinical outcomes of homeless persons with serious mental illness. Psychiatr Serv 49, 678-683.
LEBEL, Isabelle et al. Le droit à sa place, Revue Recherches Féministes, Volume 19, numéro 2, 2006, p. 125-141
Maureen Crane et al, The Causes of Homelessness in Later Life: Findings From a 3-Nation Study, Journal of Gerontology: SOCIAL SCIENCES, 2005, Vol. 60B, No. 3, S152–S159
Mental Health Commission of Canada. (2012). At Home Interim Report. Calgary: 2013 Mental Health Commission of Canada.
Podymow, T. et al. CMAJ 2006;174:45-49
Schumacher, J.E., Milby, J.B., Wallace, D., Meehan, D.C., Kertesz, S., Vuchinich, R., Dunning, J., and Usdan, S. (2007). Meta-analysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990-2006). Journal of consulting and clinical psychology 75, 823-828.
Seena Fazel, The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis. PLOS Medicine December 2, 2008
Stephen, G., Donaldson, J., Richter, T., & Gulliver, T. (2013). The State of Homelessness in Canada . Canada: Canadian Homelessness Research Network; Canadian Alliance to End Homelessness.
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of Homelessness in Canada. 2013. Toronto: Canadian Homelessness Research Network Press.
Wang, S. W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to Improve the Health of the Homeless: A Systematic Review. American Journal of Preventative Medecine , 29 (4), 311-319.
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