Mental Health and social characteristic of homeless

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Mental Health and Social Characteristics of the HomelessA Survey of Mission UsersPAME L A J . F I S CHE R, P H D , SAM S HAPI RO, BS , WI L L I AM R. BRE AKE Y, MD, JAME S C. ANT HON Y, PH D ,

AND MOR TON KRA MER, SC DAbstract:Selected m ental heeilth and social characteristics of51homeless persons drawn as a probability sample from missions arecompared to those of 1,338 m en aged 18-64 years living in hou seholdsfrom the NIMH Epidemiologic Catchment Area survey conducted inEastern Baltimore, Differences between the two groups were smallwith respect to age, race, education, and military service but thedifferences in mental health status, utilization patterns, and socialdysfunction were large. About one-third ofthe homeless scored highon the General Health Questionnaire which measures distress, Asimilar proportion had a current psychiatric disorder as ascertainedby the Diagnostic Interview Schedule (DIS), with the homeless

exhibiting higher prevalence rates in every DIS/DSM IIIdiagnosticcategory compared to domiciled men. Homeless persons reportedhigher rates of hospitalization than household men for both mental(33 per cent vs 5 per cent) and physical (20 per cent vs 10 per cent)problems but a lower proportion received ambulatory care (41 percent vs 50 per cent). Social dysfunction among the homeless wasindicated by fewer social contacts and higher rates of arrests as adultsthan domiciled men (58 per cent vs 24 per cent), including multiplearrests 38per cent vs 9 per cent) and felony conv ictions (16 per centvs 5 per cent). Implications of these findings are discussed in termsof research and health policy, AmJ Public Health1986; 76:519-524,)

IntroductionMuch has been written about the mental health serviceneeds of homeless people,' but the literature contains fewreports which provide detailed information on their mentalhealth status. T his report presen ts epidemiological data froma survey of mission users conipared with data gathered usingidentical methods from a larger sample of domiciled mensurveyed in the same community.Once resident primarily in run-down areas of inner citiesknown as skid ro ws, ^ homeless people have now dis-persed throughout urban areas, becoming more visible thanat any time since the Great Depression of the 1930s. Con-temporary homeless populatiphs appear to be more hetero-geneous than those of skid rows. New studies ofthe homelesspoint to the emergence of at least four subgroups based on acombination of personal attributes and life history,* i.e., thechronically mentally ill,' '^ street pe op le, ' skid row alco-holics,'^ '^ and the situationally homeless such as unem-ployed, evicted and transient persons.^'* While some over-lapping of subgroups is inevitable, persons in the four groupsare distinguishable according to their different psychosocialcharacteristics and patterns of coping with homelessness.The recent increase in the num bers of homeless has beenattributed to several factors including high unemploy-ment,*'? decreases in public support programs,' changes inthe structure of A merican families,'* and the unavailability oflow cost housing,' '* A large measure of the blame forincreasing the numbers of mentally ill among the hom eless isbeing djrected toward deinstitutionaiization of mental pa-

ti en ts . By restricting admissions to state facilities and bydischarging ch ronically ill peop|e* fo care in comm unitysettings, the locus of treatment fof large num bers of patientshas been shifted from the hospitals to the community.However, adequate community resources have not beenAddress reprint requests to Pamela J. Fischer, Assistant Professor,Department of Psychiatry and Behavioral Sciences, School of Medicine, JohnsHopkins University, 600 N, Wolfe Street, Baltimore, MD21205.Dr, Breakeyis Associate Professor in that same department, Mr. Shapiro is ProfessorEmeritus, Department of Health Policy and Management; Dr, Anthony isAssociate Professor, and Dr, Kramer is Professor Emeritus, both with theDepartment ofM ental Hygiene, all three with the School of Hygiene and PublicHealthat,fHU,Thispaper,submitted tothe JournalI^ay10,198S,was revisedand accepted for publication September 24, 1985,

1986 American Journal of Public Health 0090-0036/86$ 1,50

made available to provide the needed ambulatory care withthe result that some former patients fall through the crack sin the system, m any ending on the streets.^ More than anyother group, the m entally disordered h ave been linked in theminds ofthe public to the production of aberrant individuals:the image ofthe hom eless person has changed from the publicinebriate to the potentially dangerous cr az y person. Thedegree to which this stereotype h as real substance is unclear.The picture of the homeless population w hich is emerg-ing from contemporary research is of a younger population,with histories of frequent arrests and c ontacts with the mentalhealth system. '^' ^' Recent studies have indicated that asubstantial proportion of homeless persons repo rt histories ofpsychiatric hospitalization and exhibit current psychiatricsymptomatology.'''-^* However, differences in definitions ofpopulations, sample selection, diagnostic criteria, andscreening methods have produced wide variations in esti-mates of prevalence.MethodsEastern Baltimore Epidemiologic Catchment Area Study DesignThis report examines selected sociodemographic andhealth characteristics of 51 homeless persons drawn as aprobability sample for the National Institute ofMental Health(NIMH) Epidemiologic Catchment Area (ECA) programconducted in Eastern Baltimore.^' ^'The ECA program was designed to provide informationon relationships between a community's prevalence andincidence of mental disorders, an array of personal and healthcharacteristics, use of health and mental health services, andsources of care. Five geographic areas were defined invarious parts ofthe United States. In each area, face-to-facebaseline household interviews were conducted with proba-bility samples of 3,(X)O-3,5OO community residents aged 18years and older and 500 residents of institutions such asmental hospitals, nursing homes, and prisons. In Baltimore,a supplemental study was designed to augment the core EC Astudy by providing a sample of those pers ons living in settingsnot readily classifiable as households or institutions and whowere expected to bear a disproportionate burden of mentalillness. This sample included5 homeless persons located inthe survey catchment area.

The core of the ECA survey instrument was the Diag-nostic Interview Schedule (DIS),^' developed for use byAJPH May 1986, Vol, 76, No, 5 5 9


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FISCHER ET AL.trained lay inte rview ers, including a field, version of theMini-Mental S tate Examination, * a standard ized mea sure ofcognitive impairment. Data from the DIS are analyzed usinga computerized algorithih to derive DSM III diagnosticcategories'' and classify persons by recency of meetingcriteria for a disorder.The questionnaire also included a 20-item form adaptedfrom the General Health Questionnaire (GHQ).'* The num-ber of positive GHQ symptoms provides a gradient ofprobability of having a diagnosable psychiatric disorder; inthis study the identification of a high probability group isbased on a score of four or more. Since the GHQ coverscurrent distress, it corresponds generally to the current orone-month case finding period for the DIS.In addition, the questionnaire covered other character-istics of community residents. These included socioeconomiccharacteristics, physical health status, use of psychotropicmedications, life events, social supports, arid use of healthand mental health service s. The recall period w as six monthsfor ambulatory care and 12 months for inpatient episodes.Slight modifications were made to the questionnaire to tailorit to the respondents in the study reported h ere, e.g., removeinappropriate references to hou seholds, but in substance thesurvey instrument was otherwise identical to that adminis-tered to the Baltimore household sample.The E astern Baltimore EC A site is composed ofalarge,densely populated urban area of Baltimore City coveringthree contiguous mental health catchment areas with acombined population of 241,000. As in the other ECA sites,a representative sample of householders aged 18 years andolder was interviewed. All measures presented here for thehousehold sample are weighted to take into account difiFer-ential sampling rate s, response rates and the decennial censuscounts by age, race, and sex. This report compares findingsfrom the sample of5 homeless individuals to the sub-groupof 1,338 males under 65 years of age interviewed in theBaltimore ECA household survey. Te sts of statisticalsignificance were applied using the chi-square statistic with Yate s'correction for continuity. The results represent approxima-tions in view of the fact that a complex sample design wasapplied in the case of the household sample. Actually, formany characteristics the margin between the two groups is solarge there can be little question about the existence of aniajor difference.Sample ofHomeless PersonsInherent in the ECA program was the concept of ageographically defined catchment area. Because homelesspersons are urban nomads, and thus by definition do notbelong to any specific catchment area, problems were en-coun tered in establishing definitional criteria for the samplingpool. The US Bureau of the Census defines residency bywhere homeless persons sleep at night and key informantsindicated that the homeless inhabit fairly circumscribed ho m e ranges bounded by walking distance from soupkitchens and missions. Consequently, homeless personsfound in all missions within the catchment area were con-sidered to be eligible for sampling as res ide nts .Eour missions were located within the catchment area.On specified nights, interviewers went to the missions andrandomly selected respondents for interview. Psychiatricsymptomatology was not a selection criterion. The missionswere open to anyo ne seeking a bed at nominal or no cost butbecause they were open only during the night (roughly 5:00pm to 7:00 am) and have to m aintain a schedule of activities.

e.g., religious services, dinner, showering, and lights out, thetime period in which interviews might be conducted wasconsiderably restricted. It was impossible to interview allrespondents during one night. Consequently, sampling wasspread over two or three nights for each m ission. B ecause itwas not feasible to roster the sheltered guests ahead of time,bed size of each m ission was used to estimate the number of residents . A sampling ratio of 1:5 was applied to eachrnission's guests. In order to eliminate problems of duplica-tion of respondents across the interview nights, a differentportion of the alphabet was used on each occasion to definethe sample pool.The response rate was high (98 per cent); only onerefusal was encounte red, resulting in a total homeless sampleof5 individuals. Respondents were offered a small gratuity($5) which w as judged to be a powerful incentive to p artic-ipate in the study among m embers of this low resource group.The interview took on average one and one-half hours toadminister to the homeless and one and one-quarter hours tohousehold survey respondents. The field operations of thehomeless study were co nducted during the winter of 1981-82,roughly midway through the Baltimore ECA survey work,and the homeless study interviewers were the same as thehousehold survey interviewers.This sampling strategy was considered to be the bestalternative to other possible means of identifying the hom e-less population, e.g., through field observations of streetpeople. Ho wever, it is recognized that bias was introduced infavor of males in that three ofthe four missions located in thecatchment area restrict their services to men. The onewom en's residence had only 12 beds . Moreove r, while thehomeless sample accurately portrays the mission populationof the catchment area, it does not necessarily represent theuniverse of homeless persons, some of whom, e.g., streetpeople, may never frequent missions. sultsSociodemographic Characteristics oftheHomeless SampleThe hom eless were virtually all male (94 per cent) due tothe structure ofthe missions and only2per cent were65yearsor older, compared to 15 per cent of the males in thehousehold sample. Therefore, the subgroup of men under theage of65years from the household survey was considered tobe the most appropriate comparison group for the sample ofthe homeless. Conseque ntly, all ofthe following o bservationson household males refer to this subgroup of males aged18-64 ye ars.The homeless did not differ importantly in terms of age,race, educa tion, or military service from the household malesaged 18-64 years. However, there is some suggestion thatfewer ofthe homeless were very young adults and fewer hadcompleted high school (Table 1). Less than one-fourth ofthehom eless had resided in Baltimore less than six mo nths, andnearly 60 per cent had lived in Baltimore for 10 years orlonger. Sixty-two per cent of the homeless persons reportedspending most of their time within the catchment area, andthe majority (80 per cent) reported staying in the cityyear-round rather than migrating for part of the year. Sev-enty-nine per cent planned to return to a mission to sleep onthe night following interview and 14 per ce nt planne d to be on the street.

Household males reported median annual personal in-comes around $7,000 compared to under $2,000 for thehomeless (Table 1). One-third of the homeless reportedreceipt of some form of public support compared to about520 AJPH May 1986 Vol. 76 No. 5


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FISCHER, ET AL.TABLE 3Prevalence of Mentai Disorder as indicated by Distribution of DiS/DSiU III Disorders and Groupe dGHQ Score among Homeiess and Househoid Survey Respondents (%)

DIS Diagnosis

Any DisorderSubstance Abuse/DependenceSchizophrenic DisordersAffective DisordersAnxiety/Somatoform DisordersAntisocial PersonalityCognitive ImpairmentNo Disorder(N)G H O S C O R E '

0 -34 -89-20(N)

One Month

37.319.62.02.019.69.87.862.7(51)

64.717.617.6(51)

HomelessSix Months

45.131.42.02.021.611.87.854.9(51)

Lifetime

78.470.62.013.739.215.77.821.6(51)

HouseholdOne Month

18.29.30.31.57.81.12.381.8(1338)

87.58.53.9(1307)

Males AgesSix Months

22.812.50.41.910.31.52.377.3(1337)

1 8 -6 4Lifetime

41.628.00.63.221.54.72.358.3(1337)

Weighted data, < OO1 (x2).Prior population studies have indicated that ascending scores on the GHO are associated with increasing probability of beingdiagnosed by a psychiatrist as mentally ill. Scores 0-3 are interpreted as iow probabiiity; 4 and above are high probability of disorder.

ealth and Mental eaith Service UtiiizationAccording to self-report,39per cent ofthe homeless feltthemselves to be in poor health compared to 21 per cent ofhousehold men, but similar proportions of both groupsreported chronic conditions. In addition, for the precedingthree months, 20 per cent of the homeless reported trauma(e.g., were mugged);4per cent had been bitten by an animal;10 per cent had skin ulce rs; and 18 per cent reportedinfestation by lice or other parasite s. The proportion seekingcare for these conditions ranged from 20 to 50 per cent.Two-thirds of the homeless had no form of health carecoveragemore than three times the rate found among menin the household sample. One-third of the homeless wereMedicaid enroUees and 4 per cent w ere covered by M edicarecompared to less than1 per cent of household m en under age

65enrolled in either program. N early three-fourths of house-hold men but only 2 per cent of the homeless had privateinsurance coverage for physicians services.Of the homeless who reported a usual source of care,three-fourths relied upon a general hospital with majordependence on the emergency room (Table 4). Almost noneidentified a private practitioner as their usual source of carewhereas nearly half of household men reported this source.Similar proportions of homeless and household menreported that they received no ambulatory health care duringthe six months prior to interview (Table 4). Among thosereporting any care during the period, the homeless w ere fairlyevenly divided between ambulatory medical care and ambu-latory mental health care and the bulk of these m ental healthservices were from mental health specialty providers. Incontrast, the majority of men in the household sample whoreported ambulatory care indicated it to have been of ageneral medical nature but those receiving mental healthservices were about as likely to receive it from generalmedical providers as from mental health specialists.

Twice as many ofthehomeless as m en in the householdsample had been admitted to a general hospiteil for a physicalproblem for an overnight stay or longer at least once during

TABLE 4Usuai Source of Care and Utilization of Ambuiatory Health andMental Health Care during Six Months Prior to interview byType of Care for Homeless and Household Survey Respondents (%)

Utiiization CharacteristicUsuai Source of CareNoneGeneral HospitalPsychiatric Hospitai (or MHresidential facility)

Ambulatory Medical Clinic(free-standing)Private Practitioner(N) ,Utiiization of Ambulatory C areNo CareGeneral Medical OnlyMH ServicesGeneral MedicalMH Specialist(N)

Homeless

36.749.04.18.22.0(49)

58.823.517.62.015.7(51)

Household MalesAges 18-64

7.939.00.07.944.8(1310)

50.342.77.03.33.7(1341)Weighted data, < O1 (x^).

the year prior to interview (Table 5). One-tHird of thehomeless had a previous psychiatric hospitalization com-pared to only5per cent ofmale householders and three-fifthsof those reporting inpatient episodes of care indicated it tohave been recent, i.e., had occurred w ithin the previous year.is ussion

This sample of 51 homeless persons, although small,reveals attributes which distinguish them from householdmen in the same geographic area. Resource constraintsprohibited a larger sam ple; accordingly, confidence intervalsare very large. Nevertheless, a clear pattern emerges ofdifferences in health and social characteristics.Alienation and particular patterns of psychopathologyare the two principal characteristics which distinguish the52 2 AJPH May 1986, Vol. 76, No. 5


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MENTAL HEALTH OF THE HOMELESSTABLE Per Cent of Homeless and Household Survey RespondentsHospitalized In General Hospital for Physical Problems and InHospital and Treatment Programs for M ental Health Problems

HospitalizationGeneral Hospital' '

(Physicai Problems)No admissions within year priorto interviewOne or more admissions(N)Hospitais and Treatment Programs(Mentai Problems)NeverWithin year prior to InterviewMore than 1 year prior tointerview(N)

Homeiess

80.419.6(51)

66.719.613.7(51)

Househoid MaiesAges 18-64

89.910.1(1331)

95.01.04.0(1312)

'Weighted data,p


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FISCHER ET A L14. Blumberg L, Shipley FE, Barsky SF: Liquor and PovertySkid Row asa Human Condition. Ne w Brunswick: Rutgers Center of Alcohol Studies,1978.15. Freeman SJJ, Formo A, Alampur AG, Somm ers AF: Psychiatric disorderin a skid-row m ission population. Compr Psychiatry 1979; 32:21-27.16. Bobo BF: A Report to the Secretary on the Homeless and EmergencyShelters. Washington, DC: US Department of Housing and Urban Devel-opment, 1984.17. Alcohol, Drug Abuse and Mental Health Administration: Alcohol, Drug

Abuse and Mental Health Problems of the Homeless. Proceedings of aRoundtable. Washington, DC: USDHHS, 1983.18. Jon es RE: Street people and psychiatry: an introduction. Hosp Com mu-nity Psychiatry 1983; 34:807-81 1.19. Lamb HR: Deinstitutionalization and the homeless mentally i l l . HospCommunity Psychiatry 1984; 35:899-907.20 . Breakey WR: A public health approach to schizophrenia. Johns HopkinsMedJ 1982; 150:188-195.21 . Cumming E: Prisons, shelters and homeless men. Psychiatric Q 1974;48:496-504.22 . Gunn J: Prisons, sh elters and homele ss m en. Psychiatr Q 1974;48:505-512.23. Huelsman M: Violence on Anchorage's 4th avenue from the perspectiveof street pe ople . Alaska M ed 1 983; 25:39^-44.24 . Lamb HR: Alternatives to hospitals. In Talbott JA (ed): The ChronicMental Patient: Five Years Later. Orlando: Gmne and Stratton, 1984;215-232.25 . Lamb HR , Grant RW: The mentally ill in an urban coun ty jail. Arch Ge n

Psychiatry 1982; 39:17-22.26. Lamb HR, Grant RW: Mentally i l l women in a county jail . Arch GenPsychiatry 1983; 40:363-368.27 . Lindelius R, Salum I: Criminality among homeless m en. BrJ Addict 1976;71:149-153.28 . Bassuk EL , Rubin L, Lauriat A: Is hom elessness a mental health problem?Am J Psychiatry 1984; 141:1546-1549.29. Fischer PJ: Group Quarters Study: Final Report Submitted to NationalInstitute of Mental Health Division of Biometry and Epidemiology.Baltimore, MD: Health Services Research and Development Center,Johns Hopkins University, 1984.

30. Eaton WW, Holzer CE, von Korff M, et at The design of the Epidemi-ologic Catchment Area Survey. Arch Gen Psychiatry 1984; 41:942-948.31 . Eaton WW, Kessler LG (eds): Epidemiologic Field Methods in Psychiatry:The NIMH Epidemiologic Catchment Area Program. New York: Aca-. demic Press, 1985.32 . Regier DA, Myers JK, Kramer M, et al The NIMH EpidemiologicCatchment Area Program. Arch Gen Psychiatry 1984; 41:93 4-941 .33. Robins LN, Helzer JE, Croughan J, Ratcliff SK: National Institute ofMental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 1981;38:381-389.34 . Folstein MF , Folstein SE, McHugh PR: Mini-Mental State : a practicalmethod for grading the cognitive state of patients for the clinician. JPsychiatr Res 1975; 12:189-198.35 . American Psychiatric Association: Diagnostic and Statistical Manual ofMental Disorders (3d Ed). Washington, DC: APA, 1980.36. Goldberg DP: The Detection of Psychiatric Il lness by Questionnaire.London: Oxford University Press, 1972.37. Ball FLJ, Havassy BE: A survey of the problems and needs of hom elessconsumers of acute psychiatric services. Hosp Community Psychiatry1984; 35:917-921.38. Brown C, MacFarlane S, Paredes R, Stark L: The Hom eless of Phoenix:Who are They and What Should Be Done. Phoenix: Phoenix SouthCommunity Mental Health Center, 1983.39. Crystal S, Goldstein M: The Hom eless in New Y ork City Shelters. N ewYork: Human Resources Administration, 1984.

40 . McGerigle P, Lauriat AS: More than Shelter: A Community R espon se toHomelessness. Boston: United Community Planning Corporation, Mas-sachusetts Association for Mental Health, 1983.41 . Task Force on Emergency Shelter: Hom elessn ess in Chicago. Chicago:Department of Human Services, 1983.

42 . Anthony JC, Foistein M, Romanoski AJ, et al Comparison of the layDiagnostic Interview Schedule and a standardized psychiatric diagnosis:experience in Eastern Baltimore. Arch Gen Psychiatry 1985; 42:667-676.43 . Helzer JE, Robins LN , McEroy LT, et al A comparison of clinical andDiagnostic Interview Schedule diagnoses: physician reexamination oflay-interviewed cases in the general population. Arch Gen Psychiatry1985; 42:657-666.

Call for Abstracts forI APHA Late Breaker Epidemiology Exchange Session I

The Epidemiology Section will sponsor a Late-Breaker Epidemiologic Exchange on Wednesday,October 1, 1986 at AP HA s A nnual Meeting in Las Vegas, NV . The E xchange will provide a forum forpresentation of investigations, studies, methods, etc., which have been conceived, conducted, and/orconcluded so recently that abstracts could not meet the deadline for submission to other E pidemiologySessions. Papers submitted should report on work conducted during the last 6-12 months.Abstracts should be limited to 200 words; no special form is required. Abstracts should besubmitted to Robert A. Gunn, MDDivision of Field ServicesEpidemiology Program OflBceBldg. 1, Room 3070Centers for Disease ControlAtlanta, GA 30333Abstracts must be received by August 15, 1986.

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Mental Health and social characteristic of homeless

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