Predictors of Mental Health Recovery in Homeless Adults with Mental Illness

Cognitive functioning and functional ability in women with schizophrenia and homelessness

Background

Studies of schizophrenia and homelessness are minimal from the Indian subcontinent. Women with schizophrenia and homelessness in India remain a highly vulnerable group and there is no data to date regarding their clinical characteristics. Cognitive impairment in schizophrenia remains a major factor determining outcomes in schizophrenia. We examined the cognitive functioning of women with schizophrenia and homelessness (WSH) and compared it to an age-matched group of women with schizophrenia living with their family (WSF).

Methods

36 women with schizophrenia and homelessness, and 32 women with schizophrenia who were living with family were evaluated for psychopathology using Scale for Assessment of Positive Symptoms (SAPS)/ Scale for assessment of negative symptoms (SANS) scales. Cognitive function was assessed using Montreal Cognitive Assessment (MOCA)/Rowland Universal Dementia Scale (RUDAS), and Frontal Assessment Battery (FAB), disability using World Health Organization - Disability assessment Scale (WHO-DAS) and psychosocial factors using a semi-structured proforma. The groups were compared using t-tests and chi-square for continuous and categorical variables respectively.

Results

Women with schizophrenia and homelessness were found to have significantly lower cognitive functioning, and much higher disability. Cognition and disability for women with schizophrenia and homelessness differed by 2-3 standard deviations with the mean for women living with family (i.e. z scores). Women with schizophrenia experiencing homelessness (WSH group) exhibited higher literacy levels and previous work experience compared to their counterparts. Those with family support are likely to face reduced pressures to work or earn, which further suggests that premorbid levels of functioning may not be the primary factors influencing the differences observed in cognitive assessments.

Conclusions

The study demonstrates significantly higher cognitive dysfunction in women with homelessness and schizophrenia, raising the possibility of much higher cognitive dysfunction being a predictor for homelessness in Indian women with schizophrenia.

Examining the Prevalence and Forms of Leveraged Treatment Pressure and Its Relationship to Personal Recovery: A Canadian Cross-Sectional Study

Across jurisdictions, the use of 'leverage' to promote adherence to mental health treatment is widespread. However, little research exists on the possible association between the application of leverage and personal recovery. We examined the prevalence of various forms of leverage in a Canadian context and compared these rates with those in other jurisdictions. Additionally, we examined the relationship between two prominent forms of leverage (financial and housing) and the experience of personal recovery. Structured interviews were conducted with people receiving community-based mental health care in Toronto, Canada. Rates of overall leverage in our sample were similar to rates reported in other jurisdictions. Personal recovery was negatively associated with financial leverage but was not associated with housing leverage. Our results highlight the importance of separately examining the relationship of specific forms of leverage and personal recovery and raise questions for future research about the possible effect of financial leverage on recovery.

Characterization of an extreme phenotype of schizophrenia among women with homelessness

Background

Studies of schizophrenia and homelessness are often confounded by comorbid substance use. Women with schizophrenia and homelessness in India have very low rates of substance use and provide a unique opportunity to disentangle the effects of illness from that of substance use. We examined the clinical characteristics of women with schizophrenia and homelessness and compared it to an age-matched group of women with schizophrenia living with their family.

Methods

36 women with schizophrenia and homelessness, and 32 women with schizophrenia who were illness living with family were evaluated for psychopathology using Scale for Assessment of Positive Symptoms (SAPS)/ Scale for assessment of negative symptoms (SANS) scales, cognitive difficulties using Montreal Cognitive Assessment (MOCA)/Rowland Universal Dementia Scale (RUDAS), and Frontal Assessment Battery(FAB), disability using World Health Organization - Disability assessment Scale (WHO-DAS) and psychosocial factors using a semi-structured proforma. The groups were compared using t-tests and chi-square for continuous and categorical variables respectively.

Results

Women with schizophrenia and homelessness were found to have significantly higher scores on measures of psychopathology, significantly lower cognitive functioning, and much higher disability, and were also on higher doses of antipsychotics. The mean scores on measures of psychopathology, cognition and disability for women with schizophrenia and homelessness differed by 2-3 standard deviations with the mean for women living with family (i.e. z scores) suggesting that they represented an extreme phenotype. Rates of past employment were higher among women with schizophrenia and homelessness. Hence these differences were not accounted for by premorbid functioning.

Conclusions

The study raises the possibility of an extreme phenotype of schizophrenia with severe and persistent psychopathology non-responsive to dopamine blocking drugs, cognitive impairment, and disability, which needs further exploration.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Relapse among MHCUs after a Short-Term Admission in an Acute Psychiatric Unit: Primary Caregivers' Perspective

South Africa has taken initiative to strengthen its mental health system, by improving the Mental Health Care Act 17 of 2002 which proclaims that mental healthcare users (MHCUs) can be treated in communities and homes. Due to short-term hospitalisations for acute MHCUs and advocacy for community-based care, families play a significant role in providing care to severe mental healthcare users. The objective of the study was to explore primary caregivers' perspective regarding the relapse of MHCUs following a short-term admission in acute psychiatric units. A qualitative explorative design was used. In-depth individual interviews were conducted with 18 primary caregivers whose family members were readmitted to four hospitals with units designated for acute MHCUs in Limpopo. NVivo computer software version 11 was used to analyse data. The findings are that MHCUs deny the mental health condition. Mental illness is considered a short illness that can be cured, which shows misconceptions about self-mental health conditions. Refusal of direct observed treatment support also emerged; hence, it is difficult for caregivers to identify if the patient is taking the correct doses or not taking the medication at all. Perceived wrong beliefs about mental illness can affect the patient's desire to seek proper management and it can be damaging in many ways. Drugs and alcohol abuse makes MHCUs display disruptive behaviours and contribute to treatment non-adherence resulting in caregivers becoming reluctant to be around them. In conclusion, mixing traditional and faith-based mental healthcare practices as reported by primary caregivers can mean that tailor-fabricated culture-specific mental healthcare is required.

Mental health needs of homeless and recently housed individuals in Canada: A meta-ethnography

Homeless individuals are disproportionately likely to experience mental health conditions, and typically face many systemic barriers to access mental health services. This study sought to determine the mental health needs of homeless and recently housed individuals in Canada. A meta-ethnography was conducted to synthesise existing qualitative data and translate themes across a broader context. Thirty-five studies on the experiences of 1511 individuals with a history of homelessness were included. Themes were interpreted by comparing and contrasting findings across multiple contexts. Distinct, yet highly interrelated, unmet mental health needs were revealed through personal narratives of trauma, stigmatisation, victimisation, and a lack of basic necessities. Six themes that characterised this population's mental health needs were ontological security, autonomy, hope and purpose, empowerment, social connection and belonging, and access to services. This study revealed homeless individuals' unmet mental health needs to inform social and policy change and improve psychological well-being.

Effect of Portable Rent Subsidies and Mentorship on Socioeconomic Inclusion for Young People Exiting Homelessness: A Community-Based Pilot Randomized Clinical Trial

IMPORTANCE

There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness.

OBJECTIVE

To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young people who received only rent subsidies.

DESIGN, SETTING, AND PARTICIPANTS

This was a convergent mixed-methods, unblinded, 2-group, parallel randomized clinical trial with 1:1 allocation embedded within a community-based framework in 3 cities in Ontario, Canada. Participants were enrolled between March 1 and September 30, 2019, and were followed up through March 31, 2022.

INTERVENTIONS

Participants (n = 24) were randomly assigned adult mentors (n = 13) who had been recruited and screened by community partner agencies. All participants received portable rent subsidies (subsidy not tied to a specific location) for 2 years.

MAIN OUTCOMES AND MEASURES

Primary quantitative outcomes were self-reported measures of community integration (psychological and physical) and self-esteem-proxy indicators of socioeconomic inclusion. Community integration was measured with the Community Integration Scale, with a score range of 1 to 7 for the physical component and 4 to 20 for the psychological component; higher scores indicate higher integration. Self-esteem was measured with the Rosenberg Self-Esteem Scale, with a score range of 0 to 30; higher scores indicate greater self-esteem. Secondary quantitative outcomes included social connectedness, hopelessness, and academic and vocational participation. All analyses followed the intention-to-treat principle.

RESULTS

A total of 24 youths (12 women [50.0%]; mean [SD] age, 21.8 [2.2] years [range, 18-26 years]; race and ethnicity: 10 White [41.7%], 8 Black [33.3%], 2 Asian [8.3%], 2 Indigenous [8.3%], and 2 different choice [8.3%]) transitioned out of homelessness and into market-rent housing. All youths in the group that received mentorship and in the group that did not receive mentorship had stable or nonsignificant improvements in all study outcomes at the primary end point of 18 months compared with baseline (mean [SD] Community Integration Scale psychological score: mentorship group, 11.3 [2.6] at baseline and 11.2 [3.9] at 18 months; no-mentorship group, 10.8 [4.1] at baseline and 13.2 [2.9] at 18 months; mean [SD] Rosenberg Self-Esteem Scale score: mentorship group, 16.0 [4.6] at baseline and 18.1 [5.2] at 18 months; no-mentorship group, 16.3 [6.1] at baseline and 19.6 [5.7] at 18 months). However, there were no significant differences between the 2 groups in the Community Integration Scale psychological score (adjusted mean difference, -2.0; 95% CI, -5.0 to 1.0; P = .18) and Rosenberg Self-Esteem Scale score (adjusted mean difference, -1.4; 95% CI, -5.0 to 2.3; P = .44) 18 months after randomization. Ancillary analysis suggested that youths with informal mentors (mentors outside the study) at baseline felt more psychologically integrated at 18 months relative to those with no informal mentors at baseline (adjusted mean difference, 3.6; 95% CI, 0.4-6.8; P = .03).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, COVID-19 pandemic-related restrictions made it challenging for mentors and mentees to connect, which may have affected the findings. Steady socioeconomic outcomes-potentially attributable to portable rent subsidies-are noteworthy, given the socioeconomic inequities this population has faced during the COVID-19 pandemic. The possible benefit of informal mentorship warrants further investigation. This small pilot study was designed with the intention of generating data and hypotheses for a full-scale study; findings should be interpreted with caution.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03779204.

Association between Psychological Integration and Permanent Supportive Housing: An Exploratory Study with a Focus on Ethnicity

There is limited research on the association between Permanent Supportive Housing (PSH) and psychological integration. The purpose of this study was to explore this association among individuals with mental illness and/or substance use disorder (SUD) enrolled in PSH and to identify variables associated with sense of belonging. Given differences in outcomes of PSH by ethnicity, we were interested to determine if an association existed between PSH and psychological integration and whether it was equally observed among Hispanics and non-Hispanics. The target population included individuals who were chronically homeless and diagnosed with a mental illness and/or SUD. Baseline data were collected upon intake (N = 370). Follow-up data were collected at six-months post baseline (N = 286) and discharge (N = 143). Predictor and control variables included demographics, overall health, PTSD symptom severity, interactions with family and friends, and participation in recovery-related groups in the community. Psychological integration scores increased significantly from the baseline to the 6-month follow-up (t = −3.41, p = 0.003) and between the 6-month follow-up and discharge (t = −2.97, p = 0.007). Significant predictors of psychological integration included overall health, interactions with family and/or friends, PTSD symptoms, income, education, and diagnosis. No differences were observed between Hispanics and non-Hispanics. The findings from this exploratory study suggest that future research in this area is warranted.

Motivational network intervention to reduce substance use and increase supportive connections among formerly homeless emerging adults transitioning to housing: study protocol for a pilot randomized controlled trial

BACKGROUND

Studies indicate high rates of substance use among youth experiencing homelessness (YEH). Further, the social networks of YEH, although multi-dimensional in composition, are largely comprised of other YEH, substance users, and individuals who do not provide the youth with tangible or emotional support. For YEH who have the opportunity to enter a housing program, helping them to reduce their substance use and strengthen their prosocial supportive connections during this critical transition period may increase their stability and reduce their risk of re-entering homelessness. The goal of this study is to pilot test a brief motivational network intervention (MNI), delivered by case managers, to help former YEH who have recently transitioned to a housing program reduce their substance use and strengthen their prosocial supportive connections.

METHODS/DESIGN

Up to 60 residents of housing programs in the Los Angeles area will be randomized to receive four sessions of usual case manager support or four sessions of case manager support + MNI. Each MNI session consists of three parts: (1) identifying two goals that are most important for the resident over the next year (e.g., get or keep a job, finish or stay in school, reduce substance use); (2) a network interview with the resident to capture network data pertaining to their interactions in the past 2 weeks; and (3) a discussion between the case manager and the resident of the resulting network visualizations, conducted in a Motivational Interviewing (MI) style, and what role the resident's network may play in reaching their most important goals over the next year.

DISCUSSION

This study addresses a critical gap by pilot testing a computer-assisted MNI, delivered using MI techniques, that can help case managers work with recent YEH to reduce substance use and increase permanent supportive connections during the critical transitional period from homelessness to housing. Trial registration ClinicalTrials.gov Identifier: NCT04637815. Registered November 10, 2020.

Patterns and effects of social integration on housing stability, mental health and substance use outcomes among participants in a randomized controlled Housing First trial

INTRODUCTION

Recent research has shown that social integration, involving community integration and social support, can be protective resources for the health of homeless individuals. However, it is not clear how social integration affects health in the transition from homelessness into housing, and subsequent housing retention. This paper examines, through mixed quantitative and qualitative methods, how social integration changes over time, and how these changes relate to housing stability, substance use and mental health outcomes among a sample of homeless individuals experiencing mental illness participating in the At Home/Chez Soi Housing First randomized controlled trial in Canada.

METHODS

Longitudinal quantitative data (baseline, 6, 12, 24 month) and qualitative data ( 18 month) from the five trial sites (Moncton, Montreal, Toronto, Winnipeg and Vancouver) were examined using mixed models, mediation analyses, and thematic analysis.

RESULTS

Social integration (i.e., social network size, social interest, psychological integration) increased over time among study participants, with social network size increasing significantly more among Housing First participants than Treatment as Usual participants. Social network size mediated the effect of the intervention on the percentage of days in stable housing, indicating that the Housing First intervention may have increased participants' social network size, which in turn increased the percentage of days stably housed. No significant mediation of social integration on the effects of the intervention on mental health and substance use outcomes was found. Findings from the qualitative interviews support and expand upon these quantitative findings.

Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States

In the United States and abroad, health systems have begun to address housing insecurity through programs that adhere to the Housing First model. The model provides permanent supportive housing without disqualification due to current mental health problems or substance use, along with optional case management services. This study used qualitative methods to explore how housing stability affected chronic disease management and social and community relationships among individuals with complex health and social needs and patterns of high hospital utilisation who were housed as part of a scattered-site Housing First program in a mid-size city in the northeastern United States. 26 individual, semi-structured interviews were conducted with Housing First clients in their homes or day program sites between March and July 2017. Interviews were digitally recorded and transcripts were analysed using a qualitative descriptive methodology until thematic saturation was reached. Findings suggest that housing provided the physical location to manage the logistical aspects of care for these clients, and an environment where they were better able to focus on their health and wellness. Study participants reported less frequent use of emergency services and more regular interaction with primary care providers. Additionally, case managers' role in connecting clients to behavioural health services removed barriers to care that clients had previously faced. Housing also facilitated reconnection with family and friends whose relationships with participants had become strained or distant. Changes to physical and social communities sometimes resulted in experiences of stigmatisation and exclusion, especially for clients who moved to areas with less racial and socioeconomic diversity, but participation in the program promoted an increased sense of safety and security for many clients.