Faculty Bibliography

OBJECTIVES: We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. METHODS: Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, symptoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. RESULTS: Eighty-one percent of participants returned to community housing during the follow-up period; the median duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group P<.05) and arrest history (P<.01) were the strongest predictors of a longer duration of homelessness. CONCLUSIONS: Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventions

Outreach is a treatment modality for engaging underserved populations in health care. Nowhere is outreach more relevant than in delivering services to homeless persons with mental illness. Programs providing outreach to homeless people have been in existence for at least two decades and a craft has developed naturalistically. However, there has been insufficient formal examination of factors that influence the effectiveness of outreach and how it is actually performed. The authors present an in-depth examination of issues related to outreach to the homeless. They review different outreach modalities, the role of the individual clinician, and the art of teamwork. They also discuss external issues such as financing, access to housing, interactions with other professions, and working conditions. The authors conclude with a brief discussion concerning the application of outreach to populations other than homeless individuals with psychiatric disorders and suggest future directions for improving our understanding of this important modality

OBJECTIVES: This study aims to document how psychiatric residencies address homelessness and mental illness, to discover training barriers, and to identify educational recommendations. METHODS: The authors mailed a survey to 178 American psychiatric residency programs, requesting information about didactic and clinical offerings in homelessness. Programs without offerings were asked to provide reasons why. RESULTS: Of 106 responses, 60% had educational offerings. Concerning clinical experiences, most had fewer than 20% of residents rotating, and only 11% had mandatory rotations. Programs without offerings usually noted that training in this area was a low priority, and this was most frequently linked with perceived low community homelessness prevalence. CONCLUSION: Psychiatric residency programs have addressed education in mental illness and homelessness in various ways. That there were few residents in clinical rotations suggests a need to explore causes, including funding problems, and whether there is sufficient academic community psychiatry faculty. The findings also evoke the need for a model curriculum that enables clinical competency in this public health problem.

The authors examine current challenges confronting psychiatry in caring for homeless people with psychiatric disorders. After reviewing how psychiatry has historically addressed homelessness and mental illness, the authors discuss the roles that the profession has developed in working with homeless populations. These roles, which encompass clinical, administrative, academic, and advocacy functions, have evolved as a result of trends both in homelessness services and within the profession of psychiatry. Challenges implicit in this evolution are discussed, including recent trends in homelessness, particularly an increase in prevalence, especially among families and children and some clinical subpopulations. The authors propose that these epidemiological trends are affecting the mental health care needs of homeless people. To be effective and credible in continuing to help solve the problems of homeless people with psychiatric disorders, psychiatry must adapt to these new challenges, using the roles it has developed.

Using data collected by Project Renewal's mobile medical services to homeless people in New York City, this paper discusses a tension between an emergency medicine model of outreach and that of primary care. In the former model, clinicians evaluate clients on the basis of presenting complaints and refer them, as necessary, for specialized treatment. The latter is a broader model of comprehensive outreach and/or treatment, where clinicians screen clients and assess them for various conditions offering ongoing evaluation and treatment on site. The model of outreach is applicable for some homeless clients, but the prevalence and overlap of physical complaints, infectious diseases, substance abuse, and psychiatric symptoms among homeless people in New York City has resulted in an evolution toward broader approaches to outreach in this population. Improvements in diagnostic testing and increasingly portable medical technology may make the mobile delivery of medical care to homeless persons increasingly feasible.

OBJECTIVE: This study compared changes in receipt of government entitlements by homeless persons with and without psychotic ideation in New York City between January 1997 and July 1998, a period characterized by changing state government policies and greater bureaucratic monitoring of eligibility. METHODS: In conjunction with an experimental study of the efficacy of social work services provided to homeless persons in Manhattan by a mobile medical van, 25 persons who were assessed as having experienced psychotic ideation in the previous year and 134 nonpsychotic persons were followed up after four months to identify changes in their receipt of Medicaid benefits, Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), food stamps, and home relief (state welfare for single persons). The social work intervention was designed to help eligible clients gain access to entitlements and substance abuse treatment. RESULTS: The proportion of clients with psychotic ideation who received Medicaid, food stamps, or home relief decreased during the study period, while the proportion of nonpsychotic clients who received these entitlements increased. Little change was observed in receipt of SSI or SSDI by either group. CONCLUSIONS: Psychotic ideation among homeless persons may be a significant factor in access to and maintenance of government entitlements. In the context of an increasingly restrictive and bureaucratic welfare system, providing assistance to homeless persons who have severe psychopathology presents new challenges to service providers.