Housing placement and subsequent days homeless among formerly homeless adults with mental illness.

OBJECTIVE: The study examined the influence of group or individual housing placement and consumer characteristics on the number of days subsequently homeless among formerly homeless mentally ill persons. METHODS: A total of 303 homeless shelter residents with severe mental illness were screened for dangerousness, 118 were randomly assigned to either independent apartment or staffed group living sites, and 110 were followed for 18 months. Study participants' sociodemographic characteristics, diagnosis, and residential preferences and the residential recommendations made by clinicians were measured at baseline. RESULTS: Overall, 76 percent of the study participants were housed at the end of the 18-month follow-up period, although 27 percent had experienced at least one episode of homelessness during the period. The number of days homeless was greater for individuals assigned to independent apartments than for those placed in staffed group homes, but only for members of minority groups. Substance abuse was the strongest individual-level predictor of days homeless. Individuals whom clinicians identified as needing group living experienced more days homeless, irrespective of the type of housing they received. Consumers who stated a strong preference for independent living had more days homeless than those who were amenable to staffed group homes. CONCLUSIONS: Although consumers more frequently prefer independent living, placement in staffed group housing resulted in somewhat fewer days homeless for some groups of consumers. Further experience of homelessness by formerly homeless mentally ill individuals may be reduced by providing effective substance abuse treatment and by paying special attention to consumers identified by clinicians to be at particular risk for housing loss.

Public-academic liaison research centers in an era of managed care.

Public-Academic Liaison research centers (PALs) have traditionally provided benefits to both state mental health authorities (SMHAs) and academic institutions. The advent of managed care, austere state fiscal budgets, and a restructured national research development capacity suggests the need for new administrative approaches to PAL research efforts to maintain these benefits in this era of rapidly changing health care. This brief report outlines one such approach by the Massachusetts SMHA in its efforts to establish two PAL research centers: one for clinical neuroscience, and one for behavioral and forensic science. Preliminary two-year outcomes are presented, and the implications of the model are discussed.

Housing costs for adults who are mentally ill and formerly homeless.

The goal of this study was to evaluate the costs, under two different housing conditions, to the state mental health agency of caring for adults who are homeless and mentally ill. One hundred and twelve clients of the Massachusetts Department of Mental Health, living in psychiatric shelters, were randomly assigned to one of two housing types: Evolving Consumer Households or Independent Living apartments. For the next 18 months each client was followed so that the cost of treatment, case management, and housing could be collected and compared. The authors found that treatment and case management costs did not vary by housing type, but housing costs were significantly higher for those assigned to Evolving Consumer Households. Regardless of original housing assignment, treatment costs were lower for clients who remained where they were originally placed. The authors conclude that providing support for clients that increases housing stability reduces their need for treatment and that independent living arrangements may be a more cost-effective policy choice.

Injection drug use among homeless adults with severe mental illness.

OBJECTIVES: This study examined injection drug use among homeless men and women with severe mental illness in two sites. METHODS: The data were drawn from related clinical trials conducted in Baltimore (101 men, 49 women) and Boston (85 men, 33 women). RESULTS: The percentages of homeless men with a history of injection drug use were 26% in Baltimore and 16% in Boston; the corresponding rates among homeless women were 8% and 6%. CONCLUSIONS: Taken together, these and previous results suggest high lifetime prevalences of injection drug use-and associated risks of HIV transmission-in this elusive population.

Neuropsychological function in homeless mentally ill individuals.

Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.

Lost time, found hope and sorrow: the search for self, connection, and purpose during "awakenings" on the new antipsychotics.

The novel antipsychotic medications clozapine and olanzapine provide well-documented clinical improvement for some patients with psychosis. We interviewed 15 patients with chronic psychosis who demonstrated significant improvement on these new medications and offer a conceptual framework to organize their narratives. In our conceptual model, our patients' descriptions are divided into three broad areas: sense of self, sense of connection, and sense of purpose. We also highlight the opportunities for psychotherapy with this population.

Self-report and observer measures of substance abuse among homeless mentally ill persons in the cross-section and over time.

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be-overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Assessing homeless mentally ill persons for permanent housing: screening for safety.

Although placement in community housing is a frequent intervention with populations of seriously mentally ill homeless individuals, there has been little formal investigation of the criteria used by clinicians in screening individuals for such placement. In this paper, we describe screening a population of 303 homeless people with severe mental illness for placement in independent apartments. We assess subjects' level of risk along multiple dimensions and determine the contribution of each risk dimension to the final safety decision. In addition, we evaluate the validity of the risk measures with other measures of clinical condition. Two-thirds of the sample were judged as safe for independent living. Assaultiveness was the most frequent risk identified, followed by self-destructiveness, substance abuse, and medication non-compliance. The final safety decision was associated most strongly with assaultiveness, self-destructiveness, and medication non-compliance. We conclude that it is possible to assess risk with measures that are available from shelter and medical records, and call for more research on the role of medication non-compliance in safety decisions and for longitudinal research to validate risk assessments.

Housing preferences and perceptions of health and functioning among homeless mentally ill persons.

OBJECTIVE: Most homeless persons who have received services for serious mental illness want to live on their own, but mental health professionals usually recommend group housing. This study examined the relationship between the types of residential arrangements preferred by homeless mentally ill persons and their demographic and clinical characteristics and perceptions of their health and functional status. METHODS: The study sample consisted of 118 homeless mentally ill persons living in publicly funded shelters in Boston who were enrolled in a research demonstration project that would provide them with housing. Before random assignment to housing, study participants were interviewed about their interest in moving, in staff support, and in living with others. Their clinical status and functional strengths and impairments were assessed using a variety of objective and subjective measures. RESULTS: Study participants reported a marked preference for independent living but expressed substantial interest in staff support. The desire for independent living was associated with a perceived ability to manage independent living, but was also associated with current substance abuse. Most indicators of clinical status and functional ability were not associated with housing preferences. CONCLUSIONS: Self-perceived functional ability may not be an influence on housing preferences, except when that ability is perceived as making independent living more difficult. Symptoms of mental illness did not appear to interfere with study participants' rational decision making about where to live. However, the study finding that substance abusers expressed a desire for independent living suggests the need for caution in adhering to homeless mentally ill persons' housing preferences, given the problems posed by substance abuse for their ability to maintain stable community housing.

Comparison of clinicians' housing recommendations and preferences of homeless mentally ill persons.

Housing recommendations made by two clinicians for 86 homeless mentally ill consumers were compared with the consumers' own housing preferences. Clinicians recommended independent living much less often than did the consumers. The two groups varied less on specific housing features such as eagerness for consumers to leave the shelter and consumers' need for part-time staff help. Only one of the clinicians took into account some aspects of social background and health status in formulating housing recommendations. The authors conclude that housing providers should encourage clinicians to work together with consumers to identify appropriate placements.

The role of psychiatrists in community mental health centers: a survey of job descriptions.

There is little data about the role of psychiatrists within CMHCs. To gain perspective on this issue, job descriptions for medical directors and staff psychiatrists were collected from 214 CMHCs. The data demonstrated that most CMHCs want fully trained psychiatrists involved in a variety of activities in addition to prescribing medication. Policy development was specifically included as part of the medical director's job for 69% of the CMHCs, and 50% mentioned training as part of the staff psychiatrist's job. Although job descriptions may not accurately reflect the actual roles of the psychiatrist in all cases, these data suggest that CMHCs support a multifaceted role for their psychiatrists.

Factors in the quality of patient evaluations in general hospital psychiatric emergency services.

OBJECTIVES: The study examined the usefulness of a three-perspective model for determining the quality of evaluations in psychiatric emergency services. The model was used to evaluate the hypothesis that the provision of high-quality care in emergency services is primarily influenced by service objectives related to patients' clinical characteristics rather than by institutional constraints, such as workload or physical facilities, or by social biases, such as clinicians' attitudes toward patients or perceptions of community expectations. METHODS: The evaluation of 683 persons assessed in nine California public facilities were independently observed. Multivariate techniques were used to test the relative importance of patients' clinical characteristics, possible sources of social bias among clinicians, and institutional constraints in influencing three quality-of-care dimensions: technical quality, the art of patient care, and optimum investment of time. RESULTS: The findings generally confirmed the hypothesis that patients' clinical characteristics have more influence on the quality of care provided than institutional constraints or social biases. However, one institutional constraint--increased workload demands--led to reduced technical quality and to less than optimal use of time. Further, social biases reflected in the clinician's like for and preconceptions about the patient also influenced the quality of their evaluations. CONCLUSIONS: The model is a useful tool for examining quality of care in the psychiatric emergency service. Increasing workload pressures negatively affect quality of care.

The quality of psychiatric emergency evaluations and patient outcomes in county hospitals.

Quality of care is widely assumed to be related to patient outcomes, but little is known about care in relation to outcomes in county general hospital psychiatric emergency services. It was hypothesized that conformity to professional standards (technical quality) and engagement of the patient (artful care) in psychiatric emergency services evaluations would contribute to improved patient functioning (Global Assessment Scale score) and appropriate disposition. A total of 583 cases in seven facilities were analyzed. Conformity to technical standards of care was associated with retention even after constraints, biases, and admission criteria had been taken into account. Conversely, artful care was associated with lower probability of retention and improved functioning.

Ensuring services for persons with chronic mental illness under national health care reform.

People with chronic mental illness present complex challenges for the design of health care financing reforms. In this position statement from the committee on psychiatry and community of the Group for the Advancement of Psychiatry, the authors describe chronic and severe mental illnesses as psychiatric illnesses that require acute and ongoing psychiatric assessment and treatment, as chronic medical diseases that require ongoing rehabilitative services, and as persistent disabilities that need ongoing supportive care and social services. Any proposal for health care reform must ensure parity of chronic psychiatric illnesses with other psychiatric conditions. It must also reimburse psychiatric rehabilitation at parity with other medical rehabilitation and provide equal access to and reimbursement for broad ancillary health services that reduce costs and improve quality of life.

AIDS education for patients with chronic mental illness.

Despite the AIDS epidemic's impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.

Some clinical approaches to the homeless mentally ill.

Clinicians who work with homeless people are likely to encounter a very broad spectrum of mental disorders and residential patterns. As with any other patient population, the particulars of clinical interventions must be guided by the specific constellations of biological, psychological, and social needs. However, for individuals who not only suffer from serious psychiatric disorders, but are also homeless, effective approaches may require significant modifications of traditional techniques and changes in the prioritization, timing, and framing of specific interventions. In this article we will focus on people who are severely and persistently mentally ill and who have been sleeping for months or years in shelters or in public spaces such as parks, streets, and bus terminals.

The seriously mentally ill: another perspective on treatment resistance.

There is a subpopulation of the seriously mentally ill who remain acute care recidivists, rarely becoming engaged in follow-up treatment. It has been argued that these individuals are system, rather than treatment resisters. The perceptions they have of their problems are often in conflict with staff evaluations, or with what the system has to offer. In the present study, patients who dropped out of residential care against staff's advice were compared to patients who remained in treatment. The results suggest that the greater the difference between the perceptions a patient and therapist have concerning the patient's problem, the greater the likelihood of the patient dropping out of treatment.