The impact of psychiatric diagnosis and family system relationship on problems identified by families coping with a mentally ill member.

The purpose of this study was to explore how psychiatric diagnosis and family relationships relate to problems identified by participants in three one-day public family psychoeducation workshops for families with a member with a serious mental illness. Workshop participants generated lists of problems they had faced, which were coded into eleven categories. Logistic regression models predicting listing of categories were developed based on ill member (diagnosis, sex, treatment compliance) and family member (sex, age, relationship to the ill member) characteristics. For models predicting content category from ill member characteristics, only denial/noncompliance and interpersonal/social categories were significantly predictive as dependent variables. For models predicting content categories from family member characteristics, only the resources/benefits model was predictive. The significant findings, in conjunction with the important negative results, suggest implications for further development of family intervention models. Building on previous research, groups composed of families coping with more than a single diagnosis and including a variety of family member relationships have the potential to reach consensus on curriculum topics.

Service use over time and achievement of stable housing in a mentally ill homeless population.

OBJECTIVE: Service use among clients of a multiservice agency serving homeless persons with severe mental illness was examined to determine whether patterns of service use reflected two stages in an adaptation of the transtheoretical model of change. In the adapted model, change occurs in five stages-pre-engagement, contemplation, engagement, the strategic moment, and consolidation. It was hypothesized that rates of service use would be highest immediately after clients obtained housing (the strategic moment) and would decrease in the months afterward (consolidation stage), with the greatest decreases occurring immediately after housing was obtained. METHODS: Service use data were collected for two groups: a housed group of 58 clients who had obtained and sustained stable housing for at least 24 consecutive months at the time of sampling and an unhoused group of 55 clients who were matched with the housed clients on month of service entry. Total service use and use of three service types-a drop-in center, counseling, and health services-were examined to test the hypotheses. It was hypothesized that use of services by the unhoused group would show a consistent linear decline rather than a two-stage decline. Linear spline regression using bootstrap sampling methods was used to fit service use data for both groups. RESULTS: The two-stage solution significantly modeled the patterns of service use by the housed but not the unhoused clients, supporting the hypotheses. For the housed group, use of the drop-in center and counseling fit the model, and use of health services did not. CONCLUSIONS: The results provide limited support for the hypothesized five-stage model for achieving change.

Agency-based tracking of difficult-to-follow populations: runaway and homeless youth programs in St. Louis, Missouri.

OBJECTIVES: This study explored agency-based tracking methods for one of the most difficult-to-follow populations: runaway and homeless youth. METHODS: A total of 118 program discharges from three federally funded agencies serving runaway/ homeless youth in St. Louis, Missouri were tracked for a follow-up study of this population. Agency staff attempted to locate and interview program participants three months post-discharge using a protocol that systematically varied times and location of contact attempts. Separate analyses were conducted to compare the group of subjects whose locations were ascertained with those who were not, and who were successfully interviewed with those who were not. Variables related to the tracking protocol and individual descriptive and service use variables were examined in these analyses. RESULTS: Sixty-nine percent of the sample was successfully located and fifty-nine percent interviewed. Significant findings included: fewer contact attempts over fewer days were made for individuals successfully interviewed, individuals tracked through Division of Family Services were less likely to be both located and interviewed, and individuals successfully located were significantly younger. CONCLUSIONS: This report provides encouraging evidence that even relatively unsophisticated protocols for tracking agency clients developed in collaboration with community agencies can--with consistent implementation--yield follow-up samples that are acceptably representative of program participants.

Correlates of early onset and chronicity of homelessness in a large urban homeless population.

This study examined temporal relationships between relative onsets of mental illness and homelessness in a cross-sectional study of 900 homeless people compared with a matched, never-homeless sample from the Epidemiologic Catchment Area study. All psychiatric disorders preceded homelessness in the majority. Only one disorder, alcohol use disorder (in men only), had significantly earlier onset in homeless subjects. Regarding number of symptoms or earlier age of onset of psychiatric disorders, earlier onset of homelessness was associated with several diagnoses: schizophrenia, major depression, generalized anxiety disorder, alcohol and drug use disorders, and antisocial personality. In multiple regression models, history of dysfunctional family background and maternal psychiatric illness were also associated with earlier onset of homelessness, whereas education was protective. Chronicity of homelessness was associated with number of symptoms of alcohol use disorder and earlier age of onset of drug use disorder, presence and number of symptoms of schizophrenia and antisocial personality, and earlier onset of major depression and conduct disorder. In multiple regression models, more education, but not family background problems, was associated with shorter lifetime duration of homelessness. These findings provide information relevant to the roles of mental illness and personal vulnerability factors in the onset and chronicity of homelessness.

Content and curriculum in psychoeducation groups for families of persons with severe mental illness.

OBJECTIVE: The study compared problems identified by participants in a workshop for families with a relative who had severe mental illness with topics addressed in published descriptions of multifamily psychoeducational interventions to determine whether the problems and needs of family members differed from those covered in professionally prepared psychoeducational materials. METHODS: Participants in a one-day psychoeducational workshop were asked to identify and rank in order of importance the problems they faced in managing mental illness. Most workshop participants were family members who did not have a severe mental illness, but family members with a severe mental illness and mental health service providers also attended. Lists of problems generated by 86 participants containing a total of 355 items were analyzed for content, and 11 problem categories were identified and ranked. These categories were then compared with the content of multifamily psychoeducation programs described in the literature. RESULTS: Although the methodology limited generalizability of findings, the results suggest important distinctions between content developed by professionals and the needs identified by family members, particularly in families' greater emphasis on negative symptoms and on family relationships. CONCLUSIONS: The findings suggest that input from the family, the ill family member, and mental health providers is necessary for developing psychoeducation curricula that will meet families' needs. Professionals who design multifamily psychoeducation curricula are encouraged to incorporate enough flexibility to accommodate the specific needs of members of particular groups and to provide general information that is useful for all groups.

The association of psychiatric diagnosis with weather conditions in a large urban homeless sample.

Assessment of psychiatric disorders encounters unique complexities in homeless populations. Although the use of structured diagnostic instruments has significantly improved research methodology in this area, questions remain about the validity of using cross-sectional diagnostic methods derived from studies of more general populations. In particular, the validity of structured diagnostic instruments in the assessment of schizophrenia, depression, drug use disorder, and antisocial personality disorder (ASPD) in homeless populations has been questioned. The purpose of this study was to examine the association of psychiatric diagnoses with the weather. It was hypothesized that self-report of psychiatric illness may be affected by prevailing weather conditions. Nine hundred homeless subjects randomly sampled from St. Louis shelters, day centers, and unsheltered locations were interviewed over a 1-year period. Official average daily temperature and amount of precipitation on the day of each subject's interview were compared with lifetime and current psychiatric diagnoses ascertained by the Diagnostic Interview Schedule. Similar analyses were performed in general population data from the Epidemiologic Catchment Area study. The study found that among homeless men, inclement weather on the day of interview was associated with lifetime and current diagnoses of major depression, lifetime drug use disorder, lifetime diagnosis of ASPD, and current alcohol use disorder. These findings, however, were not present in homeless women and not reflected in the general population. The results, although limited, suggest that weather may confound cross-sectional, standardized methods of psychiatric diagnosis in homeless men. Weather-related factors among homeless men are associated with ascertainment of both lifetime and current diagnosis of major depression, as well as lifetime drug use disorder and ASPD and current alcohol use disorder. Possible interpretations of these findings are discussed, with implications for intervention strategies for psychiatric disorders in the larger context of homelessness and social problems.

The family as caregiver: a group psychoeducation model for schizophrenia.

A professionally led multifamily psychoeducation program for families with a schizophrenic member was designed according to participating families' reported concerns. The families provided information on their problems, needs, coping, and requirements from the program. They expressed more concern about "negative" symptoms of schizophrenia (e.g., social withdrawal) than about positive ones (e.g., hallucinations). Participants' overall positive response to the program is discussed in terms of further development of a multifamily psychoeducation model with family-generated content.

A diagnostic comparison of homeless and nonhomeless patients in an urban mental health clinic.

This study compared demographic and diagnostic characteristics of a sample of homeless outpatient mental health clinic attenders with a domiciled comparison group from the same clinic. Data on demographic variables and DSM-III-R psychiatric diagnoses were collected over a two-year period on a consecutive sample of 166 homeless and 117 nonhomeless clinic attenders. Data on demographics and psychiatric diagnoses of the homeless clinic attenders were further compared with data collected systematically from 900 homeless individuals in the same city. In the clinic, homeless subjects were more often members of ethnic minorities, and homeless women were significantly younger and better educated than their nonhomeless counterparts. Rates of schizophrenia, bipolar disorder, and somatization disorder were not significantly different between homeless and nonhomeless groups. Major depression was about four times as prevalent in nonhomeless men as in homeless men. Homeless men were significantly more likely than nonhomeless men to qualify for a diagnosis of alcohol use disorder, and homeless women were more likely than other women to qualify for a diagnosis of drug use disorder. Both homeless men and women were significantly more likely than their domiciled counterparts to meet criteria for antisocial personality disorder. Personality disorder other than antisocial was more prevalent in nonhomeless men than in homeless men. Combined rates of personality disorder were significantly higher among homeless than nonhomeless women, but not men. Homeless clinic attenders were demographically and diagnostically very similar to a general homeless population in the same city. The only diagnosis that was more prevalent in the homeless clinic than in the homeless community was antisocial personality disorder. We concluded that because of difference in diagnostic prevalence, homeless and nonhomeless individuals in mental health clinics need to be considered independently. Clinicians treating homeless outpatients may benefit from having special facility in diagnosis and management of antisocial personality disorder and substance abuse, along with expertise in other psychiatric disorders in this population.

Predictors of achieving stable housing in a mentally ill homeless population.

Relationships among demographic characteristics, diagnostic groups, presenting problems, and service use were examined in two groups of mentally ill persons: a group of 60 formerly homeless persons who had been housed for at least 24 months and a group of 60 persons who remained homeless. Use of eight types of services over a 26-month period was examined. Women were significantly more likely to be housed than men. Individuals whose primary presenting problem was subsistence needs were more likely to be housed than those whose primary problem was mental, illness or substance abuse. Those with a diagnosis of personality disorder used fewer services. Housed individuals were more likely to use services than those who were homeless.

The relationship between transience and current life situation in the homeless services-using population.

Although transience has been the focus of an enormous amount of public attention, there has been limited empirical research on transience in the homeless population. The purpose of the study discussed in this article was to develop a construct of transience for the homeless services-using population. Transience was defined as consisting of four factors: migration, duration, intention, and involvement. This construct was used to predict current housing and employment status, substance use, receipt of entitlements, and health and mental health services use. The study collected data on 146 individuals. Findings suggest the validity of the study's conceptualization of transience, particularly in its ability to predict current substance use. This study also found indirect evidence for one previously proposed profile of transients--the "transient substance abuser," but this profile may have two categories--used drugs or used alcohol.

A comparison of clinical and structured interview diagnoses in a homeless mental health clinic.

OBJECTIVE: This study compared psychiatric diagnoses ascertained by independent clinicians with structured research interviews of homeless psychiatric patients assessed in a mental health clinic and in the community. Problems of both overdiagnosis and underdiagnosis in structured research interviews compared to clinician assessment were predicted. METHOD: Over a period of a year, 97 patients referred to a mental health clinic for homeless people were assessed with the Diagnostic Interview Schedule (DIS) administered by a clinical social worker who then completed a full clinical psychiatric social work assessment. These same patients received a thorough and systematic clinical psychiatric evaluation by a psychiatrist or psychologist, both experienced with this population. These clinicians gathered data from multiple sources, often with extended observation over time. The DIS and clinician diagnoses were made blind to one another and then compared; the clinician was often made aware of some of the symptoms that the social worker had elicited, but not whether the elicited material was from the DIS or from the clinical assessment. Diagnoses of 33 clinic patients previously assessed by trained nonclinician DIS interviews in an epidemiologic study of the homeless population in the community were also compared to clinician diagnoses, and no information from these patients' survey DIS interviews was made available to the clinicians. RESULTS: Compared to clinician assessment, structured interviews underdiagnosed antisocial personality disorder (ASPD) and overdiagnosed major depression. Alcohol use disorder and schizophrenia showed only small discrepancies by assessment method. Drug use disorder revealed no bias according to method of ascertainment, but showed very discrepant kappa levels comparing DIS to clinician assessment in the two different comparison contexts. CONCLUSIONS: If structured research methods assessing the homeless population actually overestimate depression, underestimate ASPD, and misclassify drug abuse, then policies stemming from structured interview research recommendations may call for levels and types of services not optimally suited to the reality of this population's needs. Because mental illness and substance abuse are thought to be critical factors in the generation and perpetuation of homelessness, the issue of accurate diagnosis is tantamount to understanding and providing workable solutions to the problem of homelessness. Further research is needed to untangle potential confounders of the homeless situation to psychiatric diagnosis.

Are the mentally ill homeless a distinct homeless subgroup?

The question has been raised whether it is useful or meaningful to dichotomize the homeless population by mental illness - i.e., to consider the mentally ill homeless as distinct from other homeless people. The current article presents evidence from a single data set to address this question empirically. Data from a randomly sampled population of 900 homeless men and women systemically interviewed using the Diagnostic Interview Schedule were examined to determine associations of mental illness with the problems of homelessness, controlling for the presence of substance abuse in the analyses. Although a few clinically meaningful associations with mental illness were found that might suggest directions for appropriate interventions, mental illness did not differentiate individuals in many important demographic and biographic respects. Individual diagnoses did not perform much better in differentiating the homeless by mental illness. Schizophrenia and bipolar mania showed a few significant associations not identified by the "major mental illness" construct. Major depression, constituting the majority of nonsubstance Axis I disorder in the homeless, provided no association beyond that obtained with the "major mental illness" category. The data provide little support for conceptualizing homeless subgroups or homelessness in general on the basis of mental illness alone. To do so also risks neglecting the emotional distress of the majority without major mental illness and the other problems that homeless persons share regardless of psychiatric illness. While serious mental illness is overrepresented among the homeless, it represents just one of many important vulnerability factors for homelessness. Substance abuse is far more prevalent than other Axis I disorders. Media images equating homelessness with major mental illness unnecessarily stigmatize homeless people and encourage oversimplified and narrowly conceived psychiatric interventions. While continuing attention is needed on improving identification and management of serious mental illness among the homeless, this must be accomplished within the broader context of social and economic aspects of homelessness.