Community Ment Health J DOI 10.1007/s10597-014-9721-z
ORIGINAL PAPER
Mental Health Correlates of Past Homelessness in Latinos and Asians Hans Y. Oh • Jordan E. DeVylder
Received: 21 August 2013 / Accepted: 11 March 2014 Ó Springer Science+Business Media New York 2014
Abstract Mental illness and addiction are strongly associated with homelessness, yet few studies have shown how these relationships vary across ethnic categories that are underrepresented in the homeless population. This study draws from the National Latino and Asian American Survey to examine mental health and substance abuse correlates of homelessness amongst Latinos and Asians living in the United States. Clinical and institutional factors associated with homelessness varied by ethnicity. Among Latinos, alcohol abuse or dependence, conduct disorder and intermittent explosive disorder were risk factors for homelessness, while attending a religious service more than once a week was a protective factor. Among Asians, mood disorder was a risk factor as were health problems and receiving welfare in the past. Understanding ethnicityspecific correlates of homelessness may guide culturally nuanced mental health prevention and intervention efforts. Keywords Homeless Latino Asian Mental illness Psychiatric disorder Substance abuse
Introduction While black Americans have historically been overrepresented amongst the homeless (Hopper and Milburn 1996), Latinos and Asians have been relatively underrepresented. When compared to blacks, Latinos share many risk factors of poverty, but paradoxically report lower rates of homelessness (Baker 1996; Burt 2001; Culhane and Metraux H. Y. Oh (&) J. E. DeVylder Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, USA e-mail: [email protected]
1999). The underrepresentation of Latinos amongst the homeless can be interpreted in a couple of ways: (1) Latinos may have found methods of avoiding the streets or the shelter system (e.g. tapping into social networks) (Baker 1996), or (2) Latinos are systematically undercounted in homeless samples (Conroy and Heer 2003). Homelessness among Asians is even more rare, and remains largely unexamined in studies. Lim et al. (2006) published the only study to our knowledge on homeless Asian Americans, and found that Asian veterans were at lower risk for homelessness and less likely to abuse alcohol when compared to other racial groups. Past studies have estimated that up to 80 % of homeless adults has lifetime diagnosis of serious mental illness (Scott 1993). These estimates largely stem from enumerations of homeless people living in shelters and on the streets, speaking more to the chronically homeless than to the episodically or transiently homeless. One strategy to capture a broader scope of homelessness among underrepresented populations is to utilize household surveys (Link et al. 1994; Stegman 1992). Greenberg and Rosenheck (2010) used the National Comorbidity Study Replication (NCS-R; Kessler and Merikangas 2004), a nationally representative survey of domiciled individuals living in the US, to examine lifetime occurrences of homelessness that lasted a week or more. Their study found lifetime diagnoses of substance abuse disorder (OR 2.36, 95 % CI 1.56–3.58), mood disorder (OR 1.58, 95 % CI 1.11–2.25), and impulse control disorder (OR 1.63, 95 % CI 1.63) were significantly associated with an increased likelihood of reporting homelessness. This finding in a predominantly white sample may not be generalizable across cultures, and therefore bears repeating in diverse samples. As such, we utilize data from the National Latino and Asian American Study (NLAAS) (Alegria et al. 2004;
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Heeringa et al. 2004; Pennell et al. 2004), a household survey of the general population, to investigate relationships between psychiatric diagnoses and homelessness among Latinos and Asians. To our knowledge, this is the only study to examine homelessness among Asian-Americans in the general population and one of few to examine homelessness among Latinos.
Methods This study analyzes data from NLAAS, a household survey conducted between May 2002 and November 2003 measuring psychiatric diagnoses and mental health service utilization amongst non-institutionalized Latino and Asian individuals over the age of 18 living in the contiguous United States. The sample totaled 4,864 respondents, with a weighted response rate of 73.2 % (75.5 % for Latinos, 65.6 % for Asians). Sampling included three stages: (1) core sampling, in which primary sampling units of metropolitan statistical areas/county units and secondary sampling units of contiguous groupings of census blocks were selected with probability proportionate to size, from which housing units and household members were sampled; (2) high-density supplemental sampling to oversample census block groups with 5 % or greater density of target ancestry groups; and (3) second respondent sampling to recruit participants from households in which one eligible member had already been interviewed. Sample weights were used to adjust for the joint probabilities for selection under this design. Interviews were conducted inperson (approximately 1,000 interviews were conducted over the telephone) using the respondent’s preferred language. Sampling procedures and sample characteristics have been extensively described elsewhere (Alegria et al. 2004; Heeringa et al. 2004; Pennell et al. 2004). The Asian American sample (n = 2,095) consisted of four ethnic categories: Chinese (n = 600), Filipino (n = 508), Vietnamese (n = 520), and ‘‘Other’’ (n = 467). The Latino sample (n = 2,554) consisted of four ethnic categories: Cuban (n = 577), Puerto Rican (n = 495), Mexican (n = 868), and ‘‘Other’’ (n = 614). The NLAAS weighted sample was comparable to the 2000 census population on most sociodemographic measures, but included more immigrants and low-income individuals. The main dependent variable—homelessness—was measured by the survey question: How long altogether were you homeless since the age of 18? Responses included: days, weeks, months, or years. The dependent variable was recoded into a dichotomous variable that signified homelessness for 1 week or more. The main independent variables were dichotomous variables to reflect lifetime endorsement of psychiatric diagnoses according to the Diagnostic Statistical
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Manual IV (DSM IV) criteria, with the exception of conduct disorder, which was only reported in the NLAAS using International Classification of Diseases (ICD-10) criteria. Psychiatric diagnoses included (1) substance abuse or dependence, (2) alcohol abuse or dependence, (3) anxiety disorder (endorsing at least one of the following: generalized anxiety disorder, panic disorder, PTSD, social phobia), (4) mood disorder (endorsing major depressive disorder or dysthymia), and impulse-control disorder (conduct disorder and intermittent explosive disorder). Previous studies have identified several risk factors for homelessness, such as being male, being unmarried, being middle aged, being unemployed, receiving welfare, and having low educational attainment, all of which are included in this analysis as potentially confounding factors or mechanisms underlying mental health correlates of homelessness in this sample (Greenberg and Rosenheck 2010). Additional covariates included health conditions, citizenship status, and religious service attendance. Analysis In this paper, we examined Latinos and Asians separately, but used an unconditional approach to subpopulation analysis that adjusted standard errors based on the full NLAAS data set. All analyses accounted for complex survey design using STATA. First, we performed a series of unadjusted bivariate Chi squared tests to examine whether a significant relationship existed between our main dependent variable (prior homelessness) and each independent/control variable. Second, we performed bivariate logistic regressions on homelessness to calculate the effect sizes for each independent/control variable, reported as odds ratios with 95 % confidence intervals. Finally, we used multivariable logistic regression analyses to calculate adjusted odds ratios with 95 % confidence intervals, which indicated the independent effect of each variable adjusting for other predictors and confounds. Significance of individual predictor variables was tested in all logistic regression analyses using Wald Chi square tests (two-tailed, a = .05). As a sensitivity analysis, we re-ran the multivariable logistic regressions using a re-coded dependent variable that signified homelessness for 1 month or more to test whether associations remained robust when using a more conservative definition of homelessness. Sample characteristics of Latinos are depicted in Table 1, and sample characteristics of Asians are depicted in Table 2.
Results In the entire sample, 3.8 % (SE = .43 %) of respondents reported a lifetime prevalence of past homelessness of
Community Ment Health J Table 1 Sample characteristics for Latinos Never homeless (N = 2,443)
Homeless for 1 week or more (N = 111)
Bivariate logistic regressions
N
OR1
%
SE
N
%
SE
95 % CI
df
Sociodemographic variables Age [50
623
.1926
.0118
18
.1531
.0504
.76
.34–1.67
3,955
Male
1,076
.5116
.0113
51
.5855
.0585
1.35
.86–2.11
3,955
Married
1,542
.6472
.0136
57
.5930
.0465
.79
.54–1.16
3955
High School
1,496
.5555
.0184
64
.5443
.0545
.96
.62–1.48
3,955
786
.3050
.0207
26
.2694
.0500
.84
.50–1.41
3,955
259 1,510
.0912 .6387
.0079 .0191
18 56
.1214 .5547
.0289 .0575
1.38 .70
.77–2.46 .41–1.20
3,954 3,955
934
.4268
.0182
25
.2266
.0735
0.39*
.18–.86
3,946
Income [50K Welfare Employment Citizenship Other variables Religiosity
1,403
.3211
.0133
31
.1615
.0628
.41
.16–1.02
3,952
Health2
1,387
.5179
.0159
76
.6686
.0626
1.88*
1.10–3.19
3,943
Substance use Disorder Total
203
.0970
.0106
41
.4229
.0772
6.83***
3.97–11.72
3,955
Drug abuse or dependence
102
.0504
.0054
27
.2578
.0651
6.55***
3.46–12.38
3,955
Alcohol abuse or dependence
191
.0929
.0093
37
.3850
.0669
6.11***
3.71–10.06
3,955
350
.1366
.0077
40
.2547
.0521
2.16**
1.23–3.77
3,955
81
.0275
.0043
8
.0433
.0176
1.60
113
.0402
.0044
22
.1267
.0380
Psychiatric disorder
Anxiety Disorder Total Generalized Anxiety Disorder PTSD Panic Disorder Phobia Mood Disorder Total Depression Dysthymia Impulse-control Disorder Total
.62–4.12
3,955
3.47**
1.71–7.02
3,955
1.42–7.60
3955
.93–2.79
3,955
77
.0268
.0032
14
.0828
.0326
3.28**
176
.0736
.0067
21
.1135
.0276
1.61
387 367
.1393 .1333
.0074 .007
37 33
.2833 .2325
.0566 .0546
2.44** 1.97*
1.37–4.37 1.03–3.76
3,955 3,955
83
.0247
.0032
12
.1051
.0433
4.64**
1.74–12.41
3,955
415
.1875
.0161
63
.5867
.0525
6.15***
3.65–10.36
3,955
Conduct Disorder
341
.1626
.0138
48
.4911
.0721
4.97***
2.60–9.50
3,955
Intermittent Explosive Disorder
115
.0416
.0065
23
.1786
.0308
5.01***
3.45–7.27
3,955
1
All percentages are based on unconditional subpopulation analyses that account for the full NLAAS data set. * p \ 0.05; ** p \ 0.01; *** p \ 0.001
2
Health conditions defined by the presence of one or more of the following conditions: arthritis, back/neck pain, headache, chronic pain, stroke, heart attack, high blood pressure, asthma, lung disease, diabetes, ulcer, epilepsy, and cancer
1 week or more, and 3.5 % (SE = .51 %) reported homelessness of 1 month or more. Among Latinos, 4.7 % (SE = .60 %) of respondents reported homelessness for 1 week or more, and 4.3 % (SE = .69 %) reported homelessness for 1 month or more. Prevalence was substantially lower among Asians, with 1.3 % (SE = .31 %) of respondents reporting homelessness for 1 week or more, and 1.2 % (SE = .29 %) for 1 month or more. For Latinos, individuals who endorsed a history of substance abuse or dependence were over two and a half times more likely to report homelessness for 1 week or more when compared to those who did not report a history of substance abuse. Impulse-control disorders were also significant risk factors for homelessness. Specifically, individuals who endorsed a history of conduct disorder were over two and half times more likely to report prior
homelessness, as were individuals who endorsed intermittent explosive disorder, when compared to individuals who did not endorse these disorders. Also, on average, attending a church service more than once a week was independently associated with a 67 % decreased likelihood of reporting homelessness. All effect sizes persisted in the sensitivity analysis. For Asians, individuals who reported a mood disorder at some point in their lives were 3–4 times more likely to report homelessness for 1 week or more in the past when compared to individuals who did not have mood disorder, and this was also true using the more conservative definition of homelessness. History of alcohol abuse or dependence increased the likelihood of past homelessness by almost fourfold, but only when redefining the dependent variable as homelessness for 1 month or more. Receiving
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Community Ment Health J Table 2 Sample characteristics for Asians Never Homeless (N = 2,067)
Homeless for one week or more (N = 28)
Bivariate logistic regressions
N
N
OR
%
SE
%
SE
95 % CI
df
Sociodemographic variables Age [50
525
.2618
.0236
3
.1317
.0805
.43
.10–1.81
3,937
Male
986
.4761
.0117
12
.3540
.1063
.60
.23–1.57
3937
Married
1,452
.6920
.0163
18
.5745
.1090
.60
.25–1.46
3,937
High School
1,756
.8487
.015
23
.8398
.0749
.93
.30–2.90
3,937
Income [50K
1,133
.5430
.0175
9
.3412
.1008
.44
.18–1.07
3937
Welfare Employment
168 1,369
.0558 .6392
.0062 .0140
7 16
.2458 .6081
.0945 .1091
5.51 .88
1.95–15.56 .36–2.13
3,936 3,937
689
.3536
.0227
5
.2126
.1113
.49
.13–1.85
3928
Citizenship Other variables Religiosity
674
.3138
.0185
8
.3674
.1058
1.27
.50–3.25
3,931
1,075
.5194
.0183
21
.7970
.0748
3.63*
1.38–9.53
3,926
Substance use Disorder Total
77
.0373
.0062
8
.2111
.0396
6.91***
2.55–18.72
3,937
Drug abuse or dependence
42
.0188
.0041
6
.1552
.0766
9.61***
3.18–29.07
3,937
Alcohol abuse or dependence
64
.0320
.0062
7
.1907
.0808
7.12***
2.48–20.45
3,937
1.32–8.88
3,937
Health Psychiatric disorders
Total anxiety
179
.0926
.0089
7
.2589
.0953
3.42*
Generalized Anxiety Disorder
35
.0169
.0028
1
.0474
.0445
2.89
PTSD
37
.0185
.0047
3
.1426
.0862
Panic Disorder Phobia Mood Disorder Total Depression Dysthymia Impulse-control Disorder Total Conduct Disorder IED
.38–22.02
3,937
8.85**
1.98–39.62
3,937
36
.0202
.0049
4
.1122
.0569
6.14**
1.91–19.71
3,937
112
.0537
.0061
1
.0279
.0289
.51
.06–4.04
3,937
188 179
.0881 .0837
.0092 .0088
11 10
.4058 .3823
.0939 .0980
7.07*** 6.78***
3.34–14.97 3.09–14.89
3,937 3,937
36
.0195
.0043
5
.2086
.1000
13.28***
3.76–46.90
3,938
277
.1330
.0098
10
.2927
.1049
2.70
.98–7.41
3,937
231
.1096
.008
10
.2927
.1049
3.36*
1.22–9.30
3,937
68
.0339
.0066
1
.0205
.0191
.60
.09–3.96
3,937
1
All percentages are based on unconditional subpopulation analyses that account for the full NLAAS data set. * p \ .05; ** p \ .01; *** p \ .001
2
Health conditions defined by the presence of one or more of the following conditions: arthritis, back/neck pain, headache, chronic pain, stroke, heart attack, high blood pressure, asthma, lung disease, diabetes, ulcer, epilepsy, and cancer
welfare services in the past increased likelihood of homelessness by fourfold to fivefold, and endorsing at least one health condition increased the likelihood of homelessness by over three fold, but these associations lost significance when using the more conservative definition of homelessness. Variations in the sensitivity analysis may be a result of diminishing power, since relatively few Asians endorsed homelessness for at least 1 month (Table 3).
Discussion This study examined the mental health correlates of homelessness among Latinos and Asians, two ethnic categories that have been historically underrepresented in homeless samples. In our analysis, we found that among
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Latinos, alcohol abuse or dependence, and impulse-control disorders were risk factors for past homelessness, while religious service attendance was a protective factor. For Asians, mood disorder, receiving welfare services, and having at least one physical health condition were all risk factors. Our results align with Greenberg and Rosenheck’s findings on lifetime substance abuse or dependence disorder in a nationally representative (primarily white) sample, though for Asians, this was only true when coding the dependent variable to signify homelessness for 1 month or more. Greenberg and Rosenheck found that lifetime impulse-control disorder diagnosis was highly predictive of past homelessness, which was also true for Latinos in our analysis, but not for Asians. The strongest predictor of past homelessness in Greenberg and Rosenheck’s study was a history of receiving welfare services (OR 5.72; 95 % CI
Community Ment Health J Table 3 Likelihood of reporting homelessness in the past Latino
Asian
More than 1 week
More than 1 month
More than 1 week
More than 1 month
OR
OR
OR
OR
95 % CI
95 % CI
95 % CI
95 % CI
Psychiatric disorders Substance abuse or dependence
1.81
.76–4.33
1.72
.73–4.05
2.68
.74–9.69
2.01
.55–7.30
Alcohol abuse or dependence
2.54*
1.12–5.77
2.71*
1.17–6.29
2.52
.63–10.06
3.86*
1.08–13.77
Anxiety disorder
1.10
.56–2.17
1.01
.51–2.01
1.01
.32–3.16
.81
.19–3.35
Mood disorder
1.34
.73–2.45
1.33
.75–2.36
3.85***
1.97–7.54
3.55**
1.75–7.21
Conduct disorder
2.74*
1.29–5.84
2.39**
1.30–4.39
1.22
.37–4.02
1.34
.39–4.53
Intermittent explosive disorder
2.54**
1.48–4.36
2.62**
1.10–5.81
.26
.04–1.66
.34
.05–2.32
1.06
.38–2.96
1.13
.39–3.29
.40
.10–1.65
.50
.12–1.97
.96
.56–1.65
1.15
.72–1.82
.58
.19–1.74
.47
.16–1.36
1.01
.59–1.73
.86
.45–1.63
.89
.32–2.47
.93
.30–2.89
.80 .80
.46–1.39 .34–1.90
.81 .66
.46–1.40 .28–1.54
.66 .72
.24–1.82 .18–2.89
.58 .70
.21–1.59 .15–3.21
Sociodemographic Variables Age [50 years Male Married High School Graduate Citizen Employed
.73
.36–1.48
.70
.39–1.26
.91
1.06
.59–1.88
1.03
.57–1.86
4.78**
Religious service attendance
0.33*
.14–.76
0.36*
.01–.07
.32
Health
1.40
.82–2.41
1.31
.70–2.47
3.46*
History of welfare use
.36–2.33
1.18
.42–3.27
1.62–14.07
3.04
.86–10.79
.04–2.76
.33
.04–2.97
1.24–9.66
2.94
.98–8.79
Other variables
Bold values indicate all OR with significance of at least p \ 0.05 Results were calculated using unconditional subpopulation analyses *** p \ 0.001; ** p \ 0.01; * p \ 0.05
3.36–9.76); however, in our study, this was only true for Asians. Our analyses differed from that of Greenberg and Rosenheck with respect to gender, as they found men to be more likely to report a history of homelessness (OR 1.77; 95 % CI 1.16–2.69), while we did not find this to be the case for either Latinos or Asians. According to our study, key sociodemographic variables (gender, marital status, education, citizenship status, and employment status) were not significant predictors of past homelessness. Furthermore, the impact of anxiety disorder and substance abuse disorder were not significant across ethnic categories. Our study suggests that religious service attendance is a protective factor for Latinos. Conceivably, Latinos may be using religion and spirituality as coping mechanisms to counteract the risk factors associated with homelessness. Additionally, past studies have used religiosity as a proxy for social capital (Chatterji et al. 2007), and so religious service attendance may indicate that Latinos possess networks of relationships at church that protect against homelessness. If this is in fact the case, future research should examine the effect of social capital on homelessness by way of material support (e.g. relying on family or friends to secure ‘doubled up’ housing arrangements) (Baker 1996), and by way of mental health status
(McCulloch 2001; McKenzie et al. 2002; Rose 2000), which both affect the likelihood of being homeless. Our study also elucidates an interesting risk factor for Latinos, which is impulse-control disorder. Both conduct and intermittent explosive disorders were highly predictive of homelessness, and currently, there is little research on why this might be true for Latinos, but not Asians. We speculate that this may have to do with the relatively lower social status of Latinos and the neighborhood effects that make Latinos vulnerable to impulse-control disorder (or vulnerable to being labeled with behavioral problems in general). Though the cross-sectional nature of the data does not allow us to make any causal claims, the diagnosis of conduct disorder presents an opportunity to infer causality since it is a clinical term that is used only to describe antisocial behavior in children and adolescents under the age of 18. The dependent variable in our analysis is homelessness after the age of 18, lending temporal support for a causal argument. History of incarceration was not included in our analysis, and may have mediated the impact of impulse-control disorders on homelessness. To our knowledge, this paper is the first to examine homeless Asian Americans in the general population. Lim et al. (2006) were the first to examine homeless Asian
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Americans using a sample of veterans, and in their study, Asians reported fewer instances of homelessness when compared to other ethnicities. Lim and colleagues speculate that the lower risk of homelessness among AsianAmericans may reflect a cultural tendency for Asians to assume the burden of caring for family members with mental illnesses (Leong and Lau 2001). Our analyses do not capture the protective effect of family caretakers, and so future studies should investigate the mitigating impact of social support on homelessness among Asians. Studies have shown that Asians delay seeking help due to stigma and thus present later in the course of illness with more severe symptoms (Lin and Cheung 1999). Future research may also check to see if this pattern of delayed helpseeking due to stigma has a specific effect on alcohol abuse/dependence and mood disorders, since these disorders in particular are highly predictive of homelessness. It is important to note that neither ‘Latino’ nor ‘Asian’ represents a monolithic group, and so future studies should explore associations between mental health and homelessness using ethnic subcategories. For example, our analyses found that a history of welfare for Asians is highly predictive of a history of homelessness. Overall, Asians were less likely than Latinos to report a history of using welfare, and so it seems that those Asians who are on welfare represent a particularly vulnerable subset of the Asian population. Prior studies have shown that Southeast Asians have higher rates of welfare utilization (Ong and Blumenberg 1994), and so an effect modification using more nuanced ethnic categories may elucidate the relationship between welfare utilization and homelessness for specific Asian groups. However, given the relative scarcity of Asian homeless individuals with a history of being on welfare, analyses using general population samples are likely to be underpowered. Several potential limitations exist in our study. In light of the relative paucity of homeless Latinos and Asians, this study utilized data from a national household survey of Latinos and Asians to identify individuals with prior histories of homelessness in the general population. The sample and study design excluded currently (and presumably more chronically) homeless individuals, and thus limited the inferences of our study to individuals who were homeless for shorter durations. Since all respondents were domiciled at the time of interview, this data reveals patterns that can only be applied to those individuals who were able to emerge out of homelessness into housing. However, this data also provided an opportunity to look at a broader definition of homelessness that includes the episodic and transient homeless (individuals who reported homelessness for weeks, months, and years). Also, undocumented immigrants were not included in the NLAAS, and their inclusion may have painted a different
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portrait of how Latinos and Asians rely on social support networks, perhaps out of reluctance to utilize social service or shelter systems. Another weakness of the study is that lifetime diagnoses and lifetime homelessness were assessed retrospectively, which can be subject to recall bias. Furthermore, while surveys were conducted in the language preferred by the respondent, problems of cultural validity were still plausible. One example is the clinical phenomenon amongst Latinos called ataques de nervios, which in English translates as ‘nervous attacks’. Studies have shown that ataques de nervios may be a cultural syndrome that signals clinical issues and disturbances that are not associated with anxiety disorders (Lewis-Fernandez et al. 2002). Future analyses may consider using ataques de nervios in addition to or instead of anxiety disorders. Also, several important diagnoses—such as bi-polar disorder, attention deficit hyperactivity disorder, and psychosis—were not measured in the NLAAS and were therefore excluded from the analysis. This is problematic since these psychiatric disorders are also correlated with homelessness, and their omission may have created bias. Lim and colleagues’ study found that Asian American veterans were more likely than white veterans to be diagnosed with schizophrenia or other psychotic disorders. As they point out, higher rates of schizophrenia in Asians may have been a result of culturally unresponsive assessments of Asians, which points to the complexities and misattributions of diagnoses in general for Latinos and Asians, calling for culturally nuanced mental health and homeless services. Future research using social network analysis can examine the unique ways in which Latinos and Asians acquire emotional, material, and instrumental support to buffer against the risk factors that cause homelessness. Conflict of interest The authors declare no conflict of interest or funding sources for this manuscript.
References Alegria, M., Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., et al. (2004). Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos. International Journal of Methods in Psychiatric Research, 13(4), 270–288. Baker, S. G. (1996). Homelessness and the Latino paradox. In J. Baumohl (Ed.), Homeless in America (pp. 132–140). Phoenix: Oryx Press. Burt, M. R. (2001). Helping America’s homeless: Emergency shelter or affordable housing? The Urban Insitute. Retrieved from http://books.google.com/books?hl=en&lr=&id=8_XzWQEhRGg C&oi=fnd&pg=PA1&dq=Burt?2001?homeless&ots=l0PMr5Gzj&sig=f1ywZ15_CbJ_NIU8dOEAY2kXd_E. Chatterji, P., Alegria, M., Lu, M., & Takeuchi, D. (2007). Psychiatric disorders and labor market outcomes: evidence from the
Community Ment Health J National Latino and Asian American Study. Health Economics, 16(10), 1069–1090. Conroy, S. J., & Heer, D. M. (2003). Hidden Hispanic homelessness in Los Angeles: The ‘‘Latino paradox’’ revisited. Hispanic Journal of Behavioral Sciences, 25(4), 530–538. Culhane, D., & Metraux, S. (1999). One-year rates of public shelter utilization by race/ethnicity, age, sex and poverty status for New York City (1990 and 1995) and Philadelphia (1995). Population Research and Policy Review, 18(3), 219–236. Greenberg, G. A., & Rosenheck, R. A. (2010). Mental health correlates of past homelessness in the National Comorbidity Study Replication. Journal of Health Care for the Poor and Underserved, 21(4), 1234–1249. Heeringa, S. G., Wagner, J., Torres, M., Duan, N., Adams, T., & Berglund, P. (2004). Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). International journal of methods in psychiatric research, 13(4), 221–240. Hopper, K. & Milburn, N. G. (1996). Homelessness among African Americans: A historical and contemporary perspective. In J. Baumohl (Ed.), Homeless in America (pp. 123-131). Phoenix: Oryx Press. Kessler, R. C., & Merikangas, K. R. (2004). The National Comorbidity Survey Replication (NCS-R): background and aims. International journal of methods in psychiatric research, 13(2), 60–68. Leong, F. T., & Lau, A. S. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3(4), 201–214. Lewis-Ferna´ndez, R., Guarnaccia, P. J., Martinez, I. E., Salma´n, E., Schmidt, A., & Liebowitz, M. (2002). Comparative phenomenology of ataques de nervios, panic attacks, and panic disorder. Culture, Medicine and Psychiatry, 26(2), 199–223.
Lim, S., Kasprow, W., & Rosenheck, R. (2006). Brief reports: Psychiatric illness and substance abuse among homeless AsianAmerican veterans. Psychiatric Services, 57(5), 704–707. Lin, K.-M., & Cheung, F. (1999). Mental health issues for Asian Americans. Psychiatric Services, 50(6), 774–780. Link, B. G., Susser, E., Stueve, A., Phelan, J., Moore, R. E., & Struening, E. (1994). Lifetime and five-year prevalence of homelessness in the United States. American Journal of Public Health, 84(12), 1907–1912. McCulloch, A. (2001). Social environments and health: cross sectional national survey. BMJ, 323(7306), 208–209. McKenzie, K., Whitley, R., & Weich, S. (2002). Social capital and mental health. The British Journal of Psychiatry, 181(4), 280–283. Ong, P. & Blumenberg, E. (1994). Welfare and work among Southeast Asians In P. Ong (Ed.), The state of Asian Pacific America. Economic Diversity, Issues & Policies. A Public Policy Report. Los Angeles: LEAP Asian Pacific American Public Policy Institute and UCLA Asian American Studies Center. Pennell, B.-E., Bowers, A., Carr, D., Chardoul, S., Cheung, G., Dinkelmann, K., et al. (2004). The development and implementation of the national comorbidity survey replication, the national survey of American life, and the national Latino and Asian American survey. International Journal of Methods in Psychiatric Research, 13(4), 241–269. Rose, R. (2000). How much does social capital add to individual health? Social Science and Medicine, 51(9), 1421–1435. Scott, J. (1993). Homelessness and mental illness. The British Journal of Psychiatry, 162(3), 314–324. Stegman, M. (1992). Housing in New York City: Results of the housing and vacancy survey. New York City: Department of Housing Preservation and Development.
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ORIGINAL PAPER
Mental Health Correlates of Past Homelessness in Latinos and Asians Hans Y. Oh • Jordan E. DeVylder
Received: 21 August 2013 / Accepted: 11 March 2014 Ó Springer Science+Business Media New York 2014
Abstract Mental illness and addiction are strongly associated with homelessness, yet few studies have shown how these relationships vary across ethnic categories that are underrepresented in the homeless population. This study draws from the National Latino and Asian American Survey to examine mental health and substance abuse correlates of homelessness amongst Latinos and Asians living in the United States. Clinical and institutional factors associated with homelessness varied by ethnicity. Among Latinos, alcohol abuse or dependence, conduct disorder and intermittent explosive disorder were risk factors for homelessness, while attending a religious service more than once a week was a protective factor. Among Asians, mood disorder was a risk factor as were health problems and receiving welfare in the past. Understanding ethnicityspecific correlates of homelessness may guide culturally nuanced mental health prevention and intervention efforts. Keywords Homeless Latino Asian Mental illness Psychiatric disorder Substance abuse
Introduction While black Americans have historically been overrepresented amongst the homeless (Hopper and Milburn 1996), Latinos and Asians have been relatively underrepresented. When compared to blacks, Latinos share many risk factors of poverty, but paradoxically report lower rates of homelessness (Baker 1996; Burt 2001; Culhane and Metraux H. Y. Oh (&) J. E. DeVylder Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY 10027, USA e-mail: [email protected]
1999). The underrepresentation of Latinos amongst the homeless can be interpreted in a couple of ways: (1) Latinos may have found methods of avoiding the streets or the shelter system (e.g. tapping into social networks) (Baker 1996), or (2) Latinos are systematically undercounted in homeless samples (Conroy and Heer 2003). Homelessness among Asians is even more rare, and remains largely unexamined in studies. Lim et al. (2006) published the only study to our knowledge on homeless Asian Americans, and found that Asian veterans were at lower risk for homelessness and less likely to abuse alcohol when compared to other racial groups. Past studies have estimated that up to 80 % of homeless adults has lifetime diagnosis of serious mental illness (Scott 1993). These estimates largely stem from enumerations of homeless people living in shelters and on the streets, speaking more to the chronically homeless than to the episodically or transiently homeless. One strategy to capture a broader scope of homelessness among underrepresented populations is to utilize household surveys (Link et al. 1994; Stegman 1992). Greenberg and Rosenheck (2010) used the National Comorbidity Study Replication (NCS-R; Kessler and Merikangas 2004), a nationally representative survey of domiciled individuals living in the US, to examine lifetime occurrences of homelessness that lasted a week or more. Their study found lifetime diagnoses of substance abuse disorder (OR 2.36, 95 % CI 1.56–3.58), mood disorder (OR 1.58, 95 % CI 1.11–2.25), and impulse control disorder (OR 1.63, 95 % CI 1.63) were significantly associated with an increased likelihood of reporting homelessness. This finding in a predominantly white sample may not be generalizable across cultures, and therefore bears repeating in diverse samples. As such, we utilize data from the National Latino and Asian American Study (NLAAS) (Alegria et al. 2004;
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Community Ment Health J
Heeringa et al. 2004; Pennell et al. 2004), a household survey of the general population, to investigate relationships between psychiatric diagnoses and homelessness among Latinos and Asians. To our knowledge, this is the only study to examine homelessness among Asian-Americans in the general population and one of few to examine homelessness among Latinos.
Methods This study analyzes data from NLAAS, a household survey conducted between May 2002 and November 2003 measuring psychiatric diagnoses and mental health service utilization amongst non-institutionalized Latino and Asian individuals over the age of 18 living in the contiguous United States. The sample totaled 4,864 respondents, with a weighted response rate of 73.2 % (75.5 % for Latinos, 65.6 % for Asians). Sampling included three stages: (1) core sampling, in which primary sampling units of metropolitan statistical areas/county units and secondary sampling units of contiguous groupings of census blocks were selected with probability proportionate to size, from which housing units and household members were sampled; (2) high-density supplemental sampling to oversample census block groups with 5 % or greater density of target ancestry groups; and (3) second respondent sampling to recruit participants from households in which one eligible member had already been interviewed. Sample weights were used to adjust for the joint probabilities for selection under this design. Interviews were conducted inperson (approximately 1,000 interviews were conducted over the telephone) using the respondent’s preferred language. Sampling procedures and sample characteristics have been extensively described elsewhere (Alegria et al. 2004; Heeringa et al. 2004; Pennell et al. 2004). The Asian American sample (n = 2,095) consisted of four ethnic categories: Chinese (n = 600), Filipino (n = 508), Vietnamese (n = 520), and ‘‘Other’’ (n = 467). The Latino sample (n = 2,554) consisted of four ethnic categories: Cuban (n = 577), Puerto Rican (n = 495), Mexican (n = 868), and ‘‘Other’’ (n = 614). The NLAAS weighted sample was comparable to the 2000 census population on most sociodemographic measures, but included more immigrants and low-income individuals. The main dependent variable—homelessness—was measured by the survey question: How long altogether were you homeless since the age of 18? Responses included: days, weeks, months, or years. The dependent variable was recoded into a dichotomous variable that signified homelessness for 1 week or more. The main independent variables were dichotomous variables to reflect lifetime endorsement of psychiatric diagnoses according to the Diagnostic Statistical
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Manual IV (DSM IV) criteria, with the exception of conduct disorder, which was only reported in the NLAAS using International Classification of Diseases (ICD-10) criteria. Psychiatric diagnoses included (1) substance abuse or dependence, (2) alcohol abuse or dependence, (3) anxiety disorder (endorsing at least one of the following: generalized anxiety disorder, panic disorder, PTSD, social phobia), (4) mood disorder (endorsing major depressive disorder or dysthymia), and impulse-control disorder (conduct disorder and intermittent explosive disorder). Previous studies have identified several risk factors for homelessness, such as being male, being unmarried, being middle aged, being unemployed, receiving welfare, and having low educational attainment, all of which are included in this analysis as potentially confounding factors or mechanisms underlying mental health correlates of homelessness in this sample (Greenberg and Rosenheck 2010). Additional covariates included health conditions, citizenship status, and religious service attendance. Analysis In this paper, we examined Latinos and Asians separately, but used an unconditional approach to subpopulation analysis that adjusted standard errors based on the full NLAAS data set. All analyses accounted for complex survey design using STATA. First, we performed a series of unadjusted bivariate Chi squared tests to examine whether a significant relationship existed between our main dependent variable (prior homelessness) and each independent/control variable. Second, we performed bivariate logistic regressions on homelessness to calculate the effect sizes for each independent/control variable, reported as odds ratios with 95 % confidence intervals. Finally, we used multivariable logistic regression analyses to calculate adjusted odds ratios with 95 % confidence intervals, which indicated the independent effect of each variable adjusting for other predictors and confounds. Significance of individual predictor variables was tested in all logistic regression analyses using Wald Chi square tests (two-tailed, a = .05). As a sensitivity analysis, we re-ran the multivariable logistic regressions using a re-coded dependent variable that signified homelessness for 1 month or more to test whether associations remained robust when using a more conservative definition of homelessness. Sample characteristics of Latinos are depicted in Table 1, and sample characteristics of Asians are depicted in Table 2.
Results In the entire sample, 3.8 % (SE = .43 %) of respondents reported a lifetime prevalence of past homelessness of
Community Ment Health J Table 1 Sample characteristics for Latinos Never homeless (N = 2,443)
Homeless for 1 week or more (N = 111)
Bivariate logistic regressions
N
OR1
%
SE
N
%
SE
95 % CI
df
Sociodemographic variables Age [50
623
.1926
.0118
18
.1531
.0504
.76
.34–1.67
3,955
Male
1,076
.5116
.0113
51
.5855
.0585
1.35
.86–2.11
3,955
Married
1,542
.6472
.0136
57
.5930
.0465
.79
.54–1.16
3955
High School
1,496
.5555
.0184
64
.5443
.0545
.96
.62–1.48
3,955
786
.3050
.0207
26
.2694
.0500
.84
.50–1.41
3,955
259 1,510
.0912 .6387
.0079 .0191
18 56
.1214 .5547
.0289 .0575
1.38 .70
.77–2.46 .41–1.20
3,954 3,955
934
.4268
.0182
25
.2266
.0735
0.39*
.18–.86
3,946
Income [50K Welfare Employment Citizenship Other variables Religiosity
1,403
.3211
.0133
31
.1615
.0628
.41
.16–1.02
3,952
Health2
1,387
.5179
.0159
76
.6686
.0626
1.88*
1.10–3.19
3,943
Substance use Disorder Total
203
.0970
.0106
41
.4229
.0772
6.83***
3.97–11.72
3,955
Drug abuse or dependence
102
.0504
.0054
27
.2578
.0651
6.55***
3.46–12.38
3,955
Alcohol abuse or dependence
191
.0929
.0093
37
.3850
.0669
6.11***
3.71–10.06
3,955
350
.1366
.0077
40
.2547
.0521
2.16**
1.23–3.77
3,955
81
.0275
.0043
8
.0433
.0176
1.60
113
.0402
.0044
22
.1267
.0380
Psychiatric disorder
Anxiety Disorder Total Generalized Anxiety Disorder PTSD Panic Disorder Phobia Mood Disorder Total Depression Dysthymia Impulse-control Disorder Total
.62–4.12
3,955
3.47**
1.71–7.02
3,955
1.42–7.60
3955
.93–2.79
3,955
77
.0268
.0032
14
.0828
.0326
3.28**
176
.0736
.0067
21
.1135
.0276
1.61
387 367
.1393 .1333
.0074 .007
37 33
.2833 .2325
.0566 .0546
2.44** 1.97*
1.37–4.37 1.03–3.76
3,955 3,955
83
.0247
.0032
12
.1051
.0433
4.64**
1.74–12.41
3,955
415
.1875
.0161
63
.5867
.0525
6.15***
3.65–10.36
3,955
Conduct Disorder
341
.1626
.0138
48
.4911
.0721
4.97***
2.60–9.50
3,955
Intermittent Explosive Disorder
115
.0416
.0065
23
.1786
.0308
5.01***
3.45–7.27
3,955
1
All percentages are based on unconditional subpopulation analyses that account for the full NLAAS data set. * p \ 0.05; ** p \ 0.01; *** p \ 0.001
2
Health conditions defined by the presence of one or more of the following conditions: arthritis, back/neck pain, headache, chronic pain, stroke, heart attack, high blood pressure, asthma, lung disease, diabetes, ulcer, epilepsy, and cancer
1 week or more, and 3.5 % (SE = .51 %) reported homelessness of 1 month or more. Among Latinos, 4.7 % (SE = .60 %) of respondents reported homelessness for 1 week or more, and 4.3 % (SE = .69 %) reported homelessness for 1 month or more. Prevalence was substantially lower among Asians, with 1.3 % (SE = .31 %) of respondents reporting homelessness for 1 week or more, and 1.2 % (SE = .29 %) for 1 month or more. For Latinos, individuals who endorsed a history of substance abuse or dependence were over two and a half times more likely to report homelessness for 1 week or more when compared to those who did not report a history of substance abuse. Impulse-control disorders were also significant risk factors for homelessness. Specifically, individuals who endorsed a history of conduct disorder were over two and half times more likely to report prior
homelessness, as were individuals who endorsed intermittent explosive disorder, when compared to individuals who did not endorse these disorders. Also, on average, attending a church service more than once a week was independently associated with a 67 % decreased likelihood of reporting homelessness. All effect sizes persisted in the sensitivity analysis. For Asians, individuals who reported a mood disorder at some point in their lives were 3–4 times more likely to report homelessness for 1 week or more in the past when compared to individuals who did not have mood disorder, and this was also true using the more conservative definition of homelessness. History of alcohol abuse or dependence increased the likelihood of past homelessness by almost fourfold, but only when redefining the dependent variable as homelessness for 1 month or more. Receiving
123
Community Ment Health J Table 2 Sample characteristics for Asians Never Homeless (N = 2,067)
Homeless for one week or more (N = 28)
Bivariate logistic regressions
N
N
OR
%
SE
%
SE
95 % CI
df
Sociodemographic variables Age [50
525
.2618
.0236
3
.1317
.0805
.43
.10–1.81
3,937
Male
986
.4761
.0117
12
.3540
.1063
.60
.23–1.57
3937
Married
1,452
.6920
.0163
18
.5745
.1090
.60
.25–1.46
3,937
High School
1,756
.8487
.015
23
.8398
.0749
.93
.30–2.90
3,937
Income [50K
1,133
.5430
.0175
9
.3412
.1008
.44
.18–1.07
3937
Welfare Employment
168 1,369
.0558 .6392
.0062 .0140
7 16
.2458 .6081
.0945 .1091
5.51 .88
1.95–15.56 .36–2.13
3,936 3,937
689
.3536
.0227
5
.2126
.1113
.49
.13–1.85
3928
Citizenship Other variables Religiosity
674
.3138
.0185
8
.3674
.1058
1.27
.50–3.25
3,931
1,075
.5194
.0183
21
.7970
.0748
3.63*
1.38–9.53
3,926
Substance use Disorder Total
77
.0373
.0062
8
.2111
.0396
6.91***
2.55–18.72
3,937
Drug abuse or dependence
42
.0188
.0041
6
.1552
.0766
9.61***
3.18–29.07
3,937
Alcohol abuse or dependence
64
.0320
.0062
7
.1907
.0808
7.12***
2.48–20.45
3,937
1.32–8.88
3,937
Health Psychiatric disorders
Total anxiety
179
.0926
.0089
7
.2589
.0953
3.42*
Generalized Anxiety Disorder
35
.0169
.0028
1
.0474
.0445
2.89
PTSD
37
.0185
.0047
3
.1426
.0862
Panic Disorder Phobia Mood Disorder Total Depression Dysthymia Impulse-control Disorder Total Conduct Disorder IED
.38–22.02
3,937
8.85**
1.98–39.62
3,937
36
.0202
.0049
4
.1122
.0569
6.14**
1.91–19.71
3,937
112
.0537
.0061
1
.0279
.0289
.51
.06–4.04
3,937
188 179
.0881 .0837
.0092 .0088
11 10
.4058 .3823
.0939 .0980
7.07*** 6.78***
3.34–14.97 3.09–14.89
3,937 3,937
36
.0195
.0043
5
.2086
.1000
13.28***
3.76–46.90
3,938
277
.1330
.0098
10
.2927
.1049
2.70
.98–7.41
3,937
231
.1096
.008
10
.2927
.1049
3.36*
1.22–9.30
3,937
68
.0339
.0066
1
.0205
.0191
.60
.09–3.96
3,937
1
All percentages are based on unconditional subpopulation analyses that account for the full NLAAS data set. * p \ .05; ** p \ .01; *** p \ .001
2
Health conditions defined by the presence of one or more of the following conditions: arthritis, back/neck pain, headache, chronic pain, stroke, heart attack, high blood pressure, asthma, lung disease, diabetes, ulcer, epilepsy, and cancer
welfare services in the past increased likelihood of homelessness by fourfold to fivefold, and endorsing at least one health condition increased the likelihood of homelessness by over three fold, but these associations lost significance when using the more conservative definition of homelessness. Variations in the sensitivity analysis may be a result of diminishing power, since relatively few Asians endorsed homelessness for at least 1 month (Table 3).
Discussion This study examined the mental health correlates of homelessness among Latinos and Asians, two ethnic categories that have been historically underrepresented in homeless samples. In our analysis, we found that among
123
Latinos, alcohol abuse or dependence, and impulse-control disorders were risk factors for past homelessness, while religious service attendance was a protective factor. For Asians, mood disorder, receiving welfare services, and having at least one physical health condition were all risk factors. Our results align with Greenberg and Rosenheck’s findings on lifetime substance abuse or dependence disorder in a nationally representative (primarily white) sample, though for Asians, this was only true when coding the dependent variable to signify homelessness for 1 month or more. Greenberg and Rosenheck found that lifetime impulse-control disorder diagnosis was highly predictive of past homelessness, which was also true for Latinos in our analysis, but not for Asians. The strongest predictor of past homelessness in Greenberg and Rosenheck’s study was a history of receiving welfare services (OR 5.72; 95 % CI
Community Ment Health J Table 3 Likelihood of reporting homelessness in the past Latino
Asian
More than 1 week
More than 1 month
More than 1 week
More than 1 month
OR
OR
OR
OR
95 % CI
95 % CI
95 % CI
95 % CI
Psychiatric disorders Substance abuse or dependence
1.81
.76–4.33
1.72
.73–4.05
2.68
.74–9.69
2.01
.55–7.30
Alcohol abuse or dependence
2.54*
1.12–5.77
2.71*
1.17–6.29
2.52
.63–10.06
3.86*
1.08–13.77
Anxiety disorder
1.10
.56–2.17
1.01
.51–2.01
1.01
.32–3.16
.81
.19–3.35
Mood disorder
1.34
.73–2.45
1.33
.75–2.36
3.85***
1.97–7.54
3.55**
1.75–7.21
Conduct disorder
2.74*
1.29–5.84
2.39**
1.30–4.39
1.22
.37–4.02
1.34
.39–4.53
Intermittent explosive disorder
2.54**
1.48–4.36
2.62**
1.10–5.81
.26
.04–1.66
.34
.05–2.32
1.06
.38–2.96
1.13
.39–3.29
.40
.10–1.65
.50
.12–1.97
.96
.56–1.65
1.15
.72–1.82
.58
.19–1.74
.47
.16–1.36
1.01
.59–1.73
.86
.45–1.63
.89
.32–2.47
.93
.30–2.89
.80 .80
.46–1.39 .34–1.90
.81 .66
.46–1.40 .28–1.54
.66 .72
.24–1.82 .18–2.89
.58 .70
.21–1.59 .15–3.21
Sociodemographic Variables Age [50 years Male Married High School Graduate Citizen Employed
.73
.36–1.48
.70
.39–1.26
.91
1.06
.59–1.88
1.03
.57–1.86
4.78**
Religious service attendance
0.33*
.14–.76
0.36*
.01–.07
.32
Health
1.40
.82–2.41
1.31
.70–2.47
3.46*
History of welfare use
.36–2.33
1.18
.42–3.27
1.62–14.07
3.04
.86–10.79
.04–2.76
.33
.04–2.97
1.24–9.66
2.94
.98–8.79
Other variables
Bold values indicate all OR with significance of at least p \ 0.05 Results were calculated using unconditional subpopulation analyses *** p \ 0.001; ** p \ 0.01; * p \ 0.05
3.36–9.76); however, in our study, this was only true for Asians. Our analyses differed from that of Greenberg and Rosenheck with respect to gender, as they found men to be more likely to report a history of homelessness (OR 1.77; 95 % CI 1.16–2.69), while we did not find this to be the case for either Latinos or Asians. According to our study, key sociodemographic variables (gender, marital status, education, citizenship status, and employment status) were not significant predictors of past homelessness. Furthermore, the impact of anxiety disorder and substance abuse disorder were not significant across ethnic categories. Our study suggests that religious service attendance is a protective factor for Latinos. Conceivably, Latinos may be using religion and spirituality as coping mechanisms to counteract the risk factors associated with homelessness. Additionally, past studies have used religiosity as a proxy for social capital (Chatterji et al. 2007), and so religious service attendance may indicate that Latinos possess networks of relationships at church that protect against homelessness. If this is in fact the case, future research should examine the effect of social capital on homelessness by way of material support (e.g. relying on family or friends to secure ‘doubled up’ housing arrangements) (Baker 1996), and by way of mental health status
(McCulloch 2001; McKenzie et al. 2002; Rose 2000), which both affect the likelihood of being homeless. Our study also elucidates an interesting risk factor for Latinos, which is impulse-control disorder. Both conduct and intermittent explosive disorders were highly predictive of homelessness, and currently, there is little research on why this might be true for Latinos, but not Asians. We speculate that this may have to do with the relatively lower social status of Latinos and the neighborhood effects that make Latinos vulnerable to impulse-control disorder (or vulnerable to being labeled with behavioral problems in general). Though the cross-sectional nature of the data does not allow us to make any causal claims, the diagnosis of conduct disorder presents an opportunity to infer causality since it is a clinical term that is used only to describe antisocial behavior in children and adolescents under the age of 18. The dependent variable in our analysis is homelessness after the age of 18, lending temporal support for a causal argument. History of incarceration was not included in our analysis, and may have mediated the impact of impulse-control disorders on homelessness. To our knowledge, this paper is the first to examine homeless Asian Americans in the general population. Lim et al. (2006) were the first to examine homeless Asian
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Americans using a sample of veterans, and in their study, Asians reported fewer instances of homelessness when compared to other ethnicities. Lim and colleagues speculate that the lower risk of homelessness among AsianAmericans may reflect a cultural tendency for Asians to assume the burden of caring for family members with mental illnesses (Leong and Lau 2001). Our analyses do not capture the protective effect of family caretakers, and so future studies should investigate the mitigating impact of social support on homelessness among Asians. Studies have shown that Asians delay seeking help due to stigma and thus present later in the course of illness with more severe symptoms (Lin and Cheung 1999). Future research may also check to see if this pattern of delayed helpseeking due to stigma has a specific effect on alcohol abuse/dependence and mood disorders, since these disorders in particular are highly predictive of homelessness. It is important to note that neither ‘Latino’ nor ‘Asian’ represents a monolithic group, and so future studies should explore associations between mental health and homelessness using ethnic subcategories. For example, our analyses found that a history of welfare for Asians is highly predictive of a history of homelessness. Overall, Asians were less likely than Latinos to report a history of using welfare, and so it seems that those Asians who are on welfare represent a particularly vulnerable subset of the Asian population. Prior studies have shown that Southeast Asians have higher rates of welfare utilization (Ong and Blumenberg 1994), and so an effect modification using more nuanced ethnic categories may elucidate the relationship between welfare utilization and homelessness for specific Asian groups. However, given the relative scarcity of Asian homeless individuals with a history of being on welfare, analyses using general population samples are likely to be underpowered. Several potential limitations exist in our study. In light of the relative paucity of homeless Latinos and Asians, this study utilized data from a national household survey of Latinos and Asians to identify individuals with prior histories of homelessness in the general population. The sample and study design excluded currently (and presumably more chronically) homeless individuals, and thus limited the inferences of our study to individuals who were homeless for shorter durations. Since all respondents were domiciled at the time of interview, this data reveals patterns that can only be applied to those individuals who were able to emerge out of homelessness into housing. However, this data also provided an opportunity to look at a broader definition of homelessness that includes the episodic and transient homeless (individuals who reported homelessness for weeks, months, and years). Also, undocumented immigrants were not included in the NLAAS, and their inclusion may have painted a different
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portrait of how Latinos and Asians rely on social support networks, perhaps out of reluctance to utilize social service or shelter systems. Another weakness of the study is that lifetime diagnoses and lifetime homelessness were assessed retrospectively, which can be subject to recall bias. Furthermore, while surveys were conducted in the language preferred by the respondent, problems of cultural validity were still plausible. One example is the clinical phenomenon amongst Latinos called ataques de nervios, which in English translates as ‘nervous attacks’. Studies have shown that ataques de nervios may be a cultural syndrome that signals clinical issues and disturbances that are not associated with anxiety disorders (Lewis-Fernandez et al. 2002). Future analyses may consider using ataques de nervios in addition to or instead of anxiety disorders. Also, several important diagnoses—such as bi-polar disorder, attention deficit hyperactivity disorder, and psychosis—were not measured in the NLAAS and were therefore excluded from the analysis. This is problematic since these psychiatric disorders are also correlated with homelessness, and their omission may have created bias. Lim and colleagues’ study found that Asian American veterans were more likely than white veterans to be diagnosed with schizophrenia or other psychotic disorders. As they point out, higher rates of schizophrenia in Asians may have been a result of culturally unresponsive assessments of Asians, which points to the complexities and misattributions of diagnoses in general for Latinos and Asians, calling for culturally nuanced mental health and homeless services. Future research using social network analysis can examine the unique ways in which Latinos and Asians acquire emotional, material, and instrumental support to buffer against the risk factors that cause homelessness. Conflict of interest The authors declare no conflict of interest or funding sources for this manuscript.
References Alegria, M., Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., et al. (2004). Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos. International Journal of Methods in Psychiatric Research, 13(4), 270–288. Baker, S. G. (1996). Homelessness and the Latino paradox. In J. Baumohl (Ed.), Homeless in America (pp. 132–140). Phoenix: Oryx Press. Burt, M. R. (2001). Helping America’s homeless: Emergency shelter or affordable housing? The Urban Insitute. Retrieved from http://books.google.com/books?hl=en&lr=&id=8_XzWQEhRGg C&oi=fnd&pg=PA1&dq=Burt?2001?homeless&ots=l0PMr5Gzj&sig=f1ywZ15_CbJ_NIU8dOEAY2kXd_E. Chatterji, P., Alegria, M., Lu, M., & Takeuchi, D. (2007). Psychiatric disorders and labor market outcomes: evidence from the
Community Ment Health J National Latino and Asian American Study. Health Economics, 16(10), 1069–1090. Conroy, S. J., & Heer, D. M. (2003). Hidden Hispanic homelessness in Los Angeles: The ‘‘Latino paradox’’ revisited. Hispanic Journal of Behavioral Sciences, 25(4), 530–538. Culhane, D., & Metraux, S. (1999). One-year rates of public shelter utilization by race/ethnicity, age, sex and poverty status for New York City (1990 and 1995) and Philadelphia (1995). Population Research and Policy Review, 18(3), 219–236. Greenberg, G. A., & Rosenheck, R. A. (2010). Mental health correlates of past homelessness in the National Comorbidity Study Replication. Journal of Health Care for the Poor and Underserved, 21(4), 1234–1249. Heeringa, S. G., Wagner, J., Torres, M., Duan, N., Adams, T., & Berglund, P. (2004). Sample designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies (CPES). International journal of methods in psychiatric research, 13(4), 221–240. Hopper, K. & Milburn, N. G. (1996). Homelessness among African Americans: A historical and contemporary perspective. In J. Baumohl (Ed.), Homeless in America (pp. 123-131). Phoenix: Oryx Press. Kessler, R. C., & Merikangas, K. R. (2004). The National Comorbidity Survey Replication (NCS-R): background and aims. International journal of methods in psychiatric research, 13(2), 60–68. Leong, F. T., & Lau, A. S. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3(4), 201–214. Lewis-Ferna´ndez, R., Guarnaccia, P. J., Martinez, I. E., Salma´n, E., Schmidt, A., & Liebowitz, M. (2002). Comparative phenomenology of ataques de nervios, panic attacks, and panic disorder. Culture, Medicine and Psychiatry, 26(2), 199–223.
Lim, S., Kasprow, W., & Rosenheck, R. (2006). Brief reports: Psychiatric illness and substance abuse among homeless AsianAmerican veterans. Psychiatric Services, 57(5), 704–707. Lin, K.-M., & Cheung, F. (1999). Mental health issues for Asian Americans. Psychiatric Services, 50(6), 774–780. Link, B. G., Susser, E., Stueve, A., Phelan, J., Moore, R. E., & Struening, E. (1994). Lifetime and five-year prevalence of homelessness in the United States. American Journal of Public Health, 84(12), 1907–1912. McCulloch, A. (2001). Social environments and health: cross sectional national survey. BMJ, 323(7306), 208–209. McKenzie, K., Whitley, R., & Weich, S. (2002). Social capital and mental health. The British Journal of Psychiatry, 181(4), 280–283. Ong, P. & Blumenberg, E. (1994). Welfare and work among Southeast Asians In P. Ong (Ed.), The state of Asian Pacific America. Economic Diversity, Issues & Policies. A Public Policy Report. Los Angeles: LEAP Asian Pacific American Public Policy Institute and UCLA Asian American Studies Center. Pennell, B.-E., Bowers, A., Carr, D., Chardoul, S., Cheung, G., Dinkelmann, K., et al. (2004). The development and implementation of the national comorbidity survey replication, the national survey of American life, and the national Latino and Asian American survey. International Journal of Methods in Psychiatric Research, 13(4), 241–269. Rose, R. (2000). How much does social capital add to individual health? Social Science and Medicine, 51(9), 1421–1435. Scott, J. (1993). Homelessness and mental illness. The British Journal of Psychiatry, 162(3), 314–324. Stegman, M. (1992). Housing in New York City: Results of the housing and vacancy survey. New York City: Department of Housing Preservation and Development.
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