563187 research-article2014
ANP0010.1177/0004867414563187Australian & New Zealand Journal of PsychiatrySpicer et al.
Research
Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre
Australian & New Zealand Journal of Psychiatry 2015, Vol. 49(5) 471–480 DOI: 10.1177/0004867414563187 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Bridget Spicer1, David I Smith1, Elizabeth Conroy2, Paul R Flatau3 and Lucy Burns4
Abstract Objective: The over-representation of mental illness among homeless people across the globe is well documented. However, there is a dearth of Australian literature on the mental health needs of homeless individuals. Furthermore, longitudinal research examining the factors that contribute to better housing outcomes among this population is sparse. The aim of this research is to describe the mental illness profile of a sample of homeless men in an Australian urban centre (in Sydney) and examine the factors associated with better housing outcomes at 12-month follow-up. Methods: A longitudinal survey was administered to 253 homeless men who were involved in the Michael Project: a 3-year initiative which combined existing accommodation support services with assertive case management and access to coordinated additional specialist allied health and support services. A total of 107 participants were followed up 12 months later. The survey examined the demographics of the sample and lifetime mental disorder diagnoses, and also included psychological screeners for current substance use and dependence, psychological distress, psychosis, and posttraumatic stress. Results: Consistent with existing literature, the prevalence of mental illness was significantly greater amongst this sample than the general Australian population. However, mental illness presentation was not associated with housing situation at 12-month follow-up. Instead, type of support service at baseline was the best predictor of housing outcome, wherein participants who received short to medium-term accommodation and support were significantly more likely to be housed in stable, long-term housing at the 12-month follow-up than participants who received outreach or emergency accommodation support. Conclusions: This study provides evidence to support an innovative support model for homeless people in Australia and contributes to the limited Australian research on mental illness in this population. Keywords homeless, housing, mental illness, prevalence, substance use
Introduction Mental illness is one of many potential pathways into homelessness (Rota-Bartelink and Lipmann, 2007; Shelton et al., 2009), and its prevalence among the homeless population is an ever-growing concern (Toro et al., 2007). However, the task of measuring the prevalence of mental illness in homeless populations is inherently difficult, not least because of the transient lifestyle of many people experiencing homelessness. Prevalence estimates are also dependent on factors related to measurement, including how narrow or broadly the population is defined (Minnery and Greenhalgh, 2007), and the specific disorders included
1School
of Health Sciences, RMIT University, Bundoora, Australia 2Centre for Health Research, University of Western Sydney, Penrith, Australia 3Centre for Social Impact, University of Western Australia, Crawley, Australia 4National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia Corresponding author: Elizabeth Conroy, Centre for Health Research, University of Western Sydney (UWS), Locked Bag 1797, Penrith, NSW 2751, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 49(5)
472 (Fazel et al., 2008). Large discrepancies between estimates of mental illness in this population reflect these and other methodological differences. Additionally, the presence of psychopathology in an individual who is enduring extreme social exclusion and physical deprivation will also affect the estimate made (Daiski, 2007). When considering the relationship between mental illness and homelessness, there are two distinct approaches that may be taken. First, one may consider the prevalence of homelessness in the mentally ill population (for example, Holmes et al., 2005; Jablensky et al., 2000). The second approach considers the prevalence of mental illness in the homeless population. This paper takes the latter approach. A meta-analysis of prevalence studies conducted across seven western countries, including Australia, found that alcohol and drug dependence were the most common mental disorders observed among people experiencing homelessness, with prevalence estimates of 38% and 24%, respectively (Fazel et al., 2008). Personality disorder was the next most common mental disorder (23%), followed by psychotic illness (13%), and major depression (11%). In spite of establishing strict criteria for study selection using a systematic review approach, there was a high level of heterogeneity in prevalence estimates between studies resulting from diversity in the study populations and differences in methods adopted to measure prevalence. Research conducted in Germany observed marked dissimilarities between a representative sample of 265 homeless men and an age-matched comparison group on the prevalence of mental disorders outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Overall, 93% of the homeless men had at least one lifetime DSM-IV axis I diagnosis, compared to only 38% of the community controls (Fichter and Quadflieg, 2001). Specifically, a large proportion of the homeless men met criteria for a mood disorder (33% vs 3% control), anxiety disorder (16% vs 6% control), and psychotic disorder (10% vs 0.6% control). A 3-year follow-up of the participants indicated that there was a marked improvement in housing situation (Fichter and Quadflieg, 2005). Furthermore, rates of mental illness reduced from 79% to 66%, which the authors contend may be a consequence of improved housing and increased medical/psychiatric support. Interestingly, mental health status at baseline did not predict housing situation at follow-up. Only a few Australian studies have been carried out. A review of 4252 case files of clients accessing a specialist homelessness service in Melbourne found that 30% of the sample had mental health issues (Chamberlain et al., 2007). However, this figure is likely to be an underestimate given that individuals accessing homelessness support may not be forthcoming about mental illness (including substance use issues), or may have never been adequately assessed for mental illness by a mental health professional. In another Australian & New Zealand Journal of Psychiatry, 49(5)
ANZJP Articles study, which conducted structured clinical interviews with 210 randomly selected homeless individuals in Sydney, 73% of men and 81% of women met criteria for at least one mental disorder (Teesson et al., 2004). Specifically, a large proportion met criteria for alcohol dependence/abuse (men=49%; women=15%), drug dependence/abuse (men=34%; women=44%), mood disorder (men=28%; women=48%), anxiety disorder (men=22%; women=36%), and schizophrenia (men=23%; women=46%). All rates were substantially higher than the general Australian population. Moreover, over 90% of 119 men and all 38 women interviewed had experienced at least one traumatic event in their lifetime (Buhrich et al., 2000). In contrast, only 57% of the general Australian population report one major traumatic event in their life (O’Donnell et al., 2012). Given the over-representation of trauma experiences in homeless populations, it is perhaps not surprising that both the lifetime and 12-month prevalence rates for post-traumatic stress disorder (PTSD) amongst another sample of adults experiencing homelessness in Sydney were found to be high: 79% and 41%, respectively (Taylor and Sharpe, 2008). In another study, among a representative sample of men and women living in marginal housing in Melbourne (which excluded participants who were sleeping rough), the estimated prevalence for lifetime psychotic disorders was also found to be high at 42% (Herrman et al., 2004). In line with the significant social and physical deprivation associated with homelessness, psychological distress has also been found to be higher in this group than in the general population. Research conducted in the USA found distress symptoms to be most pervasive and persistent among homeless individuals who had a severe mental illness (Wong, 2002). Specifically, 90% of participants with a severe mental disorder were classified as experiencing psychological distress, while 61% of participants who were substance dependent and 54% of participants with no diagnosis were classified as experiencing psychological distress. High rates of comorbid mental illness, substance abuse, physical disorders, and cognitive impairment have been observed in this population, with prevalence estimates of comorbidity ranging from 2% to 34% of the homeless population (Drake et al., 1991; Spence et al., 2004). This pattern of multiple complex health concerns exacerbates the burden of disability and is linked to poorer treatment outcomes (Compton III et al., 2003). In turn, the provision of services to individuals with this type of comorbidity has been identified as one of the most pressing issues in the mental health field (Drake, 2007; Lee et al., 2012). However, the complexity and diversity within the homeless population presents a challenge for developing effective services appropriate to the needs of individuals within this population (Chamberlain et al., 2007). There are few published Australian studies that document the specific mental health needs of the local homeless
473
Spicer et al. population, and even fewer longitudinal studies that examine the long-term mental health and housing outcomes of homeless individuals with a mental illness. The absence of a rich evidence base ultimately impacts on the development of appropriate policy and interventions in the homelessness service sector. Thus, the first aim of this paper is to describe an Australian sample of homeless individuals and document the mental health needs of this group. The second aim is to examine whether mental health impacts on the achievement of stable, long-term housing at 12-month follow-up. Lastly, this paper will investigate whether the achievement of stable housing has any impact on participants’ mental health.
Method Design1 The study used a longitudinal design and surveyed participants at entry to support (W1) and at 3 (W2) and 12 months (W3) post-baseline. Only data from W1 and W3 is used in the present study. This research derives from a broader study that explored the effectiveness and cost-effectiveness of the Michael Project (MP), a 3-year initiative (2007– 2010) working with homeless men in Sydney. The MP was run by Mission Australia (MA), a non-denominational Christian community service organisation, and funded philanthropically. The MP was a unique model of support designed around the principles of client-centered care and integrated service delivery. It combined existing accommodation support services offered by MA with assertive case management (ACM), and access to a suite of additional specialist allied health and support services. Specifically, prior to the introduction of the MP, MA already provided seven homelessness services around Sydney, including: a mobile outreach service to homeless people on the streets; an overnight crisis accommodation service; three short-term accommodation services providing accommodation for up to 3 months; a medium-term accommodation service providing somewhat longer support; and a transitional housing service. The suite of specialist services was wrapped around these existing homelessness services to form the MP. The specialist services included: an alcohol and other drug (AOD) counsellor, a psychologist, an occupational therapist, dental health services, a podiatrist, an outreach nurse, an Indigenous outreach worker, a recreational officer, a barber, a computer tutor, and a literacy and numeracy tutor. While the MP assisted clients to find housing as part of case management goals, the model itself did not provide housing. The ACM approach drew on evidence-based practice from the assertive community treatment model, and particularly focused on being persistent and active, following clients’ selfdirected priorities and timing, respecting clients’ autonomy, and nurturing trust (Lee et al., 2010; Rosen et al., 2007).
Clients across all services were linked into the specialist services through the ACM approach, in which all caseworkers were trained.
Participants Given this study was part of a larger service-based program evaluation, two slightly different recruitment methods were used based on the duration of support provided by the different services involved. In the short–medium-term accommodation services (‘short-medium sample’), the client survey was undertaken by caseworkers as part of the assessment and case management process. Thus there was an expectation that all clients were approached. At the time of data collection there was no centralised service database and consequently the participation rate among all clients could not be verified, nor could the profile of participants and non-participants be compared. However, periodic visits to the services by the research team during the recruitment phase did not reveal any problems in the uptake of the research or in the confidence of caseworkers to undertake the client survey. There was less capacity to undertake the client survey with every client that accessed the outreach and emergency accommodation services (‘outreach/emergency sample’) as the nature of these services meant the duration of contact with clients was relatively short. Thus only every second client was approached to participate in the research. An attempt was made to record which clients were approached using the existing service contact record sheets; however, this information was not reliably collected. The MP participants were male clients of MA, aged 18 years and over. In total, 253 men participated: 156 in the short-medium sample and 97 in the outreach/emergency sample. All participants were experiencing primary homelessness (without conventional accommodation, such as sleeping rough) or secondary homelessness (in transient accommodation, including supported accommodation) when they were first interviewed. Individuals were ineligible to participate if they were intoxicated, if they were not oriented to time and place (Mini Mental State Examination; Folstein et al., 1975), or if their English level was very poor. Examination of participants recruited via the different pathways revealed that there were several significant differences between the short-medium sample and the outreach/emergency sample at W1. Compared to the short-medium sample, the outreach/emergency sample had a significantly higher proportion of Indigenous participants (13.8% vs 6.0%, p=0.036), was significantly less likely to have completed a post-school qualification (37.2% vs 52.4%, p=0.022), but more likely to be employed (12.4% vs 4.5%, p=0.022) and to meet criteria for current drug dependence (40.9% vs 23.5%, p=0.004). Regarding the high number of Indigenous participants in the outreach/ emergency sample, there was an Indigenous outreach Australian & New Zealand Journal of Psychiatry, 49(5)
474 worker employed as part of the outreach team, specifically to address the low access to MA’s accommodation services in this population. The Indigenous outreach worker contributed to the recruitment and administration of the baseline survey and, as such, the higher number of Indigenous participants in the outreach/emergency sample relative to the short-medium sample was attributed to this. At the 12-month follow-up, 42.3% of participants (n=107) were successfully followed up and re-interviewed: 47.4% (n=74) of participants from the short-medium sample, and 34.0% (n=33) of participants from the outreach/ emergency sample. Comparison of the total follow-up sample to the original W1 sample revealed no significant differences on any of the variables investigated in this paper.
Materials The MP client survey collected information on the backgrounds, needs, and outcomes of homeless men receiving support through MA’s Sydney services. The survey incorporated an extensive range of questions and instruments related to homelessness history, mental health, quality of life, service utilisation, and criminal justice contact. The survey took approximately 60–90 minutes to administer. A shorter version of the survey, which took approximately 45–60 minutes to administer, was administered to the outreach/emergency sample. This decision addressed the ethical concerns of undertaking a lengthy survey with clients in highly tenuous accommodation circumstances, and because the outreach/emergency services had a short duration of contact with clients. The current study utilised an array of mental health and housing measures, as follows. •• Psychological distress was measured using the 10-item Kessler Psychological Distress Scale (K10; Kessler et al., 2003). The K10 is a validated instrument and has Australian normative data (Slade et al., 2011). •• Self-reported mental disorder diagnoses were measured by a single question that asked participants whether they had ever been diagnosed by a medical practitioner or psychologist as experiencing any of the following mental disorders: mood disorder, anxiety disorder, personality disorder, psychotic disorder, dissociative disorder, substance use disorder, eating disorder, or impulse-control disorder. •• Substance dependence was assessed for all substances used in the previous month using the 5-item Severity of Dependence Scale (SDS). The scale has been shown to have good psychometric properties and has been used to assess dependence on different classes of drugs and alcohol (Gossop et al., 1997). Based on the research literature, different cut-off scores were used for each substance (for example, Australian & New Zealand Journal of Psychiatry, 49(5)
ANZJP Articles Cuevas et al., 2000; Kaye and Darke, 2002; Lawrinson et al., 2007; Topp and Mattick, 1997). This information was then categorised into two variables: alcohol dependence and drug dependence. •• Traumatic stress response (past month) was measured using the 17-item PTSD Checklist–Civilian Version (PCL-C; Weathers et al., 1993). The PCL-C has demonstrated strong psychometric properties (Ruggiero et al., 2003). Participants were given the option to self-complete this measure. •• Psychosis was measured using the 10-item Psychosis Screener (PS; Degenhardt et al., 2005), developed specifically for the National Survey of Mental Health and Wellbeing (NSMHW), which ascertains lifetime and 12-month prevalence of psychosis. The measure is reported to have moderate sensitivity and specificity. •• Information on housing and homelessness was collected via a series of questions regarding current and past year accommodation circumstances. Housing outcome was collapsed into a binary variable – housed or not housed in stable, long-term housing. Stable, long-term housing was defined as any option under the long-term tenure category, which included: purchasing/purchased own dwelling, private rental, public housing rental, and long-term community housing accommodation. The shorter survey used with the outreach/emergency sample did not include the traumatic stress response or psychosis measures.
Procedure The baseline client survey was administered by caseworkers to new MA clients at the start of their support period, or as soon as appropriate given the client’s needs. To assist with the slow recruitment from the outreach/emergency services, research officers conducted approximately half of the baseline surveys in this sample. All participants were provided with a Participant Information Statement and provided written consent to complete the surveys and to be contacted for the follow-up surveys. Participants were readministered the survey at 3 and 12 months by a trained research interviewer. Participants were reimbursed in vouchers for each survey attempted, whether or not the survey was completed.
Data analysis Data were analysed using the statistical software package SPSS (Version 21; IBM Corp., 2012). Analysis of variance (ANOVA) was used for analyses involving continuous outcome variables, while a combination of chi-squared and binary logistic regression analyses were used for
475
Spicer et al. categorical outcome variables. McNemar’s test was used to assess changes over time on dichotomous variables for the housed and non-housed groups. In all multivariate regression analyses, Indigenous status was included as a covariate as Indigenous people are more likely to experience homelessness than other Australians (MacKenzie and Chamberlain, 2008). In addition, age was included to control for greater potential exposure to homelessness. Furthermore, research suggests that older age is associated with greater housing success among homeless people with a mental illness (Lipton et al., 2000).
Health service utilisation
Results Demographics
Housing and mental illness at the 12-month follow-up
Table 1 presents the demographic and mental illness profile of participants at W1. Participants ranged in age from 19 to 82 years (mean: 41 years). Of the 253 participants, one in 11 (9%) identified as Aboriginal and/or Torres Strait Islander, almost half (46%) had completed a post-school qualification, and one in 13 (8%) were employed at the time of the baseline survey. The mean age that participants had first slept rough was 28 years; however, this ranged from 5 to 60 years.
To compare participants accommodated in stable, longterm housing at the 12-month follow-up (n=48) to those not accommodated in stable housing (n=59), ANOVA and chisquared analyses were conducted for continuous and categorical variables, respectively (Table 2). Overall, the two groups did not differ significantly on any of the reported demographics. Type of support service provided at baseline was found to be associated with housing status at W3, wherein participants recruited through the short-medium services were significantly more likely to be in stable housing at the 12-month follow-up than those recruited through the outreach/emergency services. Specifically, 52% of participants in the short-medium sample were stably housed at follow-up, compared to 27% of participants in the outreach/ emergency sample. In addition, participants who met criteria for drug dependence at baseline were significantly less likely to be housed at follow-up. There were no other significant differences between the housed and non-housed groups in regard to mental illness at the univariate level. Examination of the service utilisation data also indicated that there was no significant difference between the groups in terms of number of contacts with the MP psychologist or AOD counsellor.
Mental health Almost three-quarters (71%) of participants reported being diagnosed by a mental health practitioner with one or more mental disorders over their lifetime. Specifically, one in four (25%) reported one mental disorder, one in five (21%) reported having two mental disorders, and one in four (26%) reported having three or more mental disorders. Among those who had been diagnosed with a mental disorder, the average number of disorders was 2.3 (range: 1–9 diagnoses). Substance use disorder was the most commonly reported mental disorder (51%). Anxiety (34%) and mood (33%) disorders were the next most commonly reported mental disorders. Results on the K10 indicated that half of the participants were experiencing high (27%) or very high (22%) levels of psychological distress, with the mean score falling within the moderate range. Based on responses on the SDS and recent substance use, at the time of the W1 interview, almost one in three participants met criteria for drug dependence and alcohol dependence in the last month, respectively. Further analysis indicated that poly-substance dependence was common: half (50%) of the participants who were alcohol dependent were also drug dependent. Among participants who completed the full version of the survey, one in five (20%) screened positive for PTSD in the last month, and one in 10 (11%) screened positive for having experienced psychosis in the last 12 months.
Among all participants, one in nine (11%) had accessed the AOD counsellor through the MP. Of those who accessed this service, the median number of contacts was two (range: 1–14). Similarly, one in nine (11%) participants had accessed the MP psychologist. Of those who had accessed this service, the median number of contacts was 2.5 (range: 1–27). One in 17 (6%) participants had accessed both the AOD counsellor and psychologist at least once. There was a significant correlation between number of contacts with the AOD counsellor and number of contacts with the psychologist (r=0.261, p
ANP0010.1177/0004867414563187Australian & New Zealand Journal of PsychiatrySpicer et al.
Research
Mental illness and housing outcomes among a sample of homeless men in an Australian urban centre
Australian & New Zealand Journal of Psychiatry 2015, Vol. 49(5) 471–480 DOI: 10.1177/0004867414563187 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Bridget Spicer1, David I Smith1, Elizabeth Conroy2, Paul R Flatau3 and Lucy Burns4
Abstract Objective: The over-representation of mental illness among homeless people across the globe is well documented. However, there is a dearth of Australian literature on the mental health needs of homeless individuals. Furthermore, longitudinal research examining the factors that contribute to better housing outcomes among this population is sparse. The aim of this research is to describe the mental illness profile of a sample of homeless men in an Australian urban centre (in Sydney) and examine the factors associated with better housing outcomes at 12-month follow-up. Methods: A longitudinal survey was administered to 253 homeless men who were involved in the Michael Project: a 3-year initiative which combined existing accommodation support services with assertive case management and access to coordinated additional specialist allied health and support services. A total of 107 participants were followed up 12 months later. The survey examined the demographics of the sample and lifetime mental disorder diagnoses, and also included psychological screeners for current substance use and dependence, psychological distress, psychosis, and posttraumatic stress. Results: Consistent with existing literature, the prevalence of mental illness was significantly greater amongst this sample than the general Australian population. However, mental illness presentation was not associated with housing situation at 12-month follow-up. Instead, type of support service at baseline was the best predictor of housing outcome, wherein participants who received short to medium-term accommodation and support were significantly more likely to be housed in stable, long-term housing at the 12-month follow-up than participants who received outreach or emergency accommodation support. Conclusions: This study provides evidence to support an innovative support model for homeless people in Australia and contributes to the limited Australian research on mental illness in this population. Keywords homeless, housing, mental illness, prevalence, substance use
Introduction Mental illness is one of many potential pathways into homelessness (Rota-Bartelink and Lipmann, 2007; Shelton et al., 2009), and its prevalence among the homeless population is an ever-growing concern (Toro et al., 2007). However, the task of measuring the prevalence of mental illness in homeless populations is inherently difficult, not least because of the transient lifestyle of many people experiencing homelessness. Prevalence estimates are also dependent on factors related to measurement, including how narrow or broadly the population is defined (Minnery and Greenhalgh, 2007), and the specific disorders included
1School
of Health Sciences, RMIT University, Bundoora, Australia 2Centre for Health Research, University of Western Sydney, Penrith, Australia 3Centre for Social Impact, University of Western Australia, Crawley, Australia 4National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia Corresponding author: Elizabeth Conroy, Centre for Health Research, University of Western Sydney (UWS), Locked Bag 1797, Penrith, NSW 2751, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry, 49(5)
472 (Fazel et al., 2008). Large discrepancies between estimates of mental illness in this population reflect these and other methodological differences. Additionally, the presence of psychopathology in an individual who is enduring extreme social exclusion and physical deprivation will also affect the estimate made (Daiski, 2007). When considering the relationship between mental illness and homelessness, there are two distinct approaches that may be taken. First, one may consider the prevalence of homelessness in the mentally ill population (for example, Holmes et al., 2005; Jablensky et al., 2000). The second approach considers the prevalence of mental illness in the homeless population. This paper takes the latter approach. A meta-analysis of prevalence studies conducted across seven western countries, including Australia, found that alcohol and drug dependence were the most common mental disorders observed among people experiencing homelessness, with prevalence estimates of 38% and 24%, respectively (Fazel et al., 2008). Personality disorder was the next most common mental disorder (23%), followed by psychotic illness (13%), and major depression (11%). In spite of establishing strict criteria for study selection using a systematic review approach, there was a high level of heterogeneity in prevalence estimates between studies resulting from diversity in the study populations and differences in methods adopted to measure prevalence. Research conducted in Germany observed marked dissimilarities between a representative sample of 265 homeless men and an age-matched comparison group on the prevalence of mental disorders outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Overall, 93% of the homeless men had at least one lifetime DSM-IV axis I diagnosis, compared to only 38% of the community controls (Fichter and Quadflieg, 2001). Specifically, a large proportion of the homeless men met criteria for a mood disorder (33% vs 3% control), anxiety disorder (16% vs 6% control), and psychotic disorder (10% vs 0.6% control). A 3-year follow-up of the participants indicated that there was a marked improvement in housing situation (Fichter and Quadflieg, 2005). Furthermore, rates of mental illness reduced from 79% to 66%, which the authors contend may be a consequence of improved housing and increased medical/psychiatric support. Interestingly, mental health status at baseline did not predict housing situation at follow-up. Only a few Australian studies have been carried out. A review of 4252 case files of clients accessing a specialist homelessness service in Melbourne found that 30% of the sample had mental health issues (Chamberlain et al., 2007). However, this figure is likely to be an underestimate given that individuals accessing homelessness support may not be forthcoming about mental illness (including substance use issues), or may have never been adequately assessed for mental illness by a mental health professional. In another Australian & New Zealand Journal of Psychiatry, 49(5)
ANZJP Articles study, which conducted structured clinical interviews with 210 randomly selected homeless individuals in Sydney, 73% of men and 81% of women met criteria for at least one mental disorder (Teesson et al., 2004). Specifically, a large proportion met criteria for alcohol dependence/abuse (men=49%; women=15%), drug dependence/abuse (men=34%; women=44%), mood disorder (men=28%; women=48%), anxiety disorder (men=22%; women=36%), and schizophrenia (men=23%; women=46%). All rates were substantially higher than the general Australian population. Moreover, over 90% of 119 men and all 38 women interviewed had experienced at least one traumatic event in their lifetime (Buhrich et al., 2000). In contrast, only 57% of the general Australian population report one major traumatic event in their life (O’Donnell et al., 2012). Given the over-representation of trauma experiences in homeless populations, it is perhaps not surprising that both the lifetime and 12-month prevalence rates for post-traumatic stress disorder (PTSD) amongst another sample of adults experiencing homelessness in Sydney were found to be high: 79% and 41%, respectively (Taylor and Sharpe, 2008). In another study, among a representative sample of men and women living in marginal housing in Melbourne (which excluded participants who were sleeping rough), the estimated prevalence for lifetime psychotic disorders was also found to be high at 42% (Herrman et al., 2004). In line with the significant social and physical deprivation associated with homelessness, psychological distress has also been found to be higher in this group than in the general population. Research conducted in the USA found distress symptoms to be most pervasive and persistent among homeless individuals who had a severe mental illness (Wong, 2002). Specifically, 90% of participants with a severe mental disorder were classified as experiencing psychological distress, while 61% of participants who were substance dependent and 54% of participants with no diagnosis were classified as experiencing psychological distress. High rates of comorbid mental illness, substance abuse, physical disorders, and cognitive impairment have been observed in this population, with prevalence estimates of comorbidity ranging from 2% to 34% of the homeless population (Drake et al., 1991; Spence et al., 2004). This pattern of multiple complex health concerns exacerbates the burden of disability and is linked to poorer treatment outcomes (Compton III et al., 2003). In turn, the provision of services to individuals with this type of comorbidity has been identified as one of the most pressing issues in the mental health field (Drake, 2007; Lee et al., 2012). However, the complexity and diversity within the homeless population presents a challenge for developing effective services appropriate to the needs of individuals within this population (Chamberlain et al., 2007). There are few published Australian studies that document the specific mental health needs of the local homeless
473
Spicer et al. population, and even fewer longitudinal studies that examine the long-term mental health and housing outcomes of homeless individuals with a mental illness. The absence of a rich evidence base ultimately impacts on the development of appropriate policy and interventions in the homelessness service sector. Thus, the first aim of this paper is to describe an Australian sample of homeless individuals and document the mental health needs of this group. The second aim is to examine whether mental health impacts on the achievement of stable, long-term housing at 12-month follow-up. Lastly, this paper will investigate whether the achievement of stable housing has any impact on participants’ mental health.
Method Design1 The study used a longitudinal design and surveyed participants at entry to support (W1) and at 3 (W2) and 12 months (W3) post-baseline. Only data from W1 and W3 is used in the present study. This research derives from a broader study that explored the effectiveness and cost-effectiveness of the Michael Project (MP), a 3-year initiative (2007– 2010) working with homeless men in Sydney. The MP was run by Mission Australia (MA), a non-denominational Christian community service organisation, and funded philanthropically. The MP was a unique model of support designed around the principles of client-centered care and integrated service delivery. It combined existing accommodation support services offered by MA with assertive case management (ACM), and access to a suite of additional specialist allied health and support services. Specifically, prior to the introduction of the MP, MA already provided seven homelessness services around Sydney, including: a mobile outreach service to homeless people on the streets; an overnight crisis accommodation service; three short-term accommodation services providing accommodation for up to 3 months; a medium-term accommodation service providing somewhat longer support; and a transitional housing service. The suite of specialist services was wrapped around these existing homelessness services to form the MP. The specialist services included: an alcohol and other drug (AOD) counsellor, a psychologist, an occupational therapist, dental health services, a podiatrist, an outreach nurse, an Indigenous outreach worker, a recreational officer, a barber, a computer tutor, and a literacy and numeracy tutor. While the MP assisted clients to find housing as part of case management goals, the model itself did not provide housing. The ACM approach drew on evidence-based practice from the assertive community treatment model, and particularly focused on being persistent and active, following clients’ selfdirected priorities and timing, respecting clients’ autonomy, and nurturing trust (Lee et al., 2010; Rosen et al., 2007).
Clients across all services were linked into the specialist services through the ACM approach, in which all caseworkers were trained.
Participants Given this study was part of a larger service-based program evaluation, two slightly different recruitment methods were used based on the duration of support provided by the different services involved. In the short–medium-term accommodation services (‘short-medium sample’), the client survey was undertaken by caseworkers as part of the assessment and case management process. Thus there was an expectation that all clients were approached. At the time of data collection there was no centralised service database and consequently the participation rate among all clients could not be verified, nor could the profile of participants and non-participants be compared. However, periodic visits to the services by the research team during the recruitment phase did not reveal any problems in the uptake of the research or in the confidence of caseworkers to undertake the client survey. There was less capacity to undertake the client survey with every client that accessed the outreach and emergency accommodation services (‘outreach/emergency sample’) as the nature of these services meant the duration of contact with clients was relatively short. Thus only every second client was approached to participate in the research. An attempt was made to record which clients were approached using the existing service contact record sheets; however, this information was not reliably collected. The MP participants were male clients of MA, aged 18 years and over. In total, 253 men participated: 156 in the short-medium sample and 97 in the outreach/emergency sample. All participants were experiencing primary homelessness (without conventional accommodation, such as sleeping rough) or secondary homelessness (in transient accommodation, including supported accommodation) when they were first interviewed. Individuals were ineligible to participate if they were intoxicated, if they were not oriented to time and place (Mini Mental State Examination; Folstein et al., 1975), or if their English level was very poor. Examination of participants recruited via the different pathways revealed that there were several significant differences between the short-medium sample and the outreach/emergency sample at W1. Compared to the short-medium sample, the outreach/emergency sample had a significantly higher proportion of Indigenous participants (13.8% vs 6.0%, p=0.036), was significantly less likely to have completed a post-school qualification (37.2% vs 52.4%, p=0.022), but more likely to be employed (12.4% vs 4.5%, p=0.022) and to meet criteria for current drug dependence (40.9% vs 23.5%, p=0.004). Regarding the high number of Indigenous participants in the outreach/ emergency sample, there was an Indigenous outreach Australian & New Zealand Journal of Psychiatry, 49(5)
474 worker employed as part of the outreach team, specifically to address the low access to MA’s accommodation services in this population. The Indigenous outreach worker contributed to the recruitment and administration of the baseline survey and, as such, the higher number of Indigenous participants in the outreach/emergency sample relative to the short-medium sample was attributed to this. At the 12-month follow-up, 42.3% of participants (n=107) were successfully followed up and re-interviewed: 47.4% (n=74) of participants from the short-medium sample, and 34.0% (n=33) of participants from the outreach/ emergency sample. Comparison of the total follow-up sample to the original W1 sample revealed no significant differences on any of the variables investigated in this paper.
Materials The MP client survey collected information on the backgrounds, needs, and outcomes of homeless men receiving support through MA’s Sydney services. The survey incorporated an extensive range of questions and instruments related to homelessness history, mental health, quality of life, service utilisation, and criminal justice contact. The survey took approximately 60–90 minutes to administer. A shorter version of the survey, which took approximately 45–60 minutes to administer, was administered to the outreach/emergency sample. This decision addressed the ethical concerns of undertaking a lengthy survey with clients in highly tenuous accommodation circumstances, and because the outreach/emergency services had a short duration of contact with clients. The current study utilised an array of mental health and housing measures, as follows. •• Psychological distress was measured using the 10-item Kessler Psychological Distress Scale (K10; Kessler et al., 2003). The K10 is a validated instrument and has Australian normative data (Slade et al., 2011). •• Self-reported mental disorder diagnoses were measured by a single question that asked participants whether they had ever been diagnosed by a medical practitioner or psychologist as experiencing any of the following mental disorders: mood disorder, anxiety disorder, personality disorder, psychotic disorder, dissociative disorder, substance use disorder, eating disorder, or impulse-control disorder. •• Substance dependence was assessed for all substances used in the previous month using the 5-item Severity of Dependence Scale (SDS). The scale has been shown to have good psychometric properties and has been used to assess dependence on different classes of drugs and alcohol (Gossop et al., 1997). Based on the research literature, different cut-off scores were used for each substance (for example, Australian & New Zealand Journal of Psychiatry, 49(5)
ANZJP Articles Cuevas et al., 2000; Kaye and Darke, 2002; Lawrinson et al., 2007; Topp and Mattick, 1997). This information was then categorised into two variables: alcohol dependence and drug dependence. •• Traumatic stress response (past month) was measured using the 17-item PTSD Checklist–Civilian Version (PCL-C; Weathers et al., 1993). The PCL-C has demonstrated strong psychometric properties (Ruggiero et al., 2003). Participants were given the option to self-complete this measure. •• Psychosis was measured using the 10-item Psychosis Screener (PS; Degenhardt et al., 2005), developed specifically for the National Survey of Mental Health and Wellbeing (NSMHW), which ascertains lifetime and 12-month prevalence of psychosis. The measure is reported to have moderate sensitivity and specificity. •• Information on housing and homelessness was collected via a series of questions regarding current and past year accommodation circumstances. Housing outcome was collapsed into a binary variable – housed or not housed in stable, long-term housing. Stable, long-term housing was defined as any option under the long-term tenure category, which included: purchasing/purchased own dwelling, private rental, public housing rental, and long-term community housing accommodation. The shorter survey used with the outreach/emergency sample did not include the traumatic stress response or psychosis measures.
Procedure The baseline client survey was administered by caseworkers to new MA clients at the start of their support period, or as soon as appropriate given the client’s needs. To assist with the slow recruitment from the outreach/emergency services, research officers conducted approximately half of the baseline surveys in this sample. All participants were provided with a Participant Information Statement and provided written consent to complete the surveys and to be contacted for the follow-up surveys. Participants were readministered the survey at 3 and 12 months by a trained research interviewer. Participants were reimbursed in vouchers for each survey attempted, whether or not the survey was completed.
Data analysis Data were analysed using the statistical software package SPSS (Version 21; IBM Corp., 2012). Analysis of variance (ANOVA) was used for analyses involving continuous outcome variables, while a combination of chi-squared and binary logistic regression analyses were used for
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Spicer et al. categorical outcome variables. McNemar’s test was used to assess changes over time on dichotomous variables for the housed and non-housed groups. In all multivariate regression analyses, Indigenous status was included as a covariate as Indigenous people are more likely to experience homelessness than other Australians (MacKenzie and Chamberlain, 2008). In addition, age was included to control for greater potential exposure to homelessness. Furthermore, research suggests that older age is associated with greater housing success among homeless people with a mental illness (Lipton et al., 2000).
Health service utilisation
Results Demographics
Housing and mental illness at the 12-month follow-up
Table 1 presents the demographic and mental illness profile of participants at W1. Participants ranged in age from 19 to 82 years (mean: 41 years). Of the 253 participants, one in 11 (9%) identified as Aboriginal and/or Torres Strait Islander, almost half (46%) had completed a post-school qualification, and one in 13 (8%) were employed at the time of the baseline survey. The mean age that participants had first slept rough was 28 years; however, this ranged from 5 to 60 years.
To compare participants accommodated in stable, longterm housing at the 12-month follow-up (n=48) to those not accommodated in stable housing (n=59), ANOVA and chisquared analyses were conducted for continuous and categorical variables, respectively (Table 2). Overall, the two groups did not differ significantly on any of the reported demographics. Type of support service provided at baseline was found to be associated with housing status at W3, wherein participants recruited through the short-medium services were significantly more likely to be in stable housing at the 12-month follow-up than those recruited through the outreach/emergency services. Specifically, 52% of participants in the short-medium sample were stably housed at follow-up, compared to 27% of participants in the outreach/ emergency sample. In addition, participants who met criteria for drug dependence at baseline were significantly less likely to be housed at follow-up. There were no other significant differences between the housed and non-housed groups in regard to mental illness at the univariate level. Examination of the service utilisation data also indicated that there was no significant difference between the groups in terms of number of contacts with the MP psychologist or AOD counsellor.
Mental health Almost three-quarters (71%) of participants reported being diagnosed by a mental health practitioner with one or more mental disorders over their lifetime. Specifically, one in four (25%) reported one mental disorder, one in five (21%) reported having two mental disorders, and one in four (26%) reported having three or more mental disorders. Among those who had been diagnosed with a mental disorder, the average number of disorders was 2.3 (range: 1–9 diagnoses). Substance use disorder was the most commonly reported mental disorder (51%). Anxiety (34%) and mood (33%) disorders were the next most commonly reported mental disorders. Results on the K10 indicated that half of the participants were experiencing high (27%) or very high (22%) levels of psychological distress, with the mean score falling within the moderate range. Based on responses on the SDS and recent substance use, at the time of the W1 interview, almost one in three participants met criteria for drug dependence and alcohol dependence in the last month, respectively. Further analysis indicated that poly-substance dependence was common: half (50%) of the participants who were alcohol dependent were also drug dependent. Among participants who completed the full version of the survey, one in five (20%) screened positive for PTSD in the last month, and one in 10 (11%) screened positive for having experienced psychosis in the last 12 months.
Among all participants, one in nine (11%) had accessed the AOD counsellor through the MP. Of those who accessed this service, the median number of contacts was two (range: 1–14). Similarly, one in nine (11%) participants had accessed the MP psychologist. Of those who had accessed this service, the median number of contacts was 2.5 (range: 1–27). One in 17 (6%) participants had accessed both the AOD counsellor and psychologist at least once. There was a significant correlation between number of contacts with the AOD counsellor and number of contacts with the psychologist (r=0.261, p
