Mental Illness and Substance Use Problems in Relation to Homelessness Onset Sarah Childress; Lorraine R. Reitzel, PhD; Diane Santa Maria, DrPH, MSN, RN; Darla E. Kendzor, PhD; Alexis Moisiuc; Michael S. Businelle, PhD Objectives: The relationships among youth (24 years) homelessness onset, lifetime serious mental illness, and substance use problems is not well understood. We sought to explore these associations among 394 homeless adults, 124 of whom reported youth-onset homelessness. Methods: Covariate-adjusted logistic regression analyses evaluated the associations among homelessness onset, serious mental illness, and self-reported substance use problems. Results: Youth-onset homelessness was associated with greater likelihood of serious mental illness and sedative problems, and a lower
Y
outh-onset homelessness is a growing problem in the United States that is associated with a number of negative economic, cognitive, psychological, and social consequences.1 In 2013, the Department of Housing and Urban Development (HUD) called for communities to include unaccompanied homeless children and youth in point-in-time counts to enumerate this group more accurately and tailor services to meet their associated needs better.2 Unaccompanied children are defined by HUD as people who are not part of a family during their homelessness and who are under age 18. HUD defines unaccompanied youth as those in this situation who are between 18 and 24 years of age.3 Together, unaccompanied children
Sarah Childress, Senior Research Coordinator, Lorraine R. Reitzel, Associate Professor, and Alexis Moisiuc, Undergraduate Research Assistant, The University of Houston, College of Education, Department of Psychological, Health, and Learning Sciences, Houston, TX. Diane Santa Maria, Assistant Professor, The University of Texas Health Science Center, School of Nursing, Houston, TX. Darla E. Kendzor, Assistant Professor, and Michael S. Businelle, Assistant Professor, The University of Texas Health Science Center, School of Public Health, Dallas, TX. Lorraine R. Reitzel, Darla E. Kendzor, and Michael S. Businelle are the joint senior scientists on this work. Lorraine R. Reitzel was affiliated with The University of Texas MD Anderson Cancer Center in Houston, TX at the time of data collection. Correspondence Dr Reitzel; [email protected]
Am J Health Behav.™ 2015;39(4):549-555
likelihood of cocaine problems, in adjusted analyses (p values < .04). Conclusions: Serious mental illness and sedative problems may characterize homeless youth who are vulnerable to adulthood homelessness, although longitudinal cohort studies are needed to explicate temporal relations between variables. Key words: youth-onset homelessness; serious mental illness; substance abuse; chronic homelessness; adult-onset homelessness; sedative use problems; cocaine use problems; early-onset homelessness Am J Health Behav. 2015;39(4):549-555 DOI: http://dx.doi.org/10.5993/AJHB.39.4.11
and youth comprise those experiencing youthonset homelessness are referred to as homeless “youth” hereafter in this paper. Although greater consensus is needed on how to perform accurate point-in-time counts between jurisdictions and across states, current estimates have suggested that as many as 1.7 million youth are homeless on a given night.4 Several precipitants of youth-onset homelessness have been identified, including being kicked out of the home, running away from home, and aging out of foster care.5 However, relative to homeless adults who have more options for sheltered housing, homeless youth - particularly those who have not reached the age of majority - are more likely to live with friends and move around frequently.4 Consequently, less is known about factors that precipitate and perpetuate homelessness in this group relative to homeless adults, wherein some proportion of homelessness may be attributable to situational or economic factors (eg, home foreclosure, job loss). Some research among homeless youth suggests that serious mental illness (SMI) and substance use problems are implicated in the maintenance of homelessness prior to age 25.6 However, the extent to which SMI and substance use problems also may predispose homeless youth to continue to experience homelessness into adulthood is not known. Given the myriad negative health outcomes experienced by homeless
549
Mental Illness and Substance Use Problems in Relation to Homelessness Onset adults and the federal, state, and local expenses they incur,7 better descriptions of youth who are vulnerable to chronic homelessness may aid in the target of prevention and intervention efforts. Studies conducted among homeless youth and homeless adults, respectively, suggest that SMI (eg, schizophrenia, bipolar disorder) is a major healthcare issue encountered in both groups.8-11 For example, estimates indicate that as many as one-third of homeless adults experience SMI5 versus about 4.1% of the general population.9 Similarly, homeless and runaway adolescents have a 30.4% lifetime prevalence of major depression versus 14% prevalence among housed youth.10 However, the extent to which SMI might differentiate homelessness onset in youth versus adulthood is not known. Given that certain SMI diagnoses (eg, schizophrenia) typically emerge prior to age 25,12 it may be that at least some forms of SMI co-occur with youth-onset homelessness. Alternatively, youth-onset homelessness may exacerbate the risk for the development of SMI in adulthood,13 which in turn, may contribute to the risk for future or chronic homelessness.13-15 Homeless youth, similar to their adult counterparts, also tend to abuse substances at higher rates than their housed peers.16-18 For example, one study of homeless youth concluded that about 75% of those surveyed met the clinical criteria for having a drug and/or alcohol use disorder.19 According to other studies, 57%-70% of homeless youth reported recent use of alcohol,20 57%-68% reported recent use of marijuana,20 and 50% reported prescription drug misuse,21 rates that are higher than those found in the general population.22 Homeless youth report using substances to attenuate the negative psychological effects of living on the streets, to reduce depressive symptoms, and to stay awake when they experience difficulty finding a safe place to sleep.19 Homeless youth are also less likely to seek treatment for substance use compared with housed youth.19 It is possible that homeless youth do not view their substance use as problematic, which may lead to prolonged substance use problems in adulthood. Few studies have examined similarities and differences in lifetime substance use (eg, drug type) among those who first experience homelessness as youth versus as adults. Consequently, whether there are differences in rates of substance use problems between youth- versus adult-onset homelessness is not known. The purpose of the current study was to compare rates of lifetime SMI and substance use problems by homelessness onset among adult homeless individuals residing in a shelter, with the intent of delineating the extent to which SMI and substance use problems might be differentially associated with youth- relative to adult-onset homelessness. More information about these differences may contribute to the understanding of how the healthcare needs of these groups systematically vary and potentially inform the targeting of future prevention
550
or intervention programs directed toward vulnerable youth at risk of chronic homelessness. METHODS Participants and Procedures Participants (N = 394) were homeless adults recruited from a single shelter in Dallas, TX. This shelter was chosen because of a previously established research partnership,23-28 its large size (325-350 residents a night), and because of its role in the provision of services to 85% of homeless adults in Dallas. Consequently, the demographics of the residents of this shelter are similar to those of the overall Dallas area homeless population.29 Participants were recruited through study flyers posted at the shelter, which solicited volunteers for a study of “common disease risk factors” among shelter residents. Although lifetime SMI and substance use problems were among the disease risk factors of interest in this study, their associations with homelessness onset represented a secondary analysis. Individuals were eligible to participate in the study if they were at least 18 years old and English-speaking, with a 7th grade literacy level as assessed by the Rapid Estimate of Adult Literacy in Medicine-Short Form.30 After obtaining informed consent, participants completed surveys in a private area on a laptop or tablet computer, with items visible on the screen and read aloud while participants listened through headphones. All participants received a $20 department store gift card upon study completion. Data were collected in June and August of 2013. Measures Socio-demographic characteristics. Sociodemographic variables included age, sex, years of education, race/ethnicity, and number of discrete homeless episodes over the lifetime. Homelessness onset. Homelessness onset was assessed by asking: “How old were you the first time you became homeless?” Responses were categorized into youth-onset homeless (24 years of age), as consistent with previous reports.2,3 Serious mental illness (SMI). SMI was selfreported by participants. Specifically, they were asked to indicate whether they had a lifetime history of any of the following diagnoses: major depression, bipolar disorder, or schizophrenia/schizoaffective disorder. Participants who endorsed any of the diagnoses were considered to have SMI at some point over the lifetime. Substance use. Problems related to substance use were self-reported, and assessed by asking: “Have you ever had a drug problem (other than tobacco)?” Those endorsing this item were asked to indicate which of the following drugs were applicable, with multiple endorsements permitted: (1) alcohol; (2) cannabis (marijuana); (3) cocaine (crack, powder, freebase); (4) sedatives (Valium, Xanax);
Childress et al
Table 1 Participant Characteristics and Differences by Homelessness Onset Homelessness Onset Youth-onset N = 124 %[N] / M(SD)
Adult-onset N = 270 %[N] / M(SD)
p value
Total Sample N = 394 %[N] / M(SD)
34.5 (12.3)
47.4 (9.0)
Y
outh-onset homelessness is a growing problem in the United States that is associated with a number of negative economic, cognitive, psychological, and social consequences.1 In 2013, the Department of Housing and Urban Development (HUD) called for communities to include unaccompanied homeless children and youth in point-in-time counts to enumerate this group more accurately and tailor services to meet their associated needs better.2 Unaccompanied children are defined by HUD as people who are not part of a family during their homelessness and who are under age 18. HUD defines unaccompanied youth as those in this situation who are between 18 and 24 years of age.3 Together, unaccompanied children
Sarah Childress, Senior Research Coordinator, Lorraine R. Reitzel, Associate Professor, and Alexis Moisiuc, Undergraduate Research Assistant, The University of Houston, College of Education, Department of Psychological, Health, and Learning Sciences, Houston, TX. Diane Santa Maria, Assistant Professor, The University of Texas Health Science Center, School of Nursing, Houston, TX. Darla E. Kendzor, Assistant Professor, and Michael S. Businelle, Assistant Professor, The University of Texas Health Science Center, School of Public Health, Dallas, TX. Lorraine R. Reitzel, Darla E. Kendzor, and Michael S. Businelle are the joint senior scientists on this work. Lorraine R. Reitzel was affiliated with The University of Texas MD Anderson Cancer Center in Houston, TX at the time of data collection. Correspondence Dr Reitzel; [email protected]
Am J Health Behav.™ 2015;39(4):549-555
likelihood of cocaine problems, in adjusted analyses (p values < .04). Conclusions: Serious mental illness and sedative problems may characterize homeless youth who are vulnerable to adulthood homelessness, although longitudinal cohort studies are needed to explicate temporal relations between variables. Key words: youth-onset homelessness; serious mental illness; substance abuse; chronic homelessness; adult-onset homelessness; sedative use problems; cocaine use problems; early-onset homelessness Am J Health Behav. 2015;39(4):549-555 DOI: http://dx.doi.org/10.5993/AJHB.39.4.11
and youth comprise those experiencing youthonset homelessness are referred to as homeless “youth” hereafter in this paper. Although greater consensus is needed on how to perform accurate point-in-time counts between jurisdictions and across states, current estimates have suggested that as many as 1.7 million youth are homeless on a given night.4 Several precipitants of youth-onset homelessness have been identified, including being kicked out of the home, running away from home, and aging out of foster care.5 However, relative to homeless adults who have more options for sheltered housing, homeless youth - particularly those who have not reached the age of majority - are more likely to live with friends and move around frequently.4 Consequently, less is known about factors that precipitate and perpetuate homelessness in this group relative to homeless adults, wherein some proportion of homelessness may be attributable to situational or economic factors (eg, home foreclosure, job loss). Some research among homeless youth suggests that serious mental illness (SMI) and substance use problems are implicated in the maintenance of homelessness prior to age 25.6 However, the extent to which SMI and substance use problems also may predispose homeless youth to continue to experience homelessness into adulthood is not known. Given the myriad negative health outcomes experienced by homeless
549
Mental Illness and Substance Use Problems in Relation to Homelessness Onset adults and the federal, state, and local expenses they incur,7 better descriptions of youth who are vulnerable to chronic homelessness may aid in the target of prevention and intervention efforts. Studies conducted among homeless youth and homeless adults, respectively, suggest that SMI (eg, schizophrenia, bipolar disorder) is a major healthcare issue encountered in both groups.8-11 For example, estimates indicate that as many as one-third of homeless adults experience SMI5 versus about 4.1% of the general population.9 Similarly, homeless and runaway adolescents have a 30.4% lifetime prevalence of major depression versus 14% prevalence among housed youth.10 However, the extent to which SMI might differentiate homelessness onset in youth versus adulthood is not known. Given that certain SMI diagnoses (eg, schizophrenia) typically emerge prior to age 25,12 it may be that at least some forms of SMI co-occur with youth-onset homelessness. Alternatively, youth-onset homelessness may exacerbate the risk for the development of SMI in adulthood,13 which in turn, may contribute to the risk for future or chronic homelessness.13-15 Homeless youth, similar to their adult counterparts, also tend to abuse substances at higher rates than their housed peers.16-18 For example, one study of homeless youth concluded that about 75% of those surveyed met the clinical criteria for having a drug and/or alcohol use disorder.19 According to other studies, 57%-70% of homeless youth reported recent use of alcohol,20 57%-68% reported recent use of marijuana,20 and 50% reported prescription drug misuse,21 rates that are higher than those found in the general population.22 Homeless youth report using substances to attenuate the negative psychological effects of living on the streets, to reduce depressive symptoms, and to stay awake when they experience difficulty finding a safe place to sleep.19 Homeless youth are also less likely to seek treatment for substance use compared with housed youth.19 It is possible that homeless youth do not view their substance use as problematic, which may lead to prolonged substance use problems in adulthood. Few studies have examined similarities and differences in lifetime substance use (eg, drug type) among those who first experience homelessness as youth versus as adults. Consequently, whether there are differences in rates of substance use problems between youth- versus adult-onset homelessness is not known. The purpose of the current study was to compare rates of lifetime SMI and substance use problems by homelessness onset among adult homeless individuals residing in a shelter, with the intent of delineating the extent to which SMI and substance use problems might be differentially associated with youth- relative to adult-onset homelessness. More information about these differences may contribute to the understanding of how the healthcare needs of these groups systematically vary and potentially inform the targeting of future prevention
550
or intervention programs directed toward vulnerable youth at risk of chronic homelessness. METHODS Participants and Procedures Participants (N = 394) were homeless adults recruited from a single shelter in Dallas, TX. This shelter was chosen because of a previously established research partnership,23-28 its large size (325-350 residents a night), and because of its role in the provision of services to 85% of homeless adults in Dallas. Consequently, the demographics of the residents of this shelter are similar to those of the overall Dallas area homeless population.29 Participants were recruited through study flyers posted at the shelter, which solicited volunteers for a study of “common disease risk factors” among shelter residents. Although lifetime SMI and substance use problems were among the disease risk factors of interest in this study, their associations with homelessness onset represented a secondary analysis. Individuals were eligible to participate in the study if they were at least 18 years old and English-speaking, with a 7th grade literacy level as assessed by the Rapid Estimate of Adult Literacy in Medicine-Short Form.30 After obtaining informed consent, participants completed surveys in a private area on a laptop or tablet computer, with items visible on the screen and read aloud while participants listened through headphones. All participants received a $20 department store gift card upon study completion. Data were collected in June and August of 2013. Measures Socio-demographic characteristics. Sociodemographic variables included age, sex, years of education, race/ethnicity, and number of discrete homeless episodes over the lifetime. Homelessness onset. Homelessness onset was assessed by asking: “How old were you the first time you became homeless?” Responses were categorized into youth-onset homeless (24 years of age), as consistent with previous reports.2,3 Serious mental illness (SMI). SMI was selfreported by participants. Specifically, they were asked to indicate whether they had a lifetime history of any of the following diagnoses: major depression, bipolar disorder, or schizophrenia/schizoaffective disorder. Participants who endorsed any of the diagnoses were considered to have SMI at some point over the lifetime. Substance use. Problems related to substance use were self-reported, and assessed by asking: “Have you ever had a drug problem (other than tobacco)?” Those endorsing this item were asked to indicate which of the following drugs were applicable, with multiple endorsements permitted: (1) alcohol; (2) cannabis (marijuana); (3) cocaine (crack, powder, freebase); (4) sedatives (Valium, Xanax);
Childress et al
Table 1 Participant Characteristics and Differences by Homelessness Onset Homelessness Onset Youth-onset N = 124 %[N] / M(SD)
Adult-onset N = 270 %[N] / M(SD)
p value
Total Sample N = 394 %[N] / M(SD)
34.5 (12.3)
47.4 (9.0)
