Community Mental Health Journal, Vol. 28, No. 5, October 1992
Predicting Psychiatric Symptoms Among Homeless People Robert J. Calsyn, Ph.D. Gary A. Morse, Ph.D.
A B S T R A C T : Multiple regression was used to predict psychiatric symptoms among homeless people. The following variables were significant predictors of psychiatric symptoms: current life satisfaction, previous psychiatric hospitalization, the number of stressful life events, social support, problem drinking, and childhood unhappiness. The results are discussed in terms of their policy and practice implications, particularly the need for crisis intervention services and for dual-diagnosed clients.
Reported rates of mental illness among homeless people have varied widely, depending on differences in sampling and in definitions of mental illness. Some controversy still remains regarding the best estimate of psychiatric disorder among homeless people, but most experts estimate that 20% to 40% of the homeless have severe psychiatric problems (for reviews see Robertson, 1986, and Dennis, Buckner, Lipton, & Levine, 1991.) Although funding is still inadequate, service programs for the homeless mentally ill are finally being implemented in many large cities (Levine & Rog, 1990). Unfortunately, the research base guiding these programs is still quite limited. Despite the burgeoning literature on the rates of mental illness among homeless people, little attention has been directed to studying what factors account for the variation in psychiReprint requests should be directed to Robert J. Calsyn, University of Missouri-St. Louis, 8001 Natural Bridge Road, St. Louis, MO 63121-4499. Gary A. Morse is Director, Community Support Systems, St. Louis Mental Health Center, St. Louis, MO. The authors wish to thank the staff and residents of the New Life Evangelistic Center for their participation in the project. 385
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atric symptoms among homeless people. (For an exception, see LaGory, Ritchey, & Mullis' 1990 study of depression among the homeless.) The limited research that has been conducted to date has not used multivariate statistics; thus, little is known about the cumulative and combined effects of different variables on the level of psychiatric disturbance among homeless people. This study is an exploratory investigation, positing that multiple factors explain the level of psychiatric symptoms among homeless people. Multiple regression is used to compare the relative predictive power of the following types of variables: demographic characteristics, stress and social support, prior psychiatric history, and drinking problems. Research findings related to these variable categories are reviewed below. It should be noted that these findings generally do not come from prior multivariate studies predicting psychiatric symptoms, but rather from several studies that have described or compared differences between mentally ill and non-mentally ill homeless people.
DEMOGRAPHIC CHARA CTERISTICS
In the studies reviewed by Tessler and Dennis (1989) few demographic differences were found between mentally ill and non-mentally ill homeless persons. Both groups are more likely to be young, poorly educated, and African-American than the general population. Although the mentally ill homeless have even poorer employment histories than the nonmentally ill homeless, Fischer, Breakey, Shapiro, and Kramer (1986) found no relationship between work status and psychiatric symptoms.
SOCIAL SUPPORT AND S T R E S S
Two studies (Morse & Calsyn, 1986; LaGory, et al., 1990) have found that the number of stressful events experienced by homeless people was correlated with the degree of psychiatric symptoms, consistent with findings of similar research conducted on other populations (Lin, Dean, & Ensel, 1986). Most research with other populations (Cohen & Wills, 1985) has also found that social support reduces psychiatric symptoms. Research on homeless samples has produced conflicting results. Morse & Calsyn (1986) found no relationship between social support and
Robert J. Calsyn, Ph.D. a n d Gary A. Morse, Ph.D.
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psychopathology, whereas LaGory, et al., (1990) did find that higher levels of social support was related to less psychopathology.
PSYCHIATRIC HISTORY
Two studies (Roth, Bean, Lust, & Saveana, 1985; Morse, Shields, Hanneke, Calsyn, Burger, & Nelson, 1986) have found that 40-50% of former mental patients who were homeless were not currently symptomatic. However, former psychiatric patients are more likely to display psychiatric symptoms than those homeless people who were never hospitalized in a psychiatric facility (Morse & Calsyn, 1986). Thus, we predicted that prior psychiatric hospitalization would predict current psychiatric symptoms.
D R I N K I N G PROBLEMS
Several researchers have found a relationship between alcoholism and other psychopathology among the homeless. Homeless persons who were alcoholic were more likely to have been hospitalized for a psychiatric problem (Gelberg, Linn, & Leake, 1988). Similarly, in another study (Fischer & Breakey, 1987) 70 percent of the homeless alcoholics had an additional psychiatric diagnosis. Koegel and Burnam (1987) probably provide the best data relevant to the relationship of psychopathology and alcoholism among a representative sample of homeless persons. Using lifetime diagnosis figures they characterize 17.9 percent of their sample as a ~'pure alcoholic" sample, another 22.7 percent of their sample as a "pure psychiatric sample", and 46 percent of the sample as a dual diagnosed group, i.e., alcohol and psychiatric problems.
HOMELESS HISTORY
In the studies reviewed by Tessler and Dennis (1989) mentally ill homeless people were more likely to have experienced multiple episodes of homelessness and/or to have been homeless for a longer period of time than their non-mentally ill counterparts. However, the mentally ill homeless were no more likely to be from a different city than homeless people who were not mentally ill. Two prior studies (Piliavin,
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Sosin, Westerfelt, 1989; Sosin, Colson, & Grossman, 1988) have found that homeless people experienced more institutional or foster care placements as children than the average person; however, it is not known whether the mentally ill homeless experienced more childhood disruptions than their non-mentally ill counterparts. The present study predicted that childhood unhappiness would be related to psychiatric symptoms among the homeless population. In summary we made the following predictions: 1. Demographic variables would not predict psychiatric symptoms; 2. Stress would be positively correlated with psychiatric symptoms; 3. Social support would be negatively correlated with psychiatric symptoms; 4. Prior psychiatric hospitalization would correlate with psychiatric symptoms; 5. Alcohol abuse would correlate with psychiatric symptoms; 6. Longer episodes of homelessness would correlate with more psychiatric symptoms; 7. Childhood unhappiness would correlate with more psychiatric symptoms.
METHODS Sample and Setting One hundred and sixty five males who were residing in the largest emergency shelter for men in the St. Louis area provided data for this study. Participation in the study was entirely voluntary, and data were provided in an anonymous manner. Data were collected over a ten week period. The actual administration of the survey instrument was performed in small groups of approximately 6 to 10 respondents in the presence of the second author and a research assistant. This procedure allowed those respondents who had difficulty answering questions (due to reading ability, etc.) to receive assistance. Support for the reliability and validity of survey information provided by homeless samples comes from a study (Bahr & Houts, 1971) in which the authors compared the discrepancy rate of self report surveys to archival records. These researchers concluded that homeless men were no more likely than other populations to give discrepant information.
Dependent Variable The global severity index of the Brief Symptom Inventory (BSI) was used to measure psychopathology. The BSI (Derogatis & Spencer, 1984) is a short form of the SCL-90 which was considered to be the best self-report measure of psychiatric symptoms by a National Institute of Mental Health task force (Waskow & Parloff, 1974). The correla-
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tions between comparable scales of the SCL-90 and BSI are all above .90 (Derogatis & Spencer, 1984).
Predictor Variables Demographic variables included age, ethnicity (white, minority), and marital status (married or previously married versus never married). The longest period of employment ever, the duration of current unemployment, and education were three indices of socioeconomic status. Social support was measured with a nine item scale. The items for the scale were borrowed from the Social Network Index (Berkman, 1977) and from the Florida Health and Family Life Survey (Warheit, Bell, & Schwab, 1977). Four questions were asked about close relationships with friends: specifically, the number of close friends, amount of contact with friends, the degree of help seeking behavior, and the degree of associated negative emotions. Four similar questions were asked about relationships with close relatives. A final question concerned the degree of loneliness that the respondent felt. The reliability for the scale was moderate, .78 as indicated by Cronbach's alpha. The Social Readjustment Rating Scale (Holmes & Rahe, 1967) was used to measure the degree of stressful life events. Some of the items were reworded slightly to improve readability and relevance to low socioeconomic populations (Komaroff, Masuda and Holmes, 1968). Respondents were also instructed to m a r k items which occurred in the year prior to their first becoming homeless rather than in the past year as is normally done. Prior psychiatric hospitalization was measured with a single dichotomous item. The Michigan Alcoholism Screening Test (MAST) was used to measure the degree of problem drinking (Selzer, 1971). Internal consistency estimates of reliability for the MAST range from .83 to .92 (Selzer, Vinokur & Van Rooijen, 1975; Skinner, 1979). Validity estimates using criterion groups of '~known alcoholics" versus normals have been reported as high as .79 (Selzer, et al., 1975). Moreover, MAST scores correlate very little with social desirability or other response sets (Selzer, et al., 1975; Skinner, 1979). Respondents were asked how long (in months) since they first became homeless as well as the length of time (in months) they had currently been homeless. Transience was measured by asking the respondent for the number of cities lived-in during the past year. It should be noted that many homeless people are intra-city mobile, often because of tenuous economic and housing situations. For the present study, however, we selected the inter-city operationalization of transience, given a hypothesized relationship to psychiatric symptoms (Goldberg, 1972). For both the life satisfaction and childhood unhappiness variables, five point likert scales were used, with the higher score indicating the more negative response. The final variable in the analysis was a statistical control for missing data. Following the recommendations of Cohen and Cohen (1975), a variable named "missing data tendency" was formed. Each respondent's score on this variable represented the number of predictor variables which contained missing values for the respondent (with a minimum score of zero, and a maximum score of three); six subjects who had missing data on more than three predictor variables were deleted from the multivariate analysis. Missing values on the predictor variables were inserted with the variable mean. This method maximized the statistical power of the analysis, while also allowing for the assessment of non-random effects among subjects with missing data. To elaborate on this further, a significant correlation on the missing data tendency variable would indicate that the pattern of missing data is not random. This procedure was performed only for predictor variables and not the dependent variable; cases with missing data on the dependent variable were excluded from the analysis.
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Statistical Analyses In addition to descriptive statistics, multiple regression analyses were performed. The focus of these analyses was on the total explained variance (R2) which could be explained by the full scale model using the entire set of predictors. An adjusted R 2 is also reported. (Stepwise solutions were also performed which produced similar results.)
RESULTS Although the present study used a convenience sample, the mean score of .81 on the global severity index of the BSI was nearly identical to the mean of .79 found in a random sample of homeless men in another study (Calsyn & Morse, 1990). It is important to note that a score of .72 is two standard deviations above the sample mean for the normal population (Derogatis & Spencer, 1984); thus, a significant percentage of our sample had major psychiatric symptoms. As Table I indicates, half of the 16 predictor variables had significant correlations with the dependent variable. Inspection of the predictor variables with the largest correlations with the dependent variable indicates: a) persons previously hospitalized for mental problems have higher degrees of psychopathology; b) persons who experience a high degree of stressful life events in the year prior to becoming homeless display greater psychiatric impairment; c) those persons who have higher levels of drinking problems have higher levels of psychiatric problems; d) the more dissatisfaction that the person feels with his recent life, the greater the psychiatric symptoms; e) persons with low levels of social support display greater psychiatric impairment; f) persons who report more unhappiness as a child have more psychiatric symptoms; g) the longer the time since first homeless and/or the longer length of the current episode of homelessness, the greater the psychiatric symptoms. The full scale model predicting psychiatric symptoms was highly significant, F(16,129) = 6.79, p < .001, R 2 = .46, adjusted R 2 = .39. As Table 1 indicates the multivariate analysis resulted in only a slight shifting of the predictive power of some of the variables. Although the two homeless history variables were significantly correlated with psychiatric symptoms, they did not add much to the prediction of psychiatric symptoms beyond other variables in the equation. On the other hand, the longest period of employment did add to the prediction of psychiatric symptoms in the regression analysis, even though this variable was only slightly correlated with psychiatric symptoms. People who had longer periods of employment were less likely to display
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TABLE 1 Prediction of Psychiatric Symptoms
Predictor Variable
Previous mental hospitalization Stressful life events Problem drinking Current life satisfaction Social Support Scale score Childhood family unhappiness Length of time since first homeless Length of homelessness for this episode Number of city residences in past year Marital status Education Longest period of employment ever Missing data tendency Race Duration of current unemployment Age
Bivariate Correlation
Beta Coefficient
-.40*** .39*** .38*** .34*** -.25** .21"* .20*
-.26** .25** .14 .29** -.22** -.10 .05
.18"
.06
.11 -.10 -.10 -.10 .09 .02 .01 -.01
.08 -.11 -.10 -.16 .03 .09 -.03 -.01
* p < .05 ** p < .01 *** p < .001
psychiatric symptoms. With these exceptions, the results of the multivariate analysis supported the bivariate correlational analyses reported earlier.
DISCUSSION
The current study demonstrates that not only do the homeless exhibit a high level of psychiatric disturbance, but that a significant portion of the variance of their symptoms can be explained by predictor variables. Further, as expected, the results demonstrate the utility and potency of a multivariate approach over simple bivariate correlations. The results also support the study's predictions about the significant relationships between individual predictor variables and psychiatric
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symptoms. Specifically, as predicted, higher levels of psychiatric disturbance among the homeless are associated with histories of prior mental hospitalizations, higher levels of stress in the year prior to homelessness, drinking problems, lower levels of social support, greater childhood unhappiness, and longer histories of homelessness. As expected, demographic variables were not significant predictors of psychiatric symptoms, which is a finding consistent with previous literature. By accounting for overlapping variance, the multivariate analysis illustrated the relative strength of each predictor variable with psychiatric disturbance. Specifically, it was found that time homeless, childhood unhappiness, and problem drinking had less powerful unique contributions to psychiatric symptoms. Meanwhile, prior mental hospitalization, life stress prior to homelessness, and social support, as well as life satisfaction emerged as the most powerful correlates when overlapping variance was controlled. The relationship between prior hospitalization and current symptoms is not at all surprising. Many individuals with hospitalization histories suffer from severe psychiatric disorders that will persist over time. Still, it is disturbing because these individuals are probably far more symptomatic because they lack services and are homeless. These results provide further evidence of inadequate community supports for deinstitutionalized persons. Numerous research studies have demonstrated t h a t persons with severe and persistent psychiatric disorders can be satisfactorily maintained in the community in a cost efficient manner, especially through the use of intensive case management programs (see Olfson, 1990, for a review). Such programs may well help to prevent homelessness as well as re-hospitalizations. Further, similar programs have also recently demonstrated effectiveness in helping mentally ill people end homelessness (Morse, Calsyn, Allen, Tempelhoff, & Smith, in press). Additional programs such as these are needed to assist the mentally ill people who are currently homeless, as well as to prevent additional cases of homelessness. The relationship between high levels of stress and psychiatric symptoms is consistent with earlier research on homeless people (LaGory et al., 1990; Morse & Calsyn, 1986) as well as with research on the general population (Lin, Dean, & Ensel, 1986). This finding suggests that additional crisis services, both general programs and those specifically for the homeless, are needed to reduce the effects of stress for this population. Social support has often been found to be related to lower psychiatric symptoms, both in the general population (Cohen & Willis, 1985) and in the depressed homeless population (LaGory et al., 1990); that finding
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was replicated in this study. While social support may indeed buffer stress and reduce psychiatric symptoms, the economic and other problems facing the homeless population require more than just social support. Again, intensive case management programs that provide hands-on service and support are needed, as are other environmental and financial supports, such as housing subsidies and financial entitlements. As LaGory et al., point out, increasing the social support of homeless people is not likely to be a sufficient intervention to reduce their psychiatric symptoms or end their homelessness. The significant correlation between substance abuse and psychiatric symptoms is consistent with previous research (Tessler & Dennis, 1989). Although this relationship was less important in the multivariate analysis, the association indicates high co-morbidity among the homeless, and the need for services for a dual-diagnosed population. Innovative programs for dual-diagnosed homeless clients are now being implemented (Argeriou & McCarty, 1990), although research on the efficacy of these approaches has not yet appeared in the literature. Readers are reminded that the present study sampled only homeless men and that the results may not generalize to homeless women. Further, these findings are based on cross-sectional data. Thus, causal inferences regarding the relationships between variables should not be made. For example, we arbitrarily designated psychiatric symptoms as our dependent variable and the other variables in the analysis as predictor variables. However, it is certainly possible that over time, psychiatric symptoms might also have a casual impact on many variables, including homelessness. Future research needs to be longitudinal in design to determine causal relationships between predictor variables. Despite these limitations, the present study has demonstrated the utility of using a multivariate approach, with the set of predictor variables explaining a significant percentage of the variance of psychiatric symptoms. In concluding, it should also be noted that this study examined only the impact of individual difference variables on the level of psychiatric symptoms among homeless people. Undoubtedly, societal and institutional variables impact on the psychiatric symptoms of homeless people. For example, inadequate aftercare programs for former psychiatric patients, as well as the crowded and threatening conditions of many emergency shelters undoubtedly exacerbate psychiatric symptoms. However, we could not examine differences in the level of these variables in our single site study. Multi-site research is needed to examine the impact of different levels of societal and institutional type variables.
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REFERENCES Argeriou, M., & McCarty, D. Treating alcoholism and drug abuse among homeless men and women: nine community demonstration grants. Alcoholism Treatment Quarterly, 7, Number 1, 1990. Bahr, H.N., & Hours, K.C. (1971). Can you trust a homeless man? A comparison of official records and interview responses by Bowery men. Public Opinion Quarterly, 35, 374-382. Berkman, L.F. (1977). Social networks, host resistance and morality: a follow-up study of Alameda County Residents. [Doctoral Dissertation] University of California-Berkeley. Calsyn, R.J., Morse, G.A. (1990). Homeless men and women: Commonalities and a service gender gap. American Journal of Community Psychology, 4, 597-607. Cohen, S., & Wills, T.A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-375. Cohen, J., & Cohen, P. (1975). Applied multiple regression~correlation analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates. Dennis, D.L., Buckner, J.C., Lipton, F.R., Levine, I.S., (in press). A decade of research and services for homeless mentally ill persons: Where do we stand? American Psychologist. Derogatis, L., & Spencer, P. (1984). Administration and procedures: BSI Manual I. Baltimore, MD. (Available from Leonard Derogatis, 1228 Wine Spring Lane, Baltimore, Maryland 21204). Fischer, P.J., Breakey, W.R., Shapiro, S., and Kramer, M., (1986). Baltimore Mission Users: Social networks, morbidity, and employment. Psychosocial Rehabilitation Journal, 9, 51-63. Fischer, P.J., & Breakey, W.R., (1987). Profile of the Baltimore homeless with alcohol problems. Alcohol Health and Research World, 12, 36-37. Gelberg, L., Linn, L.S., & Leake, B.D. (1988). Mental health, alcohol, and drug use, and criminal history among homeless adults. American Journal of Psychiatry, 145, 191-196. Goldberg, M. (1972). The runaway Americans. Mental Hygiene, 56, 13-21. Holmes, T., & Rahe, R. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213-218. Koegel, P., & Burman, M.A. (1987). Traditional and nontraditional homeless alcoholics. Alcohol Health and Research World, 12, 28-34. Komaroff, A.L., Masuda, M., & Holmes, T. (1968). The social readjustment rating scale: A comparative study of Negro, Mexican, and White Americans. The Journal of Psychosomatic Research, 12, 121-128. LaGory, M., Ritchey, F., & Mullis, J. (1990). Depression among the homeless. Journal of Health and Social Behavior, 31, 87-101. Levine, I.S., & Rog, D. (1990). Mental health services for homeless mentally ill persons. American Psychologist, 45, 963-968. Lin, N., Dean, A., & Ensel, W. (eds.) (1986). Social Support, Life Events, & Depression. New York: Academic Press. Morse, G.A., & Calsyn, R.J. (1986). Mentally disturbed homeless people in St. Louis: Needy, willing, but underserved. The International Journal of Mental Health, 14, 74-94. Morse, G.A., Calsyn, R., Allen, G., Tempelhoff, B., & Smith, R., (in press). Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hospital and
Community Psychiatry. Morse, G.A., Shields, N., Hanneke, C., Calsyn, R.J., Burger, G., & Nelson, B. (1986). St. Louis' Homeless: Mental health needs, services, and policy implications. Psychosocial Rehabilitation Journal, 4, 39-50. Olfson, M. (1990). Assertive community treatment: An evaluation of the experimental evidence. Hospital and Community Psychiatry, 41(6), 634-641. Piliavin, I., Sosin, M., Westerfelt, H. (1989). Conditions contributing to long-term homelessness: An exploratory study. Unpublished paper. Institute for Research on Poverty, University of Wisconsin-Madison. Robertson, M. (1986). Mental disorder among homeless persons in the United States: An overview of recent empirical literature. Administration in Mental Health, 4, 14-27. Roth, D., Bean, J., Lust, N., & Saveana T. (1985). Homelessness in Ohio: A Study of People in Need. Columbus, Ohio: Ohio Department of Mental Health.
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Selzer, M.L. (1971). The Michigan alcoholism screening test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653-1658. Selzer, M.L., Vinokur, A., Van Rooijen, L. (1975). A self-administered Short Michigan Alcoholism Screening Test (SMAST). Journal of Studies of Alcoholism, 36, 117. Skinner, H.A. (1979). Guidelines for using the Michigan Alcoholism Screening Test. Unpublished paper. Sosin, M.R., Colson, P., & Grossman, S. (1988). Homelessness in Chicago: Poverty and pathology, social institutions and social change. The School of Social Service Administration, University of Chicago. Tessler, R., & Dennis, D. (1989). Synthesis of NIMH-funded research concerning persons who are homeless and mentally ill. Amherst, MA: Social and Demographic Research Institute of the University of Massachusetts. Warheit, G.J., Bell, R.A., & Schwabb, J.J. (1977). Needs assessment approaches: Concepts and methods. Washington, DC: U.S. Government Printing Office. Waskow, L., & Parloff, M. (1974). Psychotherapy change measures. Washington, DC: Superintendent of Documents. U.S. Government Printing Office.
Predicting Psychiatric Symptoms Among Homeless People Robert J. Calsyn, Ph.D. Gary A. Morse, Ph.D.
A B S T R A C T : Multiple regression was used to predict psychiatric symptoms among homeless people. The following variables were significant predictors of psychiatric symptoms: current life satisfaction, previous psychiatric hospitalization, the number of stressful life events, social support, problem drinking, and childhood unhappiness. The results are discussed in terms of their policy and practice implications, particularly the need for crisis intervention services and for dual-diagnosed clients.
Reported rates of mental illness among homeless people have varied widely, depending on differences in sampling and in definitions of mental illness. Some controversy still remains regarding the best estimate of psychiatric disorder among homeless people, but most experts estimate that 20% to 40% of the homeless have severe psychiatric problems (for reviews see Robertson, 1986, and Dennis, Buckner, Lipton, & Levine, 1991.) Although funding is still inadequate, service programs for the homeless mentally ill are finally being implemented in many large cities (Levine & Rog, 1990). Unfortunately, the research base guiding these programs is still quite limited. Despite the burgeoning literature on the rates of mental illness among homeless people, little attention has been directed to studying what factors account for the variation in psychiReprint requests should be directed to Robert J. Calsyn, University of Missouri-St. Louis, 8001 Natural Bridge Road, St. Louis, MO 63121-4499. Gary A. Morse is Director, Community Support Systems, St. Louis Mental Health Center, St. Louis, MO. The authors wish to thank the staff and residents of the New Life Evangelistic Center for their participation in the project. 385
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atric symptoms among homeless people. (For an exception, see LaGory, Ritchey, & Mullis' 1990 study of depression among the homeless.) The limited research that has been conducted to date has not used multivariate statistics; thus, little is known about the cumulative and combined effects of different variables on the level of psychiatric disturbance among homeless people. This study is an exploratory investigation, positing that multiple factors explain the level of psychiatric symptoms among homeless people. Multiple regression is used to compare the relative predictive power of the following types of variables: demographic characteristics, stress and social support, prior psychiatric history, and drinking problems. Research findings related to these variable categories are reviewed below. It should be noted that these findings generally do not come from prior multivariate studies predicting psychiatric symptoms, but rather from several studies that have described or compared differences between mentally ill and non-mentally ill homeless people.
DEMOGRAPHIC CHARA CTERISTICS
In the studies reviewed by Tessler and Dennis (1989) few demographic differences were found between mentally ill and non-mentally ill homeless persons. Both groups are more likely to be young, poorly educated, and African-American than the general population. Although the mentally ill homeless have even poorer employment histories than the nonmentally ill homeless, Fischer, Breakey, Shapiro, and Kramer (1986) found no relationship between work status and psychiatric symptoms.
SOCIAL SUPPORT AND S T R E S S
Two studies (Morse & Calsyn, 1986; LaGory, et al., 1990) have found that the number of stressful events experienced by homeless people was correlated with the degree of psychiatric symptoms, consistent with findings of similar research conducted on other populations (Lin, Dean, & Ensel, 1986). Most research with other populations (Cohen & Wills, 1985) has also found that social support reduces psychiatric symptoms. Research on homeless samples has produced conflicting results. Morse & Calsyn (1986) found no relationship between social support and
Robert J. Calsyn, Ph.D. a n d Gary A. Morse, Ph.D.
387
psychopathology, whereas LaGory, et al., (1990) did find that higher levels of social support was related to less psychopathology.
PSYCHIATRIC HISTORY
Two studies (Roth, Bean, Lust, & Saveana, 1985; Morse, Shields, Hanneke, Calsyn, Burger, & Nelson, 1986) have found that 40-50% of former mental patients who were homeless were not currently symptomatic. However, former psychiatric patients are more likely to display psychiatric symptoms than those homeless people who were never hospitalized in a psychiatric facility (Morse & Calsyn, 1986). Thus, we predicted that prior psychiatric hospitalization would predict current psychiatric symptoms.
D R I N K I N G PROBLEMS
Several researchers have found a relationship between alcoholism and other psychopathology among the homeless. Homeless persons who were alcoholic were more likely to have been hospitalized for a psychiatric problem (Gelberg, Linn, & Leake, 1988). Similarly, in another study (Fischer & Breakey, 1987) 70 percent of the homeless alcoholics had an additional psychiatric diagnosis. Koegel and Burnam (1987) probably provide the best data relevant to the relationship of psychopathology and alcoholism among a representative sample of homeless persons. Using lifetime diagnosis figures they characterize 17.9 percent of their sample as a ~'pure alcoholic" sample, another 22.7 percent of their sample as a "pure psychiatric sample", and 46 percent of the sample as a dual diagnosed group, i.e., alcohol and psychiatric problems.
HOMELESS HISTORY
In the studies reviewed by Tessler and Dennis (1989) mentally ill homeless people were more likely to have experienced multiple episodes of homelessness and/or to have been homeless for a longer period of time than their non-mentally ill counterparts. However, the mentally ill homeless were no more likely to be from a different city than homeless people who were not mentally ill. Two prior studies (Piliavin,
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Sosin, Westerfelt, 1989; Sosin, Colson, & Grossman, 1988) have found that homeless people experienced more institutional or foster care placements as children than the average person; however, it is not known whether the mentally ill homeless experienced more childhood disruptions than their non-mentally ill counterparts. The present study predicted that childhood unhappiness would be related to psychiatric symptoms among the homeless population. In summary we made the following predictions: 1. Demographic variables would not predict psychiatric symptoms; 2. Stress would be positively correlated with psychiatric symptoms; 3. Social support would be negatively correlated with psychiatric symptoms; 4. Prior psychiatric hospitalization would correlate with psychiatric symptoms; 5. Alcohol abuse would correlate with psychiatric symptoms; 6. Longer episodes of homelessness would correlate with more psychiatric symptoms; 7. Childhood unhappiness would correlate with more psychiatric symptoms.
METHODS Sample and Setting One hundred and sixty five males who were residing in the largest emergency shelter for men in the St. Louis area provided data for this study. Participation in the study was entirely voluntary, and data were provided in an anonymous manner. Data were collected over a ten week period. The actual administration of the survey instrument was performed in small groups of approximately 6 to 10 respondents in the presence of the second author and a research assistant. This procedure allowed those respondents who had difficulty answering questions (due to reading ability, etc.) to receive assistance. Support for the reliability and validity of survey information provided by homeless samples comes from a study (Bahr & Houts, 1971) in which the authors compared the discrepancy rate of self report surveys to archival records. These researchers concluded that homeless men were no more likely than other populations to give discrepant information.
Dependent Variable The global severity index of the Brief Symptom Inventory (BSI) was used to measure psychopathology. The BSI (Derogatis & Spencer, 1984) is a short form of the SCL-90 which was considered to be the best self-report measure of psychiatric symptoms by a National Institute of Mental Health task force (Waskow & Parloff, 1974). The correla-
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tions between comparable scales of the SCL-90 and BSI are all above .90 (Derogatis & Spencer, 1984).
Predictor Variables Demographic variables included age, ethnicity (white, minority), and marital status (married or previously married versus never married). The longest period of employment ever, the duration of current unemployment, and education were three indices of socioeconomic status. Social support was measured with a nine item scale. The items for the scale were borrowed from the Social Network Index (Berkman, 1977) and from the Florida Health and Family Life Survey (Warheit, Bell, & Schwab, 1977). Four questions were asked about close relationships with friends: specifically, the number of close friends, amount of contact with friends, the degree of help seeking behavior, and the degree of associated negative emotions. Four similar questions were asked about relationships with close relatives. A final question concerned the degree of loneliness that the respondent felt. The reliability for the scale was moderate, .78 as indicated by Cronbach's alpha. The Social Readjustment Rating Scale (Holmes & Rahe, 1967) was used to measure the degree of stressful life events. Some of the items were reworded slightly to improve readability and relevance to low socioeconomic populations (Komaroff, Masuda and Holmes, 1968). Respondents were also instructed to m a r k items which occurred in the year prior to their first becoming homeless rather than in the past year as is normally done. Prior psychiatric hospitalization was measured with a single dichotomous item. The Michigan Alcoholism Screening Test (MAST) was used to measure the degree of problem drinking (Selzer, 1971). Internal consistency estimates of reliability for the MAST range from .83 to .92 (Selzer, Vinokur & Van Rooijen, 1975; Skinner, 1979). Validity estimates using criterion groups of '~known alcoholics" versus normals have been reported as high as .79 (Selzer, et al., 1975). Moreover, MAST scores correlate very little with social desirability or other response sets (Selzer, et al., 1975; Skinner, 1979). Respondents were asked how long (in months) since they first became homeless as well as the length of time (in months) they had currently been homeless. Transience was measured by asking the respondent for the number of cities lived-in during the past year. It should be noted that many homeless people are intra-city mobile, often because of tenuous economic and housing situations. For the present study, however, we selected the inter-city operationalization of transience, given a hypothesized relationship to psychiatric symptoms (Goldberg, 1972). For both the life satisfaction and childhood unhappiness variables, five point likert scales were used, with the higher score indicating the more negative response. The final variable in the analysis was a statistical control for missing data. Following the recommendations of Cohen and Cohen (1975), a variable named "missing data tendency" was formed. Each respondent's score on this variable represented the number of predictor variables which contained missing values for the respondent (with a minimum score of zero, and a maximum score of three); six subjects who had missing data on more than three predictor variables were deleted from the multivariate analysis. Missing values on the predictor variables were inserted with the variable mean. This method maximized the statistical power of the analysis, while also allowing for the assessment of non-random effects among subjects with missing data. To elaborate on this further, a significant correlation on the missing data tendency variable would indicate that the pattern of missing data is not random. This procedure was performed only for predictor variables and not the dependent variable; cases with missing data on the dependent variable were excluded from the analysis.
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Statistical Analyses In addition to descriptive statistics, multiple regression analyses were performed. The focus of these analyses was on the total explained variance (R2) which could be explained by the full scale model using the entire set of predictors. An adjusted R 2 is also reported. (Stepwise solutions were also performed which produced similar results.)
RESULTS Although the present study used a convenience sample, the mean score of .81 on the global severity index of the BSI was nearly identical to the mean of .79 found in a random sample of homeless men in another study (Calsyn & Morse, 1990). It is important to note that a score of .72 is two standard deviations above the sample mean for the normal population (Derogatis & Spencer, 1984); thus, a significant percentage of our sample had major psychiatric symptoms. As Table I indicates, half of the 16 predictor variables had significant correlations with the dependent variable. Inspection of the predictor variables with the largest correlations with the dependent variable indicates: a) persons previously hospitalized for mental problems have higher degrees of psychopathology; b) persons who experience a high degree of stressful life events in the year prior to becoming homeless display greater psychiatric impairment; c) those persons who have higher levels of drinking problems have higher levels of psychiatric problems; d) the more dissatisfaction that the person feels with his recent life, the greater the psychiatric symptoms; e) persons with low levels of social support display greater psychiatric impairment; f) persons who report more unhappiness as a child have more psychiatric symptoms; g) the longer the time since first homeless and/or the longer length of the current episode of homelessness, the greater the psychiatric symptoms. The full scale model predicting psychiatric symptoms was highly significant, F(16,129) = 6.79, p < .001, R 2 = .46, adjusted R 2 = .39. As Table 1 indicates the multivariate analysis resulted in only a slight shifting of the predictive power of some of the variables. Although the two homeless history variables were significantly correlated with psychiatric symptoms, they did not add much to the prediction of psychiatric symptoms beyond other variables in the equation. On the other hand, the longest period of employment did add to the prediction of psychiatric symptoms in the regression analysis, even though this variable was only slightly correlated with psychiatric symptoms. People who had longer periods of employment were less likely to display
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TABLE 1 Prediction of Psychiatric Symptoms
Predictor Variable
Previous mental hospitalization Stressful life events Problem drinking Current life satisfaction Social Support Scale score Childhood family unhappiness Length of time since first homeless Length of homelessness for this episode Number of city residences in past year Marital status Education Longest period of employment ever Missing data tendency Race Duration of current unemployment Age
Bivariate Correlation
Beta Coefficient
-.40*** .39*** .38*** .34*** -.25** .21"* .20*
-.26** .25** .14 .29** -.22** -.10 .05
.18"
.06
.11 -.10 -.10 -.10 .09 .02 .01 -.01
.08 -.11 -.10 -.16 .03 .09 -.03 -.01
* p < .05 ** p < .01 *** p < .001
psychiatric symptoms. With these exceptions, the results of the multivariate analysis supported the bivariate correlational analyses reported earlier.
DISCUSSION
The current study demonstrates that not only do the homeless exhibit a high level of psychiatric disturbance, but that a significant portion of the variance of their symptoms can be explained by predictor variables. Further, as expected, the results demonstrate the utility and potency of a multivariate approach over simple bivariate correlations. The results also support the study's predictions about the significant relationships between individual predictor variables and psychiatric
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symptoms. Specifically, as predicted, higher levels of psychiatric disturbance among the homeless are associated with histories of prior mental hospitalizations, higher levels of stress in the year prior to homelessness, drinking problems, lower levels of social support, greater childhood unhappiness, and longer histories of homelessness. As expected, demographic variables were not significant predictors of psychiatric symptoms, which is a finding consistent with previous literature. By accounting for overlapping variance, the multivariate analysis illustrated the relative strength of each predictor variable with psychiatric disturbance. Specifically, it was found that time homeless, childhood unhappiness, and problem drinking had less powerful unique contributions to psychiatric symptoms. Meanwhile, prior mental hospitalization, life stress prior to homelessness, and social support, as well as life satisfaction emerged as the most powerful correlates when overlapping variance was controlled. The relationship between prior hospitalization and current symptoms is not at all surprising. Many individuals with hospitalization histories suffer from severe psychiatric disorders that will persist over time. Still, it is disturbing because these individuals are probably far more symptomatic because they lack services and are homeless. These results provide further evidence of inadequate community supports for deinstitutionalized persons. Numerous research studies have demonstrated t h a t persons with severe and persistent psychiatric disorders can be satisfactorily maintained in the community in a cost efficient manner, especially through the use of intensive case management programs (see Olfson, 1990, for a review). Such programs may well help to prevent homelessness as well as re-hospitalizations. Further, similar programs have also recently demonstrated effectiveness in helping mentally ill people end homelessness (Morse, Calsyn, Allen, Tempelhoff, & Smith, in press). Additional programs such as these are needed to assist the mentally ill people who are currently homeless, as well as to prevent additional cases of homelessness. The relationship between high levels of stress and psychiatric symptoms is consistent with earlier research on homeless people (LaGory et al., 1990; Morse & Calsyn, 1986) as well as with research on the general population (Lin, Dean, & Ensel, 1986). This finding suggests that additional crisis services, both general programs and those specifically for the homeless, are needed to reduce the effects of stress for this population. Social support has often been found to be related to lower psychiatric symptoms, both in the general population (Cohen & Willis, 1985) and in the depressed homeless population (LaGory et al., 1990); that finding
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was replicated in this study. While social support may indeed buffer stress and reduce psychiatric symptoms, the economic and other problems facing the homeless population require more than just social support. Again, intensive case management programs that provide hands-on service and support are needed, as are other environmental and financial supports, such as housing subsidies and financial entitlements. As LaGory et al., point out, increasing the social support of homeless people is not likely to be a sufficient intervention to reduce their psychiatric symptoms or end their homelessness. The significant correlation between substance abuse and psychiatric symptoms is consistent with previous research (Tessler & Dennis, 1989). Although this relationship was less important in the multivariate analysis, the association indicates high co-morbidity among the homeless, and the need for services for a dual-diagnosed population. Innovative programs for dual-diagnosed homeless clients are now being implemented (Argeriou & McCarty, 1990), although research on the efficacy of these approaches has not yet appeared in the literature. Readers are reminded that the present study sampled only homeless men and that the results may not generalize to homeless women. Further, these findings are based on cross-sectional data. Thus, causal inferences regarding the relationships between variables should not be made. For example, we arbitrarily designated psychiatric symptoms as our dependent variable and the other variables in the analysis as predictor variables. However, it is certainly possible that over time, psychiatric symptoms might also have a casual impact on many variables, including homelessness. Future research needs to be longitudinal in design to determine causal relationships between predictor variables. Despite these limitations, the present study has demonstrated the utility of using a multivariate approach, with the set of predictor variables explaining a significant percentage of the variance of psychiatric symptoms. In concluding, it should also be noted that this study examined only the impact of individual difference variables on the level of psychiatric symptoms among homeless people. Undoubtedly, societal and institutional variables impact on the psychiatric symptoms of homeless people. For example, inadequate aftercare programs for former psychiatric patients, as well as the crowded and threatening conditions of many emergency shelters undoubtedly exacerbate psychiatric symptoms. However, we could not examine differences in the level of these variables in our single site study. Multi-site research is needed to examine the impact of different levels of societal and institutional type variables.
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