Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
The International Journal of the Addictions, 27(3), 317-330,1992
Substance Misuse, Emotional Disturbance, and Dual Diagnosis in a MeallLine Population of Mixed Ethnicity Marvin W. Kahn Maureen Hannah Shari Kirkland Susan Lesnik Camille Clemens Daniel Chatel University of Arizona Tucson, Arizona
Abstract This study investigated the rates of severe substance misuse, severe emotional disturbance, and dual diagnosisin a meal-linepopulation of mixed ethnicity, 75 % of whom were homelessand the remaindernear-homeless. Alcohol and/or drug use was reported by 93 % and severe substance misuse was found in 39%of the population. Severe mental illness was found in 54%of the population. Both conditions, dual diagnais, was found in 29%of the cases.A cluster analysis of the total population found b e e types: those with dual diagnosis (24.27%),those with serious substance misuse and personality disorder (39.3%),and those with neither severe 317
copyright 0 1992 by Marcel D e k , Inc.
KAHNETAL.
318
disorder (37.3%). The ethnicity of the homeless individual was very weakly, if at all, associated with the disorders.
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
INTRODUCTION To what extent mental illness is associated with subtance misuse in a homeless population is the focus of this study. Both disordershave been found in a substantial proportionof American homeless populations. Mulken and Spence (1984) reviewed studiesof substancemisuse rates in the homeless and found a range from 20 to 50%. Studies of mental illness in homeless populationshave an even wider range. Bachcachs’ review (1984) found rates from 20 to 97%. While substance misuse and mental illness in homeless populations are not mutually exclusive disorders, only a few studies have focused on establishingthe rates of those with both disorders-or with dual diagnosis as it has been called (Fisher and Breakey, 1987; Kahn et al., 1987; Wright et al., 1987; Hinkin et al., 1988; Koegel and Burnham, 1987). The rates of dual diagnosisfound range from 10to 47%. Table 1summarizesthe major studiesof ratesof alcohol-drug and mental disorder in homeless vs populations. Differences in the populations studied, in the criteria used for homelessness, substanceabuse, and mental disorder, make it difficult to compare findings and to reach any fm conclusions with regard to the extent of dual diagnosis in homeless populations. Treatment and managementof those with dual diagnosispresents a challenge and a need for coordination of programs, which in recent history have tended to focus almost exclusively on one or the other disorder. This study investigated rates of each disorder and of dual diagnosis in a mealline population, using relatively objective and well-defined criteria of disorder. Since the population studied was of mixed ethnicity that variable was also considered in association with disorder rates.
METHOD Subjects Subjects (N= 163) were obtained from a soup kitchen meal line providing a midday meal in 1986-87. It was located in Tucson, Arizona,in an area bordering subsidized housing projectsfor the poor, many of whom were minorities. The center served 200 to 400 people a day, depending upon the season of the year.
SUBSTANCEMISUSE, EMOTIONAL DISTURBANCE,DUAL DIAGNOSIS
319
Sampling
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
In order to achieve a representative sample of age, sex, and ethnicity, a preliminary estimate of the proportions of these characteristics present in the total populationwas made by teamsof investigatorswho recorded their estimate of each meal-line participant's characteristic on those variables for 10 consecutive meals. Th- estimates were then compared across raters and substantial agreement was found. The research sample was set so as to meet the proportionsof the demographic characteristics determined by the preliminary estimate. Each interviewer was assigned to do 15-20 cases,each with specific characteristicsneeded for the sample. Interviewers were instructed to approach the fmt person in line who appeared to meet the assignedcharacteristic.If that person agreed to participate and the needed characteristicswere verified, the interview proceeded. Only 11misidentifications occurred,seven of which were errors of age category. Thus, it appeared that the preliminary visual identification method was reasonably valid. "he proportions found in the preliminary observations were as follows. Ethnicity:Caucasian 5748,Hispanic27 %,Black 8%,Native American 7 I. Sex: male 8956, female 11%.Age: 12-18,02%; 19-44,65%; 45-65,31%; 65+, 27%. The researchsurvey samplevaried slightlyfrom thison ethnicity.It was 62% Caucasian and 38%minority.The demographic characteristicsof the total sampleand various subgroupers are given in Table 2. Survey Instruments 1. Demographicdescriptivedata were obtained by using a 46-item structured interview f o m covering the major content areas given in Table 2. 2. Substance misuse level was determined by the subjects' answers to the G-K substance abuse patterns and effects survey (Kahn and Gingras, 1983). This is a 44-item, verbally administered objective questionnaire providing descriptive information about amount, frequency, type of substance, and problems encountered as a result of substancemisuse in the areas of social-familyrelations, health, legalarrest, and vocational functioning. 3. Emotional disturbance was assessed in most casesby using a short form of the Minnesota Multi-Phasic inventory, the MMPI-168 (Overall et al., 1976). It is reported to correlate .80 with the full MMPI. A Spanish translation was available. mostly due to language, For those who were unable to complete the -1-168 attention span, and/or difficulty in understanding the questions, the 24-item Gurin et al. (1960) list of symptoms was administered verbally.
(1SW
Studies to drtc
d e w s . 28
M u l k m d S p c n ~ e V-locations
meatally ill 1978 to 1983
d e w s . mdks ofhomeless
variouslocatioap
€3adml&(1984)
19
60
40
- -
18
- -
- -
-
-
- -
10
13
20
22
F
100
85
LoaAngeles New York City
Lipton et al. (1982)
-
80
Pau (1983)
78
78
87
&stoa
Basquk (1983)
179
M
345
philadelphi.
Arce et al. (1983)
N
Brown et al. (1983) phoenix. AZ
Location
study
% Sex
. .
Skid row inhabitants Homelessfmm missioas, shelter, and jail
Homclespperscnrs
Various subject groups and sites
less popllatiom
14 studies with sufficient data. 20-458 misuse invarioushome-
Stancemisurc. Range 18 to 29%
measure sub-
18% 5 Studies also
20+%
ing, Geaeral
Psychiatric statls 20% schedule 34% short Michigen 29.9% males, Alcohol screen- 42.3% females
varies by shady
Varies by shady
examination
Psychiahic
atriCserviCelrsas
Gfos estimate
ratings
Y
Notgiven
28 %
12-251
20to60%
97 %
50%
20%
40% 40%
25+%
iU
M
evaluation Interviewer
Skidmwbameless
Variow subject groups and sites
Substance mislEx.
Psychiatric stabs 29%
exarmnatlom
PsyclliatriC
Basis of diagwsis
Emergency psychi-
Meallheusers
Cityrunemergency shelter residents Shelterresidents
Subject4te charactaistics
Summary of Major Studies of Alcoholism-Mental Illness A the Hamekss 1983-1 988
Table 1
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
Notgiven
16%
Notdettrmined
Not determind Notdetermined
Not detCrmined
Not detedned
Not determined
Not determined
diagnosis
F
7
hhgeles
Various~ughout the USA
Koegely and (1987)
Stark (1987)
8
Meal-line users
11,797 71
Wrightetd. (1987) Variousthroughout USA 29
98 5
- -
10%
28% 23%males, IO%males,6% 37 % females females
28%
Not given
disorder
44’16schim- 47%al&l phreniaor andschizoaKectdisphmniaor order affect
30%
Range from 9 to Not given 57%.Stable mode about 30-33%
Indigent inpatients in Admission to 100% public alcohol Alcohol Tteatreceptioncenter mentMMPI Pooled data from 16 Professionally 35%males, cities of the Health 12%females diagnosed, in Care for Homeless for &ox, or Project come to clinic underthe influence
1986
Homeless populations Not given in 41 elected studies from 1890 to
a d Effects Questionnaire. WI-168 95.3 4.7 Four groups of NIMH Diagnostic 32.77%in the intercity homeless Interview last year Scbedule
92
368
-
379
106
Hinken et al. (1988) Tucsm, AZ
-
Tucsm, AZ
Kabn et al. (1987)
tionnaire, minimental stam 33% K-G DrugAlcohol Use
Health QWS-
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
$ 8 2 a tl
U
PB
i
B
P
v)
2 ;s
KAHNETAL.
322
Tnbk 2 Selected Denmgraphk-Desotfptive Charactenstbs of the Meal Population by 'Total Group" and =Ethnk, 'Substance misuse' and "EmotionalDisorder Categodes
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
&UP
Variable
misuser
Severe emotion disorder
Caucasian
Caucasian
Total
Substance
population
Non-
N
163
64
54'
101
62
Sex: M P ZAge, years SD -city:
91% 9% 36.76 12.65
98% 2% 35.78 11.36
89% 11% 35.11 12.3
91% 9% 36.70 12.65
90%
CaUCaSiao
62%
24% 7% 7%
61% 25 % 5% 9%
49% 34% 8% 9%
100%
HiSpiC
45 % 7% 45 %
38% 6% 50%
49% 9% 43%
47 96 4% 41%
43% 11% 35 %
10.975 2.61
10.89 2.46
11.09 2.80
11.19 2.23
10.63 3.12
7596
81%
55%
85 96
57%
74%
80%
55%
83%
58%
48 %
52%
42 %
50%
44%
19% 29% 6%
17% 33% 3%
32% 34% 9%
18% 31% 5%
21% 26% 8%
30% 37%
40% 38%
35% 18%
28% 43%
34% 26%
2%
0% 22% 12% 67%
0% 17% 27% 19%
2% 16% 43 96 67 %
1% 29% 16% 28%
Black Native American Marital status: Single Matrid Divorced-separated Other E4l;Cation: X Years
SD Homeless criterion: A. Slept last night in otherthanownor another's home B. Usuallysleepin other than own or another home Live alone Recently assaulted:
Beaten Robbed Sexual assault Duration of homelessness: A. Lessthan6months B. Morethanayeat Income source: Full-time job
Part-timejob 18% Public assistance,food stamps 27% Sell blood 57%
10% 36.85 13.85
100% 100% 100%
[conrinued)
SUBSTANCEMISUSE,EMOTIONALDISTURBANCE, DUAL DIAGNOSIS
323
Table 2 (continued)
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
Severe
Variable Self-& health status: Excellent-good Fair-poor Hospitnlized in the last YMental hospitalization in thelast3years Reason homeless: No job Own choice Other want off the srreets
Total population
Substance
emotion
misuser
disorder
Caucasian
NonCaucasian
65 % 35 %
50% 50%
70% 30%
65 % 35 %
66% 34%
49%
19%
50%
53%
44%
20%
18%
25%
2396
15%
39% 27% 34% 89%
33% 27 % 50% 87 %
38% 21% 41% 87 %
40%
44% 15% 41% 85%
35 96 25 % 91%
Procedure Subjects who agreed and whose required characteristics were verified were interviewed as privately as possible at a table on the grounds away from the line and administered the instruments in a fmed order. From 35 to 60 minutes was required per subject.
Criterion Definitions In order to objectively classify subjects,defintive criteriawere designatedfor the categoriesof Homelessness, Severe Mental Illness, and Severe Substance Misuse. The standards used for each designation were as follows. (1) Homelessness: From the structured questionnaire, and individual was designated homeless if his answerto both of these questions: where did you sleep last night? and where do you usually sleep? was other than "their own home" or "at the house of a friend or relative." Those that usually slept in homes other thantheir own were considered to be near-homeless. (2) Severe Substance Misuse: A score of 22 or above on the Substance Abuse Patterns and Effects Questionnaire was used, as this level is well above the cutoff scorethat distinguishedalcoholicsin treatment from medical outpatients (Kahnand Gingras, 1983). (3) Severe Mentallllness:This was defined as a -1-168 T-score of 80 or above (3 standard deviations above the mean) on one or more of the followingscales: Depression, Paranoia, Schizophrenia, and Mania.
KAHNETAL.
324
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
Data Analysis Data were analyzed descriptively by the BMDP Statistical Package pixon, 1985) for all variables for the total population. Additionally, subjects were classified by categories Caucasian, Minority, severe substance misuser, and extreme emotional disturbance. These groups were then compared. Demographic and substance abuse data were. obtained from all 163 subjects. However, only 99 subjects completed the MMPI-168, so the extreme emotional disturbance category was based on 99 subjects. A cluster analysis using the 99 subjects with both MMPI scoresand the alcohol-drug scores was performed on half of the cases, using the K-means clustering technique.This was done fmt with an exploratory 6-cluster solution,from which it was detennincd that a meaningful 3-cluster solution was indicated. That 3-cluster solutionwas then performed on the fmt half of the population and was submittedto cross-validation on the other half of the population.
RESULTS 1.
The Meal-Line Population
Table 2 surmnarizes the descriptiveinformation from the demographic interview. The data are given by category: Total Population, Substance Misuser, Severe Emotional Disorder, Caucasian, and Non-Caucasian.
Demographics The Minority group, as can be seen in Table 2, constituted 38%of the total population, and was not significantlydifferent from Caucasianswith regard to age (X = 36.85 y m ) or education, although they averaged a half year leas schaoling. They were likely to be married, although most individualsof both groups were currently single.
Homelessness By our strict criterion, the Minority population had a lower percent of homeless individuals (57.5%) than did the Caucasian population (84.0%).
11.
Substance Misuse
Only 6.8%of the total meal-line population reported that they did not drink or use drugs at all. The abstinenceproportion was highest for the minor if^ subjects (32.7%).While a quarter (28.6%)of the total population was daily drinkers,only
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SUBSTANCE MISUSE, Eh4OTIONAL DISTURBANCE, DUAL DIAGNOSIS
325
12.7%of the minorities drank daily. For the severe substance abuser designated group, 59.4%were daily drinkers. Beer was the most used beverage; two-thirds or more of all population groups used it. The mean amount of alcohol consumed per drinking occasion, for those who drank, was an equivalent of 58 oz of hard liquor. Although fewer minorities drank, those who did consumed more than did the Caucasians (64 oz compared to 58 02). The highest umsumption of alcohol was in the designatedsubstance abuse group, who reported drinking an average of 95 oz per drinking session. About two-thirds of the total population used other drugs, with 18.1% using them daily. Marijuana was used by 50 to 60% of all population groups. Narcotics, cocaine, and hallucinogenics were less frequently used. The rate of this type of drug use by the minorities (1 1%)was about twice that for the population as a whole. Serioussocial, vocational, and family difficultiesc a d by substancemisuse were reported by about a third to a half of all subpopulationsexcept for the severe substanceabusers. Sixty to 80% of that group reported such problems. About half or more of each of the various populations groupings had been in trouble with police due to substancemisuse. This rate was highest among the designated alcoholics (82%).Over half of all the arrests were for drunk and disorderly behavior or DWI.Assault and robbery accounted for about 25 % of all arrests, but 1 % for homicide. The substance misusers had the highest rate of arrest for all offense categories. The mean age when substancemisuse started was just about the same for the Caucasiansand minorities(15.3years) and youngest for the emotionally disturbed group (13.94years). A thirdto a half of all groups said that substancemisuse was a problem for them. About 50%of both Caucasian and minority groups reported other substancemisusers in their close family. The figure was 70%for the designated severe substance misusers. By the alcohol survey criterion, 64 cases,or 39% of the total population, met the criterion for severe substance misuse. Of these, 30%were minority,proportionately somewhat lower than their proportion (38%)in the population.
111.
Severe Emotional Disturbance
Overall, 54%of the 99 cases with complete MMF'I-168 scores met the criterion for severe emotional disturbance. Of these, 51 % were Caucasians and 49% minority. Proportionally, these rateswere higher for the minority group, who were only 38 % of the total population, while the proportion was lower for the Caucasians,who composed 62% of the total population. The minority group was significantlyhigher on the MMPI Fand SchizophrenicScaleand on the total Gurin score. Since 64 casesdid not completethe MMPI-168 due to factors of poor reading, confusion, or refusal, the higher rates of emotional disturbance among the non-
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
326
KAHNETAL.
Caucasians could be on artifact of that circumstance. However, the ethnicity of t h e who did not take the W I - 168 was proportional to their representation in the total population. Those who did not take the MMPI were verbally administeredthe Gwinet al. (1960) Scale, which coIlsistsof a series of symptomstatements.While there are no appropriatenonns, the minorities did report a somewhathigher number of overall symptoms and a higher number of severe symptoms than did the Caucasians, which is consistent with the MMPI results.
Dual Diagnosis
The number of cases that met criteria for both substance misuse and severe emotional disturbance, based upon the 99 cases that completed the MMPI, was 29.29%.Of those classified as severesubstancemisusers, 70.73% were also classified as severely emotionally disturbed.Of those classified as severely emotionally disturbed, 54.71% were also classified as substance misusers. Thus,severe substance misuse and severeemotional disorder were highly associated in thispopulation. Cluster Analysis-Personality Types
In order to discern meaningful subgroupsbased on personality and substance abuse variables, a K-means cluster analysiswas performed on half the total population who had MMPI scores (even numbered cases) and cross-validatedon the other half. The mean score for each variable found in the initial cluster analysis and that found in the cross-validation analysis are given in Table 3. Most variables were quite similar across the two cluster solutions, indicating that the cluster groupings were very reliable. The three resulting clusters were as follows. The Q p e Z homeless, constituting24.27% of the population. They were characterized by scores of over 80 on the MMPI Psychotic Scales of schizophrenia, paranoia, and depressionas well as on psychopathicdeviant and hypochrondriasis. This grouping also had a mean substance misuse scale score in the severe range (23-25).They were characterizedas having dual diagnosis, being severely emotionally disturbed with concurrent severe substance misuse. The Type ZZ homeless consisted of 39.3% of the population and were characterized by a mean substancemisuse score in the moderate-to-severerange (21-23) and an MMPI pattern with two scales with Tscores in the 70s (psychopathic deviant and schizophrenia).This group was designated as having a pemnality disorder-substancemisuse pattern. The Type IZZhomeless, constituting 37.3% of the population, were well within normal limits on all MMPI scales and were substantially below the criterion for
SUBSTANCEMISUSE,EMOTIONAL DISTURBANCE, DUAL DIAGNOSIS
327
Table 3 Means for Each Variable for the Initial (#1) and for the Cm-Validated (#2) Cluster Analysis
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
Extremely Disturbed
No Pathology
Personality Disorder
Typen
I)pem
Type1 #l
L F K Hs D
HY Pd
Mf Pa Pt sc
Ma Si Ak
53.11 112.00 48.77 84.11 80.00 14.66 84.63 62.54 89.54 76.90 109.09 74.36 51.81 23.00
Nil1
#2
#2
#l
48.00 91.92 49.84 78.15 83.46 76.84 81.41 58.00 81.33 80.41 98.41 67.500 60.25 25.38 N=13
50.20 78.166 47.11 64.94 73.77 66.83 80.66 55.16 71.94 76.611 82.88 70.77 60.94 23.05 N=18
50.94 87.35 46.35 55.35 66.55 61.65 75.619 55.047 79.809 62.381 72.904 65.85 60.61 21.28 N=21
#l 54.55 61.84 52.73 55.84 59.15 59.05 61.05 59.00 56.15 57.57 55.21 63.57 53.94 14.63 N=19
Table 4 Results of Analysis of Variance Testing for Univadate Differences Between the 3 Clusters
Variable
F ratio
Schizophrenia Psychopathic deviate Paranoid Psychasthenia Depression F Scale Hypochmdriasis Hysteria Alcoholism patterns and effects Social introversion
43.63 32.464 29.91 25.573 22.529 20.342 18.939 17.899 5.332 4.256 3.315 1.862 0.479 0.308
Mania K Scale L Scale Mmlinity-femininity
P .001
.001 .001 .001
.001 .001 .001 .001 .001 .010 .u28 ,149 .699 .820
#2
50.84 62.17 51.70 51.88 53.17 53.35 56.16 56.83 52.00 47.33 50.22 56.11 51.22 15.55 N=18
KAHNETAL.
328 1
TorTc
7
L
F
K
1.5K
2
D
3
Hy
4
Pdt.4K
9
6
MI
'
Pa
1
8
9
R t I K SctlK Mat.ZK
120-
0
SI
TaiTc
-120
115
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
]lo{ 105 IW'
6
95
The International Journal of the Addictions, 27(3), 317-330,1992
Substance Misuse, Emotional Disturbance, and Dual Diagnosis in a MeallLine Population of Mixed Ethnicity Marvin W. Kahn Maureen Hannah Shari Kirkland Susan Lesnik Camille Clemens Daniel Chatel University of Arizona Tucson, Arizona
Abstract This study investigated the rates of severe substance misuse, severe emotional disturbance, and dual diagnosisin a meal-linepopulation of mixed ethnicity, 75 % of whom were homelessand the remaindernear-homeless. Alcohol and/or drug use was reported by 93 % and severe substance misuse was found in 39%of the population. Severe mental illness was found in 54%of the population. Both conditions, dual diagnais, was found in 29%of the cases.A cluster analysis of the total population found b e e types: those with dual diagnosis (24.27%),those with serious substance misuse and personality disorder (39.3%),and those with neither severe 317
copyright 0 1992 by Marcel D e k , Inc.
KAHNETAL.
318
disorder (37.3%). The ethnicity of the homeless individual was very weakly, if at all, associated with the disorders.
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
INTRODUCTION To what extent mental illness is associated with subtance misuse in a homeless population is the focus of this study. Both disordershave been found in a substantial proportionof American homeless populations. Mulken and Spence (1984) reviewed studiesof substancemisuse rates in the homeless and found a range from 20 to 50%. Studies of mental illness in homeless populationshave an even wider range. Bachcachs’ review (1984) found rates from 20 to 97%. While substance misuse and mental illness in homeless populations are not mutually exclusive disorders, only a few studies have focused on establishingthe rates of those with both disorders-or with dual diagnosis as it has been called (Fisher and Breakey, 1987; Kahn et al., 1987; Wright et al., 1987; Hinkin et al., 1988; Koegel and Burnham, 1987). The rates of dual diagnosisfound range from 10to 47%. Table 1summarizesthe major studiesof ratesof alcohol-drug and mental disorder in homeless vs populations. Differences in the populations studied, in the criteria used for homelessness, substanceabuse, and mental disorder, make it difficult to compare findings and to reach any fm conclusions with regard to the extent of dual diagnosis in homeless populations. Treatment and managementof those with dual diagnosispresents a challenge and a need for coordination of programs, which in recent history have tended to focus almost exclusively on one or the other disorder. This study investigated rates of each disorder and of dual diagnosis in a mealline population, using relatively objective and well-defined criteria of disorder. Since the population studied was of mixed ethnicity that variable was also considered in association with disorder rates.
METHOD Subjects Subjects (N= 163) were obtained from a soup kitchen meal line providing a midday meal in 1986-87. It was located in Tucson, Arizona,in an area bordering subsidized housing projectsfor the poor, many of whom were minorities. The center served 200 to 400 people a day, depending upon the season of the year.
SUBSTANCEMISUSE, EMOTIONAL DISTURBANCE,DUAL DIAGNOSIS
319
Sampling
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
In order to achieve a representative sample of age, sex, and ethnicity, a preliminary estimate of the proportions of these characteristics present in the total populationwas made by teamsof investigatorswho recorded their estimate of each meal-line participant's characteristic on those variables for 10 consecutive meals. Th- estimates were then compared across raters and substantial agreement was found. The research sample was set so as to meet the proportionsof the demographic characteristics determined by the preliminary estimate. Each interviewer was assigned to do 15-20 cases,each with specific characteristicsneeded for the sample. Interviewers were instructed to approach the fmt person in line who appeared to meet the assignedcharacteristic.If that person agreed to participate and the needed characteristicswere verified, the interview proceeded. Only 11misidentifications occurred,seven of which were errors of age category. Thus, it appeared that the preliminary visual identification method was reasonably valid. "he proportions found in the preliminary observations were as follows. Ethnicity:Caucasian 5748,Hispanic27 %,Black 8%,Native American 7 I. Sex: male 8956, female 11%.Age: 12-18,02%; 19-44,65%; 45-65,31%; 65+, 27%. The researchsurvey samplevaried slightlyfrom thison ethnicity.It was 62% Caucasian and 38%minority.The demographic characteristicsof the total sampleand various subgroupers are given in Table 2. Survey Instruments 1. Demographicdescriptivedata were obtained by using a 46-item structured interview f o m covering the major content areas given in Table 2. 2. Substance misuse level was determined by the subjects' answers to the G-K substance abuse patterns and effects survey (Kahn and Gingras, 1983). This is a 44-item, verbally administered objective questionnaire providing descriptive information about amount, frequency, type of substance, and problems encountered as a result of substancemisuse in the areas of social-familyrelations, health, legalarrest, and vocational functioning. 3. Emotional disturbance was assessed in most casesby using a short form of the Minnesota Multi-Phasic inventory, the MMPI-168 (Overall et al., 1976). It is reported to correlate .80 with the full MMPI. A Spanish translation was available. mostly due to language, For those who were unable to complete the -1-168 attention span, and/or difficulty in understanding the questions, the 24-item Gurin et al. (1960) list of symptoms was administered verbally.
(1SW
Studies to drtc
d e w s . 28
M u l k m d S p c n ~ e V-locations
meatally ill 1978 to 1983
d e w s . mdks ofhomeless
variouslocatioap
€3adml&(1984)
19
60
40
- -
18
- -
- -
-
-
- -
10
13
20
22
F
100
85
LoaAngeles New York City
Lipton et al. (1982)
-
80
Pau (1983)
78
78
87
&stoa
Basquk (1983)
179
M
345
philadelphi.
Arce et al. (1983)
N
Brown et al. (1983) phoenix. AZ
Location
study
% Sex
. .
Skid row inhabitants Homelessfmm missioas, shelter, and jail
Homclespperscnrs
Various subject groups and sites
less popllatiom
14 studies with sufficient data. 20-458 misuse invarioushome-
Stancemisurc. Range 18 to 29%
measure sub-
18% 5 Studies also
20+%
ing, Geaeral
Psychiatric statls 20% schedule 34% short Michigen 29.9% males, Alcohol screen- 42.3% females
varies by shady
Varies by shady
examination
Psychiahic
atriCserviCelrsas
Gfos estimate
ratings
Y
Notgiven
28 %
12-251
20to60%
97 %
50%
20%
40% 40%
25+%
iU
M
evaluation Interviewer
Skidmwbameless
Variow subject groups and sites
Substance mislEx.
Psychiatric stabs 29%
exarmnatlom
PsyclliatriC
Basis of diagwsis
Emergency psychi-
Meallheusers
Cityrunemergency shelter residents Shelterresidents
Subject4te charactaistics
Summary of Major Studies of Alcoholism-Mental Illness A the Hamekss 1983-1 988
Table 1
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/21/14 For personal use only.
Notgiven
16%
Notdettrmined
Not determind Notdetermined
Not detCrmined
Not detedned
Not determined
Not determined
diagnosis
F
7
hhgeles
Various~ughout the USA
Koegely and (1987)
Stark (1987)
8
Meal-line users
11,797 71
Wrightetd. (1987) Variousthroughout USA 29
98 5
- -
10%
28% 23%males, IO%males,6% 37 % females females
28%
Not given
disorder
44’16schim- 47%al&l phreniaor andschizoaKectdisphmniaor order affect
30%
Range from 9 to Not given 57%.Stable mode about 30-33%
Indigent inpatients in Admission to 100% public alcohol Alcohol Tteatreceptioncenter mentMMPI Pooled data from 16 Professionally 35%males, cities of the Health 12%females diagnosed, in Care for Homeless for &ox, or Project come to clinic underthe influence
1986
Homeless populations Not given in 41 elected studies from 1890 to
a d Effects Questionnaire. WI-168 95.3 4.7 Four groups of NIMH Diagnostic 32.77%in the intercity homeless Interview last year Scbedule
92
368
-
379
106
Hinken et al. (1988) Tucsm, AZ
-
Tucsm, AZ
Kabn et al. (1987)
tionnaire, minimental stam 33% K-G DrugAlcohol Use
Health QWS-
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KAHNETAL.
322
Tnbk 2 Selected Denmgraphk-Desotfptive Charactenstbs of the Meal Population by 'Total Group" and =Ethnk, 'Substance misuse' and "EmotionalDisorder Categodes
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&UP
Variable
misuser
Severe emotion disorder
Caucasian
Caucasian
Total
Substance
population
Non-
N
163
64
54'
101
62
Sex: M P ZAge, years SD -city:
91% 9% 36.76 12.65
98% 2% 35.78 11.36
89% 11% 35.11 12.3
91% 9% 36.70 12.65
90%
CaUCaSiao
62%
24% 7% 7%
61% 25 % 5% 9%
49% 34% 8% 9%
100%
HiSpiC
45 % 7% 45 %
38% 6% 50%
49% 9% 43%
47 96 4% 41%
43% 11% 35 %
10.975 2.61
10.89 2.46
11.09 2.80
11.19 2.23
10.63 3.12
7596
81%
55%
85 96
57%
74%
80%
55%
83%
58%
48 %
52%
42 %
50%
44%
19% 29% 6%
17% 33% 3%
32% 34% 9%
18% 31% 5%
21% 26% 8%
30% 37%
40% 38%
35% 18%
28% 43%
34% 26%
2%
0% 22% 12% 67%
0% 17% 27% 19%
2% 16% 43 96 67 %
1% 29% 16% 28%
Black Native American Marital status: Single Matrid Divorced-separated Other E4l;Cation: X Years
SD Homeless criterion: A. Slept last night in otherthanownor another's home B. Usuallysleepin other than own or another home Live alone Recently assaulted:
Beaten Robbed Sexual assault Duration of homelessness: A. Lessthan6months B. Morethanayeat Income source: Full-time job
Part-timejob 18% Public assistance,food stamps 27% Sell blood 57%
10% 36.85 13.85
100% 100% 100%
[conrinued)
SUBSTANCEMISUSE,EMOTIONALDISTURBANCE, DUAL DIAGNOSIS
323
Table 2 (continued)
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Severe
Variable Self-& health status: Excellent-good Fair-poor Hospitnlized in the last YMental hospitalization in thelast3years Reason homeless: No job Own choice Other want off the srreets
Total population
Substance
emotion
misuser
disorder
Caucasian
NonCaucasian
65 % 35 %
50% 50%
70% 30%
65 % 35 %
66% 34%
49%
19%
50%
53%
44%
20%
18%
25%
2396
15%
39% 27% 34% 89%
33% 27 % 50% 87 %
38% 21% 41% 87 %
40%
44% 15% 41% 85%
35 96 25 % 91%
Procedure Subjects who agreed and whose required characteristics were verified were interviewed as privately as possible at a table on the grounds away from the line and administered the instruments in a fmed order. From 35 to 60 minutes was required per subject.
Criterion Definitions In order to objectively classify subjects,defintive criteriawere designatedfor the categoriesof Homelessness, Severe Mental Illness, and Severe Substance Misuse. The standards used for each designation were as follows. (1) Homelessness: From the structured questionnaire, and individual was designated homeless if his answerto both of these questions: where did you sleep last night? and where do you usually sleep? was other than "their own home" or "at the house of a friend or relative." Those that usually slept in homes other thantheir own were considered to be near-homeless. (2) Severe Substance Misuse: A score of 22 or above on the Substance Abuse Patterns and Effects Questionnaire was used, as this level is well above the cutoff scorethat distinguishedalcoholicsin treatment from medical outpatients (Kahnand Gingras, 1983). (3) Severe Mentallllness:This was defined as a -1-168 T-score of 80 or above (3 standard deviations above the mean) on one or more of the followingscales: Depression, Paranoia, Schizophrenia, and Mania.
KAHNETAL.
324
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Data Analysis Data were analyzed descriptively by the BMDP Statistical Package pixon, 1985) for all variables for the total population. Additionally, subjects were classified by categories Caucasian, Minority, severe substance misuser, and extreme emotional disturbance. These groups were then compared. Demographic and substance abuse data were. obtained from all 163 subjects. However, only 99 subjects completed the MMPI-168, so the extreme emotional disturbance category was based on 99 subjects. A cluster analysis using the 99 subjects with both MMPI scoresand the alcohol-drug scores was performed on half of the cases, using the K-means clustering technique.This was done fmt with an exploratory 6-cluster solution,from which it was detennincd that a meaningful 3-cluster solution was indicated. That 3-cluster solutionwas then performed on the fmt half of the population and was submittedto cross-validation on the other half of the population.
RESULTS 1.
The Meal-Line Population
Table 2 surmnarizes the descriptiveinformation from the demographic interview. The data are given by category: Total Population, Substance Misuser, Severe Emotional Disorder, Caucasian, and Non-Caucasian.
Demographics The Minority group, as can be seen in Table 2, constituted 38%of the total population, and was not significantlydifferent from Caucasianswith regard to age (X = 36.85 y m ) or education, although they averaged a half year leas schaoling. They were likely to be married, although most individualsof both groups were currently single.
Homelessness By our strict criterion, the Minority population had a lower percent of homeless individuals (57.5%) than did the Caucasian population (84.0%).
11.
Substance Misuse
Only 6.8%of the total meal-line population reported that they did not drink or use drugs at all. The abstinenceproportion was highest for the minor if^ subjects (32.7%).While a quarter (28.6%)of the total population was daily drinkers,only
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SUBSTANCE MISUSE, Eh4OTIONAL DISTURBANCE, DUAL DIAGNOSIS
325
12.7%of the minorities drank daily. For the severe substance abuser designated group, 59.4%were daily drinkers. Beer was the most used beverage; two-thirds or more of all population groups used it. The mean amount of alcohol consumed per drinking occasion, for those who drank, was an equivalent of 58 oz of hard liquor. Although fewer minorities drank, those who did consumed more than did the Caucasians (64 oz compared to 58 02). The highest umsumption of alcohol was in the designatedsubstance abuse group, who reported drinking an average of 95 oz per drinking session. About two-thirds of the total population used other drugs, with 18.1% using them daily. Marijuana was used by 50 to 60% of all population groups. Narcotics, cocaine, and hallucinogenics were less frequently used. The rate of this type of drug use by the minorities (1 1%)was about twice that for the population as a whole. Serioussocial, vocational, and family difficultiesc a d by substancemisuse were reported by about a third to a half of all subpopulationsexcept for the severe substanceabusers. Sixty to 80% of that group reported such problems. About half or more of each of the various populations groupings had been in trouble with police due to substancemisuse. This rate was highest among the designated alcoholics (82%).Over half of all the arrests were for drunk and disorderly behavior or DWI.Assault and robbery accounted for about 25 % of all arrests, but 1 % for homicide. The substance misusers had the highest rate of arrest for all offense categories. The mean age when substancemisuse started was just about the same for the Caucasiansand minorities(15.3years) and youngest for the emotionally disturbed group (13.94years). A thirdto a half of all groups said that substancemisuse was a problem for them. About 50%of both Caucasian and minority groups reported other substancemisusers in their close family. The figure was 70%for the designated severe substance misusers. By the alcohol survey criterion, 64 cases,or 39% of the total population, met the criterion for severe substance misuse. Of these, 30%were minority,proportionately somewhat lower than their proportion (38%)in the population.
111.
Severe Emotional Disturbance
Overall, 54%of the 99 cases with complete MMF'I-168 scores met the criterion for severe emotional disturbance. Of these, 51 % were Caucasians and 49% minority. Proportionally, these rateswere higher for the minority group, who were only 38 % of the total population, while the proportion was lower for the Caucasians,who composed 62% of the total population. The minority group was significantlyhigher on the MMPI Fand SchizophrenicScaleand on the total Gurin score. Since 64 casesdid not completethe MMPI-168 due to factors of poor reading, confusion, or refusal, the higher rates of emotional disturbance among the non-
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326
KAHNETAL.
Caucasians could be on artifact of that circumstance. However, the ethnicity of t h e who did not take the W I - 168 was proportional to their representation in the total population. Those who did not take the MMPI were verbally administeredthe Gwinet al. (1960) Scale, which coIlsistsof a series of symptomstatements.While there are no appropriatenonns, the minorities did report a somewhathigher number of overall symptoms and a higher number of severe symptoms than did the Caucasians, which is consistent with the MMPI results.
Dual Diagnosis
The number of cases that met criteria for both substance misuse and severe emotional disturbance, based upon the 99 cases that completed the MMPI, was 29.29%.Of those classified as severesubstancemisusers, 70.73% were also classified as severely emotionally disturbed.Of those classified as severely emotionally disturbed, 54.71% were also classified as substance misusers. Thus,severe substance misuse and severeemotional disorder were highly associated in thispopulation. Cluster Analysis-Personality Types
In order to discern meaningful subgroupsbased on personality and substance abuse variables, a K-means cluster analysiswas performed on half the total population who had MMPI scores (even numbered cases) and cross-validatedon the other half. The mean score for each variable found in the initial cluster analysis and that found in the cross-validation analysis are given in Table 3. Most variables were quite similar across the two cluster solutions, indicating that the cluster groupings were very reliable. The three resulting clusters were as follows. The Q p e Z homeless, constituting24.27% of the population. They were characterized by scores of over 80 on the MMPI Psychotic Scales of schizophrenia, paranoia, and depressionas well as on psychopathicdeviant and hypochrondriasis. This grouping also had a mean substance misuse scale score in the severe range (23-25).They were characterizedas having dual diagnosis, being severely emotionally disturbed with concurrent severe substance misuse. The Type ZZ homeless consisted of 39.3% of the population and were characterized by a mean substancemisuse score in the moderate-to-severerange (21-23) and an MMPI pattern with two scales with Tscores in the 70s (psychopathic deviant and schizophrenia).This group was designated as having a pemnality disorder-substancemisuse pattern. The Type IZZhomeless, constituting 37.3% of the population, were well within normal limits on all MMPI scales and were substantially below the criterion for
SUBSTANCEMISUSE,EMOTIONAL DISTURBANCE, DUAL DIAGNOSIS
327
Table 3 Means for Each Variable for the Initial (#1) and for the Cm-Validated (#2) Cluster Analysis
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Extremely Disturbed
No Pathology
Personality Disorder
Typen
I)pem
Type1 #l
L F K Hs D
HY Pd
Mf Pa Pt sc
Ma Si Ak
53.11 112.00 48.77 84.11 80.00 14.66 84.63 62.54 89.54 76.90 109.09 74.36 51.81 23.00
Nil1
#2
#2
#l
48.00 91.92 49.84 78.15 83.46 76.84 81.41 58.00 81.33 80.41 98.41 67.500 60.25 25.38 N=13
50.20 78.166 47.11 64.94 73.77 66.83 80.66 55.16 71.94 76.611 82.88 70.77 60.94 23.05 N=18
50.94 87.35 46.35 55.35 66.55 61.65 75.619 55.047 79.809 62.381 72.904 65.85 60.61 21.28 N=21
#l 54.55 61.84 52.73 55.84 59.15 59.05 61.05 59.00 56.15 57.57 55.21 63.57 53.94 14.63 N=19
Table 4 Results of Analysis of Variance Testing for Univadate Differences Between the 3 Clusters
Variable
F ratio
Schizophrenia Psychopathic deviate Paranoid Psychasthenia Depression F Scale Hypochmdriasis Hysteria Alcoholism patterns and effects Social introversion
43.63 32.464 29.91 25.573 22.529 20.342 18.939 17.899 5.332 4.256 3.315 1.862 0.479 0.308
Mania K Scale L Scale Mmlinity-femininity
P .001
.001 .001 .001
.001 .001 .001 .001 .001 .010 .u28 ,149 .699 .820
#2
50.84 62.17 51.70 51.88 53.17 53.35 56.16 56.83 52.00 47.33 50.22 56.11 51.22 15.55 N=18
KAHNETAL.
328 1
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