Walking through the streets of any large city, one sees many homeless people. Nearly two in three have a history of some form of mental illness.
Hospitals have become the place where homeless people with serious mental illness go during a crisis, but hospitals are poorly equipped to meet their needs.
How can society improve the health of homeless people with mental health problems?
Jack Rodriguez is a fictional name we have given to a middle-aged man who was recently admitted to an Ontario hospital. His name and some details have been changed to preserve confidentiality. Rodriguez has lived with schizophrenia since he was a teenager. At this stage in his illness he primarily has ‘negative’ symptoms – such as a reduced ability to experience pleasure and other emotions, and a lack of relationships. He also suffers from paranoid delusions, meaning he feels constantly threatened. For many years, he has been homeless. Like many homeless individuals with severe mental illness, he prefers to sleep on a sidewalk rather than in a shelter, where he would have to follow rules and a schedule.
As Rodriguez has become older he has started to develop medical problems, and he currently suffers from an ulcer on his left buttock. This ulcer occasionally becomes infected, requiring treatment with antibiotics, and is unlikely to heal without regular wound care. Rodriguez has been in hospital for two months. While there, he has not allowed the nurses to change his dressings, and he has also declined to be treated with antipsychotic medications – a class of medications that might reduce his paranoia and help clear his thinking. His doctors feel uncomfortable discharging him as his ulcer is likely to worsen if he continues to sleep on the sidewalk. A psychiatrist who sees him outside the hospital believes that he meets criteria for a treatment order that would allow him to be treated with long acting, anti psychotic medications against his will (he would receive an injection once every few weeks). Rodriguez’s doctors have applied for the treatment order.
Keeping Rodriguez in hospital for months while waiting to see if these medications will work or not seems like a wasteful use of hospital resources, but discharging him back to the street also seems like a bad option. However, the waiting list for supportive housing options is long, and few if any psychiatric institutions would take him as a long-term inpatient.
This is Mr. Rodriguez’s story, but it is a common narrative faced by some of the estimated 10,000 people who are homeless on any given night across Canada, and the hospitals that provide their health care.
Mental health care, homelessness and the health care system
Homeless people are extremely vulnerable to serious physical and mental health problems – their average life span in Canada is 7 to 10 years shorter than the general population. A recent study found that homeless men in Canada have the same chance of living to the age of 75 as the average male in 1921 – before antibiotics were developed. People who are homeless are at a much higher risk of contracting infections such as tuberculosis and HIV. Homeless people also suffer disproportionately from violent crime – almost half of homeless people in Toronto report being assaulted within the past year. Between a quarter and a third of homeless people have a serious mental illness – schizophrenia, major depression, or bipolar disorder. Most homeless people who are mentally ill are not receiving adequate treatment for their illnesses. Homelessness is a daily struggle for the essentials of life – for safe shelter, food and security. This struggle means that many homeless ignore their health care in favor of trying to cope with day-to-day necessities.
When homeless people do come in contact with the health care system, they are often in crisis. Rather than seeing a family doctor in the early stages of illness, they are more likely to show up in an emergency department with more advanced disease. And they have complex needs which go beyond dealing with medical problems. Dr. Jeff Turnbull, the president of the Canadian Medical Association says that “it is very difficult for doctors and the health care system to unravel problems of severe mental illness and addiction.” Turnbull, who has been providing health care to the homeless at shelters in Ottawa for the past two decades, says “I went into the shelters thinking I could give people antibiotics” but quickly realized that “I couldn’t do that until I controlled mental illness and I couldn’t control mental illness until there was a stable living environment.”
Housing and health – new models of care
Supportive housing services for the homeless are provided by many different agencies. In Toronto, these agencies have now coordinated their intake processes, but in other cities the intake process can be very complicated. Waiting lists are long, and people can wait many years for supportive housing. And even after finding a place, homeless people with mental illness are often rejected by landlords or housing agencies for poor behavior, interpersonal difficulties and security concerns.
Dr. Stephen Hwang, a general internist and researcher at the Centre for Research in Inner City Health at St. Michael’s Hospital in Toronto is conducting a research study in which homeless people are provided with a rent supplement, help finding housing and specialized support services. The At Home Study, as it is known, is based on the premise that “housing is a human right and a fundamental precondition for getting healthy,” says Dr. Hwang. The study is looking at both health outcomes and the costs of providing the rent subsidy. The million dollar question is whether we can save the health care system money by paying for housing.
Dr. Vicky Stergiopoulos, a psychiatrist and researcher at the Centre for Research in Inner City Health notes that “there is no one size fits all approach” when dealing with the complex population of homeless people with serious mental health issues. Stergiopoulos argues that there needs to be a more concerted push to “create a menu of housing options for people to address their various needs and choices” as many people with serious mental illness cannot live independently. Part of the problem may be that insufficient funds are spent on supportive and public housing, not just for those with mental illness, but also for individuals with low incomes. For several years, public housing advocates have been promoting the ‘One Percent Solution’, in which federal and provincial governments would spend one percent of their budgets on housing. These efforts, however, have not gained political traction.
For those with severe mental illness, providing housing and intensive case management might actually save money. This line of argument is supported by work that Dr. Hwang has done previously. For example, a study he conducted found that the health care costs of homeless patients over the course of an acute care admission were $2500 higher than housed patients for similar hospital admissions. Hwang says that “the promise of the At Home Study is that it may be cost saving by preventing hospitalizations, emergency room visits, arrests and incarcerations”. Even if this turns out not to be true, many would argue that providing mentally ill homeless people with decent housing is simply the right thing to do.