Mental Health
As the quote above suggests, mental health has been in the minds of policy makers at the highest levels for some years. In 2011, HM Government released 'No Health Without Mental Health: a cross-overnment mental health outcomes strategy for people of all ages'. This document voiced an aim of 'reducing the gap' between the outcomes of mental and physical health by giving mental health a 'parity of esteem' with physical health. The importance of achieving this 'parity of esteem' has since been ratified and vocalised by the Royal College of Psychiatry, the
Directorate of Public Health and various mental health charities and foundations (RCPsych, 2013; RCPsych, 2013) . It is still very much on the political agenda.
On this page we will consider some of the evidence from the literature relating to homelessness and mental ill health and then briefly consider some practical issues that the primary care work force might consider when addressing these issues in their day to day workings. As with lots of information relating to homelessness and health, it is unfortunate that there is almost no evidence about how mental health issues affect the 'hidden homeless', who make up the vast majority of people with unstable or unsuitable accommodation. Most of the evidence comes from analysis of roofless/rough sleepers and those who were in direct access shelters at the time of the study and on this page the descriptor of 'homeless' general means rough sleepers.
The Mental Health of Homeless Groups
Research has consistently shown that mental health problems are more common in homeless patients than in the general population. Common mental health problems (including depression, anxiety, obsessive compulsive disorder and many more) may be twice as common in the homeless population. (Office of National Statistics 1994, 2000). Serious mental illness, including major depression, schizophrenia and bi-polar disorder, are reported to be present in at least 25-30% of rough sleepers and hostel users (Folsom 2002, Buhrich 2003, Scott 1993).
The high rates of serious mental illness seen in homeless groups is further supported by data from psychiatric institutions. A Europe-wide cohort study found that over 30% of British patients diagnosed with schizophrenia, who were accessing psychiatric services, had experienced homelessness at some point in their lives (Bebbington, 2005).
Personality disorders are also common. In one Edinburgh-based study, 70% of participants in a shelter had at least one diagnosable personality disorder (Murphy et all, 2002). In a more recent UK survey, workers from a wide range of homeless services estimated that at least 2/3 of their homeless clients exhibited characteristics compatible with a personality disorder (Middleton 2008). For more discussion about personality disorders and how to approach them in practice, go to the PERSONALITY DISORDERS page.
There is also evidence that homeless patients are more likely to attend acute and emergency services regarding their mental health problem than primary care (O'Neill, 2007). In one large study, spanning all emergency department presentations in England over 14 years, 10% of all attempted suicide presentations were from people with no fixed abode, despite that group representing a tiny fraction of the population (Haw, 2006). One study in London found that 15% of all deliberate self harm episodes related to homeless people (Cullum, 1995).
Considerations in Practice
Knowing that homeless patients are at greater risk of having a mental health problem, practices might be able maximise the suitability of their services to account for this. It might all start at the front door. The reception staff of a primary care surgery are the very first interaction patients have with the surgery, whether it be over the telephone or face to face. Our survey showed that receptionists felt more able to engage and be supportive and empathetic with homeless patients after they had learned more about the issue (this was not limited to receptionists). How they learn more about the issue could vary from on the job experience to a dedicated training event hosted by the practice or local homeless charity.
When a clinician is meeting a homeless patient with a diagnosed or suspected mental health issue, a detailed history of previous treatments, admissions, self harming, overdoses and involvement with services is vital. There may well be people still involved in their situation who could provide valuable support and information.
If prescribing is indicated, then consider safety. Will there be any potential interactions with other medications or substances (prescribed or otherwise)? How long should the script be? What are the follow up arrangements? Does the patient know how to access the system for appointments or repeat prescriptions? For example, prescribing a 2 months supply of antidepressants to a new homeless patient with alcohol dependence and a recent history of overdose would not be ideal!
If the prescription of something potentially unsuitable is instigated by the patient and concerns are raised about addiction to presrcription medications or diversion then you might want to read the ADDICTION TO PRESCRIPTION MEDICATIONS page for further advice.
Continuity of care can be extremely important with vulnerable groups, who often find it more difficult and distressing coming to a surgery. Recognising this and attempting to maintain the continuity could have a substantial benefit for homeless patients in primary care.
On this page we will consider some of the evidence from the literature relating to homelessness and mental ill health and then briefly consider some practical issues that the primary care work force might consider when addressing these issues in their day to day workings. As with lots of information relating to homelessness and health, it is unfortunate that there is almost no evidence about how mental health issues affect the 'hidden homeless', who make up the vast majority of people with unstable or unsuitable accommodation. Most of the evidence comes from analysis of roofless/rough sleepers and those who were in direct access shelters at the time of the study and on this page the descriptor of 'homeless' general means rough sleepers.
The Mental Health of Homeless Groups
Research has consistently shown that mental health problems are more common in homeless patients than in the general population. Common mental health problems (including depression, anxiety, obsessive compulsive disorder and many more) may be twice as common in the homeless population. (Office of National Statistics 1994, 2000). Serious mental illness, including major depression, schizophrenia and bi-polar disorder, are reported to be present in at least 25-30% of rough sleepers and hostel users (Folsom 2002, Buhrich 2003, Scott 1993).
The high rates of serious mental illness seen in homeless groups is further supported by data from psychiatric institutions. A Europe-wide cohort study found that over 30% of British patients diagnosed with schizophrenia, who were accessing psychiatric services, had experienced homelessness at some point in their lives (Bebbington, 2005).
Personality disorders are also common. In one Edinburgh-based study, 70% of participants in a shelter had at least one diagnosable personality disorder (Murphy et all, 2002). In a more recent UK survey, workers from a wide range of homeless services estimated that at least 2/3 of their homeless clients exhibited characteristics compatible with a personality disorder (Middleton 2008). For more discussion about personality disorders and how to approach them in practice, go to the PERSONALITY DISORDERS page.
There is also evidence that homeless patients are more likely to attend acute and emergency services regarding their mental health problem than primary care (O'Neill, 2007). In one large study, spanning all emergency department presentations in England over 14 years, 10% of all attempted suicide presentations were from people with no fixed abode, despite that group representing a tiny fraction of the population (Haw, 2006). One study in London found that 15% of all deliberate self harm episodes related to homeless people (Cullum, 1995).
Considerations in Practice
Knowing that homeless patients are at greater risk of having a mental health problem, practices might be able maximise the suitability of their services to account for this. It might all start at the front door. The reception staff of a primary care surgery are the very first interaction patients have with the surgery, whether it be over the telephone or face to face. Our survey showed that receptionists felt more able to engage and be supportive and empathetic with homeless patients after they had learned more about the issue (this was not limited to receptionists). How they learn more about the issue could vary from on the job experience to a dedicated training event hosted by the practice or local homeless charity.
When a clinician is meeting a homeless patient with a diagnosed or suspected mental health issue, a detailed history of previous treatments, admissions, self harming, overdoses and involvement with services is vital. There may well be people still involved in their situation who could provide valuable support and information.
If prescribing is indicated, then consider safety. Will there be any potential interactions with other medications or substances (prescribed or otherwise)? How long should the script be? What are the follow up arrangements? Does the patient know how to access the system for appointments or repeat prescriptions? For example, prescribing a 2 months supply of antidepressants to a new homeless patient with alcohol dependence and a recent history of overdose would not be ideal!
If the prescription of something potentially unsuitable is instigated by the patient and concerns are raised about addiction to presrcription medications or diversion then you might want to read the ADDICTION TO PRESCRIPTION MEDICATIONS page for further advice.
Continuity of care can be extremely important with vulnerable groups, who often find it more difficult and distressing coming to a surgery. Recognising this and attempting to maintain the continuity could have a substantial benefit for homeless patients in primary care.
References
Bebbington, P.E., Angermeyr, M., Azorin, J., et. al. The European Schizophrenia Cohort: a naturalistic prognostic and economic study. Social Psychiatry and Psychiatric Epidemiology 2005 Vol. 40, pp. 707-17.
Buhrich, N., Hodder, T., Teesson, M. Schizophrenia among homeless people in inner-Sydney: current prevalence and historical trends. Journal of Mental Health. 2003. Vol. 12, No. 1, pp. 51-57
Cullum S., et. al. Deliberate self-harm: the hidden population. Health Trends. 1995. Vol. 27, pp. 130-32.
Folsom, D., Jeste, D. Schizophrenia in homeless persons: as systematic review of the literature,. Acta Psychiatrica Scandinavica. 2002. Vol. 162, No. 6, p. 404.
Haw, C., Hawton, K., Casey, D. Deliberate self-harm patients of no fixed abode: a study of characteristics and subsequent deaths in patients presenting to general hospital. Social Psychiatry and Psychiatric Epidemiology. 2006. Vol. 41, pp. 918-25.
Middleton R. Brokering Realities. Community Links. 2008.
Murphy, T., Burley, A. and Worthington, H. Homelessness and Personality Disorder. Executive Summary, Psychotherapy Dept, Royal Edinburgh Hospital, Edinburgh. 2002.
Office for National Statistics (1996), Psychiatric morbidity among homeless people. OPCS Survey Surveys of Psychiatric Morbidity in Great Britain: Report 7
Office for National Statistics (2000), Psychiatric Morbidity Among Adults Living in Private Households.
O’Neill, A., Casey, P., Minton, R. The homeless mentally ill - an audit from an inner city hospital. Irish Journal of Psychological Medicine. 2007. Vol. 24, No. 2, pp. 62-66.
Royal College of Psychiatrists. Bridging the Gap: the financial case for reinvesting in mental health. 2013. Available online at: http://www.rcpsych.ac.uk/pdf/Bridging_the_gap_summary.pdf
Royal College of Psychiatrists. Whole person Care - From Rhetoric to Reality: achieving parity between mental and physical health. 2013. Available online at: http://www.rcpsych.ac.uk/pdf/Parity%20of%20esteem%20sum.pdf
Scott, J. Homelessness and mental illness. British Journal of Psychiatry. 2003. Vol. 162, pp. 314-24.
Bebbington, P.E., Angermeyr, M., Azorin, J., et. al. The European Schizophrenia Cohort: a naturalistic prognostic and economic study. Social Psychiatry and Psychiatric Epidemiology 2005 Vol. 40, pp. 707-17.
Buhrich, N., Hodder, T., Teesson, M. Schizophrenia among homeless people in inner-Sydney: current prevalence and historical trends. Journal of Mental Health. 2003. Vol. 12, No. 1, pp. 51-57
Cullum S., et. al. Deliberate self-harm: the hidden population. Health Trends. 1995. Vol. 27, pp. 130-32.
Folsom, D., Jeste, D. Schizophrenia in homeless persons: as systematic review of the literature,. Acta Psychiatrica Scandinavica. 2002. Vol. 162, No. 6, p. 404.
Haw, C., Hawton, K., Casey, D. Deliberate self-harm patients of no fixed abode: a study of characteristics and subsequent deaths in patients presenting to general hospital. Social Psychiatry and Psychiatric Epidemiology. 2006. Vol. 41, pp. 918-25.
Middleton R. Brokering Realities. Community Links. 2008.
Murphy, T., Burley, A. and Worthington, H. Homelessness and Personality Disorder. Executive Summary, Psychotherapy Dept, Royal Edinburgh Hospital, Edinburgh. 2002.
Office for National Statistics (1996), Psychiatric morbidity among homeless people. OPCS Survey Surveys of Psychiatric Morbidity in Great Britain: Report 7
Office for National Statistics (2000), Psychiatric Morbidity Among Adults Living in Private Households.
O’Neill, A., Casey, P., Minton, R. The homeless mentally ill - an audit from an inner city hospital. Irish Journal of Psychological Medicine. 2007. Vol. 24, No. 2, pp. 62-66.
Royal College of Psychiatrists. Bridging the Gap: the financial case for reinvesting in mental health. 2013. Available online at: http://www.rcpsych.ac.uk/pdf/Bridging_the_gap_summary.pdf
Royal College of Psychiatrists. Whole person Care - From Rhetoric to Reality: achieving parity between mental and physical health. 2013. Available online at: http://www.rcpsych.ac.uk/pdf/Parity%20of%20esteem%20sum.pdf
Scott, J. Homelessness and mental illness. British Journal of Psychiatry. 2003. Vol. 162, pp. 314-24.