Mental Illness and Homelessness

NCH Fact Sheet #5
Published by the National Coalition for the Homeless, June 2008

An average of 16% of the single adult homeless population suffers from some form of severe and persistent mental illness (National Resource and Training Center on Homelessness and Mental Illness, 2003). While 22% of the American population suffers from a mental illness, a small percentage of the 44 million people who have a serious mental illness are homeless at any given point in time (National Institute of Mental Health, 2005). In a 2007 survey performed by the U.S. Conference of Mayors, of the 23 cities surveyed,  7.9% of the homeless population of individuals in a family suffer from some type of mental illness. Additionally, 22.4% of the homeless individuals in this survey have a mental illness.

Despite the disproportionate number of mentally ill people among the homeless population, the growth in homelessness is not attributable to the release of seriously mentally ill people from institutions. Most patients were released from mental hospitals in the 1950s and 1960s, yet vast increases in homelessness did not occur until the 1980s when incomes and housing options for those living on the margins began to diminish rapidly (see "Why Are People Homeless?," NCH Fact Sheet #1). The mass deinstitutionalization from mental health facilities occurred over forty years ago, yet the promise of community-based programs and outpatient services has not been kept especially towards the homeless and others living in poverty (Mental Illness, Chronic Homelessness: An American Disgrace, 2000). A new wave of deinstitutionalization and the denial of services or premature and unplanned discharge brought about by managed care arrangements may be contributing to the continued presence of seriously mentally ill persons within the homeless population.

Mental disorders prevent people from carrying out essential aspects of daily life, such as self-care, household management and interpersonal relationships. Homeless people with mental disorders remain homeless for longer periods of time and have less contact with family and friends. Many of the mentally ill (especially those with severe disorders such as schizophrenia, bipolar disorder, and major depression), both the homeless and others, often misinterpret the guidance of others and react irrationally because of their condition(s). This pushes away friends and family and other caregivers occasionally leading to homelessness or a longer a period of homelessness (Mental Illness, Chronic Homelessness: An American Disgrace, 2000).

The mentally ill homeless population encounters more barriers to employment, tend to be in poorer physical health, and have more contact with the legal system than homeless people who do not suffer from mental disorder. All people with mental disorders, including those who are homeless, require ongoing access to a full range of treatment and rehabilitation services to lessen the impairment and disruption produced by their condition. However, most people with mental disorder do not need hospitalization, and even fewer require long-term institutional care. According to the 2003 U.S. Department of Health and Human Services Report, most homeless persons with mental illness do not need to be institutionalized, but can live in the community with the appropriate supportive housing options (U.S. Department of Health and Human Services, 2003). Unfortunately, there are not enough community-based treatment services, nor enough appropriate, affordable housing, to accommodate the number of people disabled by mental disorders in the U.S. However, studies have found that a supported housing treatment program would most likely be more effective than other methods of treatment for homeless mentally ill individuals, and though the cost may be slightly be more, the increased benefits make supported housing the most effective method (Rosenheck, et.al., 2003)

Federal demonstration programs have produced a large body of knowledge on the service and treatment needs of homeless individuals with serious mental illnesses. The research exists to make effective programs, yet the political support and finances to support these programs has been minimal (Mental Illness, Chronic Homelessness: An American Disgrace, 2000). Many homeless people who have mental illnesses need independent housing with supports (National Resource and Training Center on Homelessness and Mental Illness, 2003).  Findings also reveal that persons with mental disorder and persons with addictive disorders share many of the same treatment needs, including carefully designed client engagement and case management, housing options, and long-term follow-up and support services.

Studies also emphasize the importance of service integration, outreach and engagement; the use of case management to negotiate care systems; the need for a range of supportive housing and treatment options that are responsive to consumer preferences; and the importance of meaningful daily activity. When combined with supportive services, meaningful daily activity in the community (including work), access to therapy, and appropriate housing can provide the framework necessary to end homelessness for many individuals.

POLICY ISSUES

Low-income people with mental disorders are at increased risk of homelessness. A variety of approaches must be employed to help them obtain and retain stable housing to prevent homelessness.

In addition, programs that assure access to mainstream and targeted community-based services for homeless people with serious mental illness, such as the Projects for Assistance in Transition from Homelessness (PATH) program, should be expanded. It was founded in FY2006 at only $54 million making it unable to meet the needs of many people with serious mental illness who are homeless or at risk of becoming homeless (National Health Care for the Homeless Council, 2007).

Supplemental Security Income (SSI) benefit levels must be increased so that disabled Americans are not forced to live in poverty.  Individual recipients of SSI receive $603 a month, and for many this is their sole source of income.  This allows an individual to afford only $180 for rent, making any kind of housing unaffordable (NLIHC, 2004). In most states, even if the SSI grant does cover the rent, only a few dollars remain for other expenses. Benefit levels have not kept up with increases in the cost of rent and therefore do not provide disabled individuals with adequate allowances for housing.

Finally, the commitment to making deinstitutionalization work as it was intended must be renewed. People with mental illness must be able to live as independently as possible with the help of expanded comprehensive, community-based mental health services and other supports. It is crucial that polices be proactive rather than reactive. Services such as crisis intervention, landlord-tenant intervention, continuous treatment teams and appropriate discharge planning in jails and inpatient facilities must be made available in all communities.

REFERENCES

Federal Task Force on Homelessness and Severe Mental Illness. Outcasts on Main Street: A Report of the Federal Task Force on Homelessness and Severe Mental Illness, 1992. Available, free, from the National Resource Center on Homelessness and Mental Illness, 262 Delaware Ave., Delmar, NY, 12054-1123; 800/444-7415.

Kaufman, Tracy L. Out of Reach: Rental Housing At What Cost? 1997. Available for $25.00 from the National Low Income Housing Coalition, 1012 14th St., NW, #610, Washington, DC 20005-3410, 202/662-1530.

Koegel, Paul, et al. "The Causes of Homelessness," in Homelessness in America, 1996, Oryx Press. National Coalition for the Homeless, 2201 P St., NW, Washington, DC, 20037; 202/462-4822.

Lezak, Anne and Elizabeth Edgar. Preventing Homelessness Among People with Serious Mental Illness: A Guide for States, 1998. Available, free, from the National Resource Center on Homelessness and Mental Illness, 262 Delaware Ave., Delmar, NY, 12054-1123; 800/444-7415.
National Institute of Mental Health. “The Numbers Count”, 2005. Available at www.nimh.nih.gov.

“Mental Illness, Chronic Homelessness: An American Disgrace”. Healing Hands, October 2000. Available from http://www.nhchc.org/healinghands.html.

National Low Income Housing Coalition. “Out of Reach 2004”. Available at www.nlihc.org.

National Resource and Training Center on Homelessness and Mental Illness, “Get the Facts”, 2003. Available at www.nrchmi.samhsa.gov.

Oakley, Deirdre and Deborah L. Dennis, "Responding to the Needs of Homeless People with Alcohol, Drug, and/or Mental Disorders," in Homelessness in America, Oryx Press, 1996. National Coalition for the Homeless, 2201 P St., NW, Washington, DC, 20037; 202/462-4822. Wells, Susan Milstrey. Projects for Assistance in Transition from Homelessness: A Summary of Fiscal Year 1994 State Implementation Reports, 1996. Available, free, from National Coalition for the Homeless, 1012 14th Street, NW, Suite 600, Washington, DC 20005; 202/737-6444.

Rosenheck, R., Kasprow, W., Frisman, L., and Liu-Mares, W. “Cost-effectiveness of Supported Housing for Homeless Persons with Mental Ilnesses”. Archive of General Psychiatry, Sepetmeber 2003. Available from www.archgenpsychiatry.com.

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National Resource Center on Homelessness and Mental Illness, Policy Research Associates, Inc., 262 Delaware Ave., Delmar, NY 12054; 1-800-444-7515; email: nrc@prainc.com.