March 2011, Volume 61, Issue 3

Opinion and Debate

Homelessness and Mental Health: Are we neglecting this grave issue?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

According to the United Nations, "absolute homelessness" describes the condition of people without physical shelter who sleep outdoors, in vehicles, abandoned buildings or other places not intended for human habitation. "Relative homelessness" describes the condition of those who have a physical shelter, but one that does not meet basic standards of health and safety.1 It is alternately defined as a "condition and social category of people without a regular house or dwelling because they cannot afford or are otherwise unable to maintain regular, safe, and adequate housing, or, fixed, regular and adequate night time residence."2 However, the legal definition varies from country to country. The United States Department of Housing and Urban Development (HUD) defines a "chronically homeless" person as an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more, or has had at least four episodes of homelessness in the past three years.3
An estimated 100 million people are homeless throughout the world, the majority of them women and dependent children whereas at least 600 million people live in shelters that are life threatening in the cities of developing countries.4 According to UN Habitat report 31.6% of the world\\\'s total urban population live in life-and health threatening homes mostly in Asia, Africa and Latin America.5
World literature does indicate a close association of mental illness with homelessness that needs attention.
A 2007 survey of 23 cities conducted by the US Conference of Mayors revealed 30% of the homeless population has mental illness.6 Senator Kirby of mental Health Commission of Canada stated that "an estimated 25-50% of homeless people have a mental illness and up to 70% of those with a severe mental illness also abuse substances. One in seven users of emergency shelters across Canada are children and almost a third of Canada\\\'s homeless are youths aged 16-24."7
In a study of a cohort of 201 homeless persons, it was found that 21% had mental illness. Seventy two percent had a diagnosis of drug abuse or dependence and 51% had alcohol abuse or dependence.8 Another review suggests alcohol abuse affects 30-40% and drug abuse 10-15% of homeless persons.9
One study10 showed that homeless adolescents demonstrated greater resilience than younger and older adults. Adolescents reported the shortest duration of homelessness, lowest number of life stressors, fewest physical symptoms, largest social networks, and fewest clinically significant mental health problems.10 Martens WH11 selected and reviewed 106 articles from MEDLINE and found that homeless persons suffer from tuberculosis, asthma, bronchitis and HIV infection. The prevalence of mental disorders varies from 80-95% in USA, Canada, Australia, Norway and Germany to 25-33% in Ireland and Spain. The most important mental disorders were: depression, affective disorders, substance abuse, psychotic disorders, schizophrenia and personality disorders. A French study revealed that Schizophrenia (43.7%) and substance use disorders (31.0%) were most common among homeless patients.12
Homeless people are also exposed to violent victimization that adds to the mental health morbidity. A study13 conducted in Australia revealed that 48% of the participants reported past year victimization. Being female, schizophrenia/ psychotic disorder, PTSD, depression and regular use of psychostimulants were associated with increased risk of victimization. Salkow and Fichter14 reviewed 200 articles that were published in 2002. The salient features in their paper mentions 3.5 million people in US experience homelessness in a given year that is 1% of the population and 0.25% of German population suffer from the same problem.14 Representative sample of homeless men in Munich, Germany show life time prevalence rates for alcohol dependence, mood, anxiety or psychotic disorders were respectively 72.7%, 32.8%, 6.2% and 9.8%.15 Schizophrenia among homeless had a weighted average prevalence of 11% with higher rates in younger persons, women and chronically homeless.16
In terms of Pakistan, exact figures on homelessness is not available, then what to talk about its association with mental illness. A beautiful country programme document 2008-2009 on Pakistan in collaboration with UN-Habitat describes Pakistan as the world\\\'s 7th most populous, second largest Muslim nation with population of 167 million (2008), annual national growth rate of 1.8% and urban of 3%. The most populated city is Karachi with 12.4 million and slum to urban population of 48%. It is the most urbanized country in South Asia with some 58 million people living in cities. The urban population is expected to rise by another 70-80 million by 2030.17
Press reports referring UN office for Coordination of Human Affairs indicate that 500, 000 people are homeless in Lahore, 5000 persons under the age 18 live on streets, 500, 000 homeless in Karachi, and over 2 million people are internally displaced because of conflict in the regions and earthquakes.18
Anecdotal reports mention the prevalence of substance abuse among homeless people. Existence of a variety of mental and physical ailments cannot be ruled out as homelessness is a very serious factor that would make an individual vulnerable. No official statistics are available on the magnitude of mental illness among homeless people in Pakistan.
The issue of mental health morbidity among homeless people is not only important but a very serious matter. There is a clear need for conducting empirical studies on this subject. The government should take this matter on board as a huge morbidity burden can be addressed by effective policy making. In view of a number of international studies, there is a strong association of mental illness with homelessness and it is now in the domain of local professionals to gather some scientific data.
Let\\\'s look into this problem now.

References

1.Begin P, Casavant L, Chenier NM. Homelessness. Ottawa: Library of Parliament, Parliamentary Research Branch, Document PRB 99-1E. (Online) (Cited 2000 Nov 15). Available from URL: www.parl.gc.ca/36/refmat/library/PRBpubs/prb991-e.htm.
2.United States Department of Housing and Urban Development. Federal Definition of Homeless. (Online) (Cited 2010 July 7). Available from URL: http://www.hud.gov/homeless/definition.cfm.
3.United States Department of Housing and Urban Development (HUD).Working definition of chronically homeless.(Online) (Cited 2010 July 7). Available from URL: http://www.hud.gov/offices/cpd/homeless/chronic.cfm.
4.United Nations Centre for Human Settlement. 100 Million Homeless in World. Habitat. Press release. (Online) (Cited 2010 July 6) Available from URL: http://www.un.org/Conferences/.../women.htm.
5.UN-habitat Global Report on Human Settlements 2003. "The challenge of slums". (Online) (Cited 2010 July 6). Available from URL: http://www.unchs.org/global_report.asp.
6.US Conference of Mayors. A status report on hunger and homelessness in America\\\'s cities: A 23-City Survey 2007. (Online) (Cited 2010 July 7). Available from URL: http://usmayors.org/HHSurvey2007/hhsurvey07.pdf
7.The Medical News. Mental Health Commission of Canada outlines startling statistics on the homelessness and mental illness. Senator Kirby: Mental Health Commission of Canada 2008. (Online) (Cited 2010 July 7). Available from URL: http://www.news-medical.net/news/2008/04/29/37855.aspx.
8.Haugland G, Siegel C, Hopper K, Alexander MJ. Mental illness among homeless individuals in a suburban county. Psychiatr Serv 1997; 48: 504-9.
9.McCarty D, Argeriou M, Huebner RB, Lubran B. Alcoholism, drug abuse, and the homeless. Am Psychol 1991; 46: 1139-48.
10.Tompsett CJ, Fowler PJ, Toro PA. Age differences among homeless individuals: adolescence through adulthood. J Prev Interv Community 2009; 37: 86-99.
11.Martens WH. A review of physical and mental health in homeless persons. Public Health Rev 2001; 29: 13-33.
12.Henry JM, Boyer L, Belzeaux R, Baumstarck-Barrau, Samuelian JC. Mental disorders among homeless people admitted to a French psychiatric emergency service. Psychiatr Serv 2010; 61: 264-71.
13.Larney S, Conroy E, Mills KL, Burns L, Teesson M. factors associated with violent victimization among homeless adults in Sydney, Australia. Aust N Z J Public Health 2009; 33: 347-51.
14.Salkow K, Manfred F. Homelessness and mental illness. Curr Opin Psychiat 2003; 16: 467-71.
15.Fichter MM, Quadflieg N. Prevalence of mental illness in homeless men in Munich, Germany: results from a representative sample. Acta Psychiatr Scand 2001; 103: 94-104.
16.Folsom D, Jeste DV. Schizophrenia in homeless persons: a systematic review of the literature. Acta Psychiatr Scand 2002; 105: 404-13.
17.United Nations Human Settlements Programme (UN-HABITAT). Country Programme Document 2008; p: 1-33. (Online) (Cited 2010 July 8). Available from URL: http://www.UN-HABITAT.org.
18.IRIN Asia. Pakistan: Cities teem with homeless, vulnerable people. (Online) (Cited 2010 July 6). Available from URL: http://www.irinnews.org/Report.aspx? Country=PK.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: