Commentary

An estimated 2.3–3.5 million Americans experience homelessness each year, and mental health problems, which are present in about one third of these individuals, significantly increase the risk of long term homelessness.¹ As a result, clinicians working in public mental health systems frequently provide care for people who are homeless. Folsom et al studied a large group of non-institutionalised patients with schizophrenia, bipolar disorder, or major depression who had contact with the public mental health system in San Diego in 1999–2000. Fifteen per cent of these individuals were homeless at some point over a one year period. In comparison, a previous study of people treated in Philadelphia’s public mental health system in the early 1990s found that only 7–10% of those with schizophrenia or affective psychoses were admitted to a homeless shelter over a three year period.² These contrasting findings raise the worrisome possibility that over the last decade, homelessness may have become much more common among Americans suffering from mental illness.

Not surprisingly, this study found that homelessness was significantly more common among people who were male or African-American, had schizophrenia or bipolar disorder, had a substance use disorder, or had a lower level of functioning. These characteristics were previously known to be risk factors for homelessness. Interestingly, people with mental health problems covered by Medicaid were about half as likely to be homeless than those without Medicaid. This association likely reflects the many barriers to obtaining entitlements that homeless people experience, although the possibility that Medicaid benefits confer some degree of protection against homelessness cannot be ruled out.

This study’s use of a large and comprehensive dataset is a notable strength. Although its findings have few direct implications for clinical practice, the study serves as a stark reminder to providers in public mental health systems that their clients’ need for stable housing may be equal to or perhaps even greater than their need for treatment of their mental illness.