The Homeless Chronicles. Part 8

This is the eighth in a multi-part series about homelessness. Previously we noted that

• Homelessness changes depending on your definition, from very narrow to very broad.
• There are three main groups of homeless people – (1) people who chose to be homeless, (2) people whose disabilities create/contribute to homelessness, and (3) people who experience a major negative event which propels them into homelessness.
• The life style homeless basically want to be left alone. The temporary homeless are looking for help to return them to their normal life. The chronic homeless have such disabling conditions they are the most difficult to reach and to help.
• In recent years, a greater percent of the homeless are coming from the temporary group, fueled largely by the high cost of housing in relationship to their income.
• The commonly used federal survey under –estimates the number of homeless. In reality, there are over a million homeless people nationwide, 250,000 in California and between 10,000 and 15,000 in Orange County.
• There is wide diversity among California counties in the percent of the population who are homeless. Orange County at 0.22% (22 homeless people for every 10,000 residents) is mid low range with an average of 0.39% for the State.
• There is wide diversity among California counties in the percent of the homeless population who are unsheltered. Orange County at 58% is mid low range with an average of 65.3% for the State.
• There is wide diversity among California counties in the percent of the homeless who self-report being mentally ill. Orange County at 28% is mid range with an average of 29.5% for the State.

Today we’ll get some deeper perspective on the homeless mentally ill.

If there are (at least) over 1,600 homeless people who report having “serious mental illness” (SMI) in OC in 2019, what types of challenges might we expect to encounter? The main problems likely will be substance abuse, physical/medical problems, and suicide. Within the broad framework of mental illness, the major syndromes represented likely will be depression, affective (mood) disorders and schizophrenia.

It's important to bear in mind that most homeless people are not mentally ill, but if a person is homeless and mentally ill, they are at substantially higher risk for other problems and in general are much more difficult to help.

Co-Morbid Disabilities

Homeless people are not merely homeless, but research shows that they have several concurrent issues that compromise their quality of life. This problem is even more pronounced for the homeless who are mentally ill. In terms of frequency, the most likely concurrent problems will be physical/medical conditions and substance abuse.

Physical/Medical Problems

Data suggests that the majority of homeless mentally ill people have at least one medical condition. These include hypertension, dyslipidemia, asthma, and diabetes. In addition, many have sensory and motor defects. The 2019 OC PIT survey reported 30.8% of unsheltered and 15% of sheltered adults had a “physical disability” that kept them “…from holding a job or living in stable housing.” The total number of individuals was 1,471.

Substance Abuse

Substance abuse has been identified as a separate problem for homeless people. The incidence ranges widely (9% to 62%) but most studies are within 25% to 40% with an average of 36%. In OC in 2019 the figure was 31% (32.9% for unsheltered and 26.7% for sheltered adults).

Few studies specifically look at the prevalence of substance abuse among the mentally ill homeless, although many studies have reported the existence of both among the homeless in general. The few studies which have been done generally report about 50% of homeless mentally ill have a substance abuse problem.

Based on the research and the data, there are likely to be well over 500 homeless people in OC who are mentally ill and have a substance abuse problem. This is a “high risk” group and presents challenges at every level.

Suicide

Suicide is more prevalent among the homeless and among the homeless, more prevalent for those who are mentally ill. One study surveyed 7,224 homeless mentally ill patients from 15 different cities in the U.S. and reported that “lifetime suicide ideation” was present for 66.2% and 51.3% reported at least one attempt with 8% within the previous 30 days.

Developmental Disabilities (DD)

The 2019 OC PIT survey reported that 11% of the 5,883 homeless adults were “developmentally disabled” (13.7% among unsheltered and 5.2% among sheltered), but did not indicate which of these people also reported SMI. Studies of concurrent DD and SMI report rates of SMI among people with a DD varying from 10% to 70%, but only one study looked at the rate of DD among people with a SMI – in a 6-month study of state psychiatric hospitals in 2002, 5.5% of “episodes of care” were for people with developmental disabilities.

In 2009 the Association of Regional Center Agencies estimated that among people with DD, 72% live with their families, 12% in community care, 9% independent living, and 1.3% in state hospitals, leaving 5% homeless. For an estimated 323,215 in the State, that equates to 11,250 homeless with a DD.

Data from Orange County’s HMIS system. Among 8,658 adult and child clients in the County’s system served in July 2019, 391 (4.5%) were classified as DD or DD as well as SMI. There were 263 adults and 11 children who had SMI and DD.

Types of Mental Illness

Mental illness is not a single entity. The 2013 edition of the DSM-V lists 20 different disorders.

Depression

Many studies report depression among mentally ill homeless individuals. The range is from 10% to 59% with an average of 28.6%. Using only studies from the U.S. and Canada that involved a diagnosis from a Mental Health Professional (MHP), the range is 15% to 46% with an average of 25%.

Mood disorders

Mood disorders (including bi-polar) are the second most common problem among mentally ill homeless individuals. The range is from 2% to 62% with an average of 19.9%. Using only studies from the U.S. and Canada that involved a diagnosis from an MHP, the range is 2% to 26% with an average of 11.6%.

Schizophrenia

Schizophrenia is not uncommon among mentally ill homeless individuals. The range is from 2% to 52% with an average of 17.6%. Using only studies from the U.S. and Canada that involved a diagnosis from an MHP, the range is 2% to 37% with an average of 13.2%.

Regardless of whether we use the total studies or just those studies from the U.S. and Canada employing a diagnosis from a MHP, the most prevalent types of mental illness exhibited by homeless mentally ill people are depression, mood disorder, and schizophrenia. These three diagnoses likely will encompass half the conditions among the homeless mentally ill.

Summary

Homeless people in OC with SMI are likely to also suffer with physical/medical problems, substance abuse, and thoughts of suicide. A small proportion may also be developmentally disabled. Among those individuals with SMI, the most common types of mental illness symptoms that are likely to be displayed revolve around depression, mood disorders, and schizophrenia. Based on the research and the data, there are likely to be more than 500 homeless people in OC who are mentally ill and have a substance abuse problem.

About the Author

Dr. Jim Gardner is the former Mayor of Lake Forest. A Clinical Psychologist, he is a former University Professor and Department Head. He authored several reports about homelessness.