Rohit Bansali

Executive Summary Mental health problems have been a long standing issue universally. For this study, we focused on 127 Homeless individuals and surveyed them with a comprehensive review of mental health symptoms. Participants were then matched to subjects in a data set of individuals from the general public. A number of disparities were seen, and the disparities were most pronounced in the prevalence of thought problems, internalizing problems, externalizing problems, and OCD symptoms.. One particular challenge we found was that homeless participants were significantly more likely to suffer from multiple comorbid conditions. A lack of access was the most commonly cited reason participants were not receiving mental health treatment. We found high rates of clinically-significant symptoms among those who had never been treated and even higher rates among those who reported their symptoms had improved, those who reported that treatment was ineffective or intolerable, and those who reported a lack of access. Despite the challenges, this study gives us all the pre-requisites necessary to aggressively and effectively provide primary, secondary and tertiary levels of Prevention, including creative solutions like peer health navigator training. Contrary to popular perceptions, homeless participants were no more likely to have drug or alcohol problems than matched members of the general public Background Decades of research have demonstrated homeless individuals suffer from significantly more severe and frequent mental health problems than people who have stable housing (1,2). Invariably, all research identifies barriers for a Homeless man to access the Mental health fraternity(3,4,5).Researchers have also demonstrated that significant variability in both the prevalence of various mental disorders among the homeless and barriers to accessing care across different regions and cities (6). It is thus essential to study these issues on a regional or even community level to provide a foundation of knowledge upon which programs can be built to effectively address these challenges. No studies have been conducted which could answer these questions regarding homeless individuals in Nebraska. The prevalence of mental health problems among homeless people has varied significantly with some studies finding rates under 50% and others at over 80% (6,9) and a significant proportion of homeless individuals with psychiatric problems receive care less frequently than the general public. In some of the most recent studies, only 16 to 21% of individuals currently meeting criteria for a psychiatric disorder were receiving care for medication management (1,6). Apathy amongst the homeless individuals forms the crux of psychosocial problems. Identified barriers include cost/lack of health insurance, stigma, transportation problems, lack of time. While the General Populace can overcome most barriers easily, many homeless individuals used clinics designed to meet temporary health needs rather than long-term providers.These clinics were poorly connected to the General health care system, authorized to Rehabilitate homeless individuals at a fraction the costs(6). Regular patient-provider relationships are especially important in mental health where the establishment of trust may take longer and is arguably more critical to treatment success relative to other areas of healthcare (8). A number of studies addressing barriers to mental health care have been conducted in Canada, producing results which have limited generalizability to the U. S. given their different health care systems (9). In addition, many of the studies conducted in the U. S. have been completed in areas such as the east coast (4). With differences in Medicaid qualifications by state, these findings may not reflect the reality of individuals in the Midwest. Furthermore, individuals in states that expanded Medicaid such as Iowa may have better access to healthcare than people in states that did not expand Medicaid such as Nebraska. Regardless of the larger context of the healthcare system, homeless individuals will require programs designed to meet their unique needs due to the particular challenges they often face (10). The purpose of this study is to appropriately identify these unique needs and provide a basis which can solve these problems at the grass-root levels first and at larger institutions in the future. Aims: 1. Determine the prevalence of untreated mental health symptoms in a local homeless population, and 2. Identify the primary barriers to seeking mental healthcare among homeless individuals. Methods We conducted a cross-sectional study surveying 127 individuals staying at a not-for-profit shelter for homeless individuals in Nebraska. The shelter has an emergency section for men (180 beds), a family section for women and their children (60 beds), and a transitional housing section for men who are approved to stay for a longer period of time (60 beds). The survey recorded age, sex, and mental health treatment history (i.e. if an individual had ever been treated for mental health symptoms, if he or she is currently being treated, if not why not). It also included the Achenbach System of Empirically Based Assessment Adult Self-Report (ASEBA ASR).It is based on National Probability sample testing and experts have opined that it is consistent with DSM-5 Criterion. The study was approved by the University of Nebraska Medical Center Institutional Review Board and each participant completed an informed consent. Survey participants were recruited on a convenience-basis through presentations at shelter meetings, posted flyers, and intercom announcements made by shelter staff. The surveys were administered to 127 individuals in a private room of the shelter by psychiatric nursing graduate students (research assistants). Surveys were offered at a variety of times throughout the day and evening, on weekdays and weekends to expand the number of individuals who had the opportunity to participate. The interviews were conducted over approximately four months during the fall and early winter when the census of shelter is higher than during the summer. In addition, during the summer, many of the individuals who have been homeless for a longer period of time sleep outside. As a result, conducting the study during the fall and winter likely produced a sample more accurately reflecting the homeless population of the city. Each survey took about an Hour and participants were given a $15 McDonald’s Gift card in return. Once the surveys were complete, participants were matched based on age and sex with individuals from a normative data set-developed by a group that manages the ASEBA instruments. Normative data set comprised of Non-Referred participants, which formed the "Control" group because they were the most similar to the General Public. The "Test" group consisted Individuals who were referred for Psychiatric care. All individuals were from within the United States. Results The mean age of homeless participants was 41.7 years and that of controls was 42.7 years (see Figure 1). Both groups had 36 females (28.3% of participants Each section of the shelter was appropriately represented in proportion to the number of beds. More than half-55.9% were individuals from the Emergency Men's shelter (180 Beds), 29.1% from the Family shelter (60 Beds) and 15% from the Transitional men’s shelter(60 Beds) Figure 1: Demographics of Study Groups Homeless Controls Mean age 41.7 years (SD=11.1) 42.7 years (SD=9.5) Proportion of females 28.3% (36) 28.3% (36) Emergency men’s shelter 55.9% (71) Family shelter 29.1% (37) Transitional men’s shelter 15% (19) Prevalence Among homeless participants, 66.9% met the clinical threshold for having at least one mental health problem compared with only 18.1% of controls (see Figure 2). This difference was statistically significant (χ2(1)=61.921, p<0.001). Twenty-two percent of homeless individuals had depressive problems versus less than 2 percent of controls (χ2(1)=25.551, p<0.001). Anxiety problems were detected in 11 percent of homeless individuals but only 1.6% of controls (χ2(1)=9.605, p=0.002). Twenty-eight percent of homeless individuals had OCD problems whereas only 2.3% of controls met the same criteria (χ2(1)=31.688, p<0.001). Among the most striking results was that 38.6% of homeless individuals had thought problems versus 3.2% of controls (χ2(1)=48.282, p<0.001). Thought problems included hallucinations, self-harm thoughts, repetitive actions, and having strange ideas or behaviors. Similarly, 40% of homeless individuals had internalizing problems versus 7% of controls (χ2(1)=21.738, p<0.001). Lastly, externalizing problems were detected in 35% of homeless individuals but only 10% of controls (χ2(1)=21.738, p<0.001). There were no differences in alcohol or drug use problems with 13% of both homeless individuals and controls meeting criteria for alcohol problems and 15.7% of homeless individuals and controls meeting criteria for drug problems. Figure 2: Prevalence of Clinically Significant Mental Health Problems by Study Group Multiple Morbidity Homeless individuals were significantly more likely than controls to have multiple mental health problems (χ2(3)=64.124, p<0.001) (see Figure 3). Twice as many homeless participants had one disorder (14.2% v. 7.1%), over three and a half times more had two disorders (8.7% v. 2.4%), and over five times as many had three or more disorders (44.8% v. 8.6%). Figure 3: Rates of Multiple Morbidity by Study Group Barriers to Care A total of 62% of homeless participants reported that they had been treated for a mental health problem at some point in their lives (see Figure 4). Of the individuals who reported previous treatment, 48.4% were being treated at the time of the interview. Figure 4: Treatment History of Homeless Participants A majority of the individuals (41%) who received treatment in the past did not continue due to lack of access. About 1 in 10 found the treatment ineffective and/or intolerable or lacked an understanding of Mental Healthcare (i.e., no treatments exist for mental healthcare).1 in 3 People not receiving treatment believed that their symptoms had been resolved. Figure 5: Reasons for no Treatment among Homeless Participants Less than half (45.3%) of the "Test" group having a clinically significant problem were receiving treatment at the time of the interview. As many as 69% of this group reported persisting Symptoms inspite of treatment leaving behind only 10% individuals with a successful treatment plan. Similarly, Clinical problems persisted in 63.6% of individuals who had previously sought treatment and had a remission in clinical symptoms. An equal number (87.5%) individuals with clinically significant found treatment Ineffective/Intolerable or gave other reasons, further, 8 out of 9 individuals (88.2%) reported lack of access as the main barrier. Lack of Mental health education amongst the "Test" group resulted in 50% people having Clinically Significant problems, but not receiving treatment either in the past or at the time of the study. (See Figure 6). Figure 6: Rates of Clinical Problems by Treatment Status At least one clinical problem Never treated 50% Currently treated 69% Treated in past Symptoms resolved 63.6% Treatment ineffective/intolerable 87.5% Lack of access 88.2% Other 87.5% Discussion As expected (Based on Previous research), the Prevalence and incidence of almost every mental health problem was significantly higher in Homeless group when compared with the controls. Thought problems, most of which can be treated are Twelve (12) times more common in the "Test" group compared to the "Control" groups.Consequently, Internalizing and Externalizing problems are Six(6) times and 3.5 times more common,respectively.Internalizing occurs when problems an individual faces manifest themselves in symptoms such as withdrawal, somatic complaints (physical sensations stemming from emotional problems), anxiety, and depression. Conversely, externalizing problems occur when an individual’s stressors result in delinquent or aggressive behavior. As discussed, Lack of access happens to be the most important barrier for Homeless Individuals. This problem is compounded by a triad of Thought Problems, Internalizing problems and externalizing Problems making it difficult to overcome basic navigation challenges. Additionally, Homeless individuals face a large number of Daily stressors and may have more difficulty in advocating for their needs. While anxiety, somatic complaints and depression are symptoms of Internalization; In contrast rage, acting out are symptoms of Externalization. Externalization begs special interest from Law-enforcement because an Individual can act in a confrontational manner further escalating potentially hostile situations. The prevalence of depressive and anxiety problems was significantly higher than in the general population.OCD,a mental disorder with a prevalence of 2-3% in the United States has a treatment rate of about 50% OCD symptoms.(11) While the "Control" group had a Negligible 1-2% Prevalence,the "Test" group recorded an abysmal 27.6% prevalence. The reasons for this will require further research but it is clear that obsessions and compulsions would have the potential to interfere with an individual’s daily functioning, contribute to an individual becoming homeless, and make it more difficult for them to pull themselves out of a cycle of homelessness. Lastly, contrary to common stereotypes, rates of drug and alcohol problems were no higher among homeless participants than their matched controls. The high rate of multiple morbidity found in this sample should be of particular concern. With almost 45% of participants meeting the clinical threshold for three or more problems, it is clear that many homeless individuals face multiple psychological challenges. Psychopharmacology is unique because most therapeutic agents require appropriate and periodic dosing over a period of 6-8 Weeks before any improvements are visible and Treatment for a Particular disorder may give rise to/exacerbate another Mental disorder owing to its side-effects. For Example, SSRI's given in Bipolar Depression can trigger a Bipolar Manic Episode, Treatments for Attention-Deficit Disorder(ADHD) can increase Anxiety problems. Further, taking multiple medicines periodically and bearing the financial costs in an Unstable, Transitory living environment can significantly reduce Patient Compliance. Due to these reasons, Patients may give up on the Treatment Plan altogether and become a part of the "Finding treatment intolerable/ineffective" group. Another significant finding was the relatively low proportion of individuals receiving treatment. Although an impressive 62% of participants reported being treated for mental health problems at some point in their lives, less than half of them were currently receiving help. Encouragingly, a third of those who were no longer being treated reported their symptoms had resolved. However, 17% reported that past treatment was ineffective or intolerable and almost 43% cited a lack of access. Professionals working with homeless individuals may need to do more to encourage people in need to try additional treatments (Like Cognitive Behavioral Therapy[C.B.T] and Electroconvulsive Therapy). Individuals may find success with other psychotherapy approaches or medications which were unavailable when they first tried treatment. In addition, it is imperative to reduce barriers to care, especially for the Homeless. Providers can advocate for case managers to help homeless individuals navigate complex healthcare systems. The most commonly cited barrier to accessing care was a lack of health insurance. Although Nebraska has historically had a relatively low uninsured rate, state officials chose not to expand Medicaid. Furthermore, regardless of how positive the state-level picture may look, it is clear that those at the lowest socioeconomic levels will suffer the most. Homeless individuals would clearly benefit from expanded health insurance coverage. Other barriers frequently cited included more practical concerns such as a lack of transportation. Many practices in the city have relocated far from the city center, making them difficult for people to access with limited public transportation. In addition, many individuals with mental health challenges (i.e. anxiety) have difficulty taking multiple buses to get to an appointment. Technology with its time-tested ability to dissolve many Physical Barriers must be used to heed to the Homeless. Ease of Access to a Mental Health Provider virtually (via Telehealth Services) will Improve Patience Compliance multifold and also in saving the Mental Health workers a lot of time. A number of individuals cited reasons for not receiving care that indicated a lack of information either about particular disorders (i.e. that no treatment exists for PTSD) or accessing care (i.e. having no access to medications despite the existence of patient assistant programs).With the conventional programs have thus far been inefficient and under-used, a creative solution which would be tailored to the Homeless was essential. We recently secured a small grant to develop a peer health navigator training program. This will be established by adapting the existing framework of programs used to educate individuals to assist their peers in managing HIV. Within this program, a number of homeless individuals will be recruited to participate in training that will increase their understanding of mental illness and identifying community resources. The training will improve their ability to recognize potential mental health problems among their peers, develop skills on approaching individuals with regards to getting help, and referring for accessible community resources. Although lay persons have less experience and expertise with regards to mental health, their peers may be more open to suggestions made by people they know and who are in similar situations rather than unknown healthcare professionals coming from the outside the community. The analysis of clinical problem rates by treatment status should be of particular concern to providers. A full half of individuals who reported never having been treated met the clinical threshold for at least one problem. Unfortunately we did not ask about reasons for not being treated in this group because scores required interpretation after the interview, so the underlying factors for this high rate are unclear. Almost 70% of individuals who reported currently receiving treatment also met criteria for a current clinical problem. This proportion is alarming and suggests a very high rate of treatment resistance among homeless individuals. High rates of mental health problems among those already being treated indicate that providers may need to engage in more aggressive treatment when appropriate. Clinicians who are aware of this possibility can alter their treatment plans by scheduling more frequent appointments, advancing treatment earlier, or other interventions more likely to result in symptom remission. Not surprisingly, a very high proportion of individuals who found past treatment ineffective/intolerable or lacked access (87.5% and 88.2%, respectively) had clinical-level problems. Possible solutions to these challenges were discussed above. The majority participants (87.5%) of who cited “other” reasons they were no longer being treated also had clinical level symptoms. The fact that mental illness has been a significant problem among homeless individuals for decades may lead some people to believe that nothing can be done to improve this situation. However, renewed efforts to understand and address local challenges can have a significant impact for many of the most vulnerable members of our communities. Advancements in technology combined with creative new solutions such as peer navigator training can improve the access and effectiveness of mental health treatment for homeless individuals. As members of society with at least some degree of privilege, we have an obligation to help those most in need of assistance. We may often be surprised by how little help some individuals need to become self-sufficient and lead fulfilling lives. 1. Strehlau V, et al. "Mental health, concurrent disorders, and health care utilization in homeless women." Journal of Psychiatric Practice 18.5 (2012):-. Weber M, et al. "Perception of access to health care by homeless individuals seeking services at a day shelter." Archives of Psychiatric Nursing 27.4 (2013):-. Edidin JP, et al. "The mental and physical health of homeless youth: a literature review." Child Psychiatry & Human Development 43.3 (2012):-. Kim MM, et al. "Healthcare barriers among severely mentally ill homeless adults: Evidence from the five-site health and risk study." Administration and Policy in Mental Health and Mental Health Services Research 34.4 (2007):-. Nickasch B & Marnocha SK. "Healthcare experiences of the homeless." Journal of the American Association of Nurse Practitioners 21.1 (2009): 39-46. 6. Krausz RM, et al. "Mental disorder, service use, and barriers to care among 500 homeless people in 3 different urban settings." Social Psychiatry and Psychiatric Epidemiology 48.8 (2013):-. Weber M, et al. "Perception of access to health care by homeless individuals seeking services at a day shelter." Archives of Psychiatric Nursing 27.4 (2013):-. Eliacin J, et al. "Factors influencing patients’ preferences and perceived involvement in shared decision-making in mental health care." Journal of Mental Health 24.1 (2015): 24-28. 9. Hwang SW, et al. "A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance." American Journal of Public Health 103.S2 (2013): S294-S301. 10. Tsai J, et al. "Medicaid expansion: chronically homeless adults will need targeted enrollment and access to a broad range of services." Health Affairs 32.9 (2013):-. Koran LM, et al. "Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder," American Journal of Psychiatry (July 2007): Vol. 164, No. 7