Addiction Woes Haunt the Homeless

Years on the street make treatment benefit less likely, study finds

WEDNESDAY, May 25, 2005 (HealthDay News) -- Psychological distress and functional impairments worsen the longer homeless addicts remain on the streets, a new study finds.

Researchers have found that, among people entering treatment programs for drug and alcohol addiction, those who were chronically homeless experienced much less improvement in psychological distress, compared with people who had a place to live or were only "transitionally" homeless. The severity of individual addictions was not enough to explain these disparities, the researchers said.

"Emotional distress and limitations in functioning among the chronically homeless are driven by a host of factors that go well beyond mental illness and addiction, even when addiction is part of the problem," said study author Dr. Stefan Kertesz, an assistant professor of preventive and general internal medicine at the University of Alabama at Birmingham.

The study appears in the June issue of Medical Care, a publication of the American Public Health Association.

While most experts agree that chronically homeless people are likely to have different needs than people who experience homelessness for shorter periods of time, there has been relatively little data to clarify what those specific needs are.

"Although it seems intuitive and like common sense, it's important to demonstrate through research that a person who is experiencing chronic homelessness generally has a more complex set of treatment needs than other people," said Philip Mangano, executive director of the U.S. Interagency Council on Homelessness. "This study is pointing in that direction."

The authors analyzed data from a two-year survey of 274 homeless people entering public detoxification programs in Boston.

Participants were classified into three groups: housed, transitionally homeless and chronically homeless. Chronically homeless people (22 percent of the sample) had to have spent one or more nights in shelters or on the street during each six-month time interval analyzed. Transitionally homeless people had to have spent one or more nights in shelters or on the street during one of two or three six-month periods.

These definitions roughly corresponded to current federal definitions.

The researchers then looked at how the groups differed in health-related quality of life measures.

With regard to physical health, all three groups were a little worse than the U.S. mean, but not significantly different from each other.

In the area of mental health, all three groups had extremely poor mental status when they entered a treatment program. After that, however, things started to diverge.

"People who were housed showed a very nice improvement over the subsequent two years," Kertesz said. "People who were chronically homeless showed only a small improvement over the subsequent two years, and those who were transitionally homeless fell between these two extremes."

The difference between those who were housed and those who were chronically homeless was a large one, the researchers added.

"The chronically homeless failed to show anything like the mental state improvement shown in housed individuals," Kertesz said. "Chronically homeless people represent a distinctly vulnerable subgroup among people going into addiction treatment."

Four different factors emerged as possible explanations for this difference: addiction, mental illness, social support and medical illness.

"When trying to address problems of chronic homelessness, we really are required to think about the full range of vulnerabilities, and that includes medical problems, lack of social support and addiction," Kertesz said.

The study suggests that individuals or organizations providing services to homeless people might first want to ask whether the person is chronically homeless.

"It's worth knowing whether or not homeless individuals are chronically homeless," Kertesz said. "That should influence the next set of questions that you ask, and the kinds of plans that you make."

The study did not address what kinds of programs work best.

According to Mangano, however, various communities around the country are implementing programs that combine permanent supportive housing with team support services, and these seem to work.

But still others do not believe enough is being done to help the chronically homeless.

Ellen Dailey, vice president of the board of directors for the outreach group Boston Health Care for the Homeless, said her organization has "not funded the support service piece, just the housing."

The one thing everyone seemed to agree on is that chronically homeless people need extra assistance. "They can't survive without it," said Dailey, who was herself homeless for 18 months. "A lot of these guys have been out on the street 10, 12, 14 years, sleeping under bridges, whatever. So without the support services, they can't possibly succeed."

More information

For more on health-care issues affecting homeless people, visit the National Health Care for the Homeless Council.

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