Definition and demography of homelessness and its link to mental illness

The term 'homeless' has been used to describe populations as diverse as those sleeping in the shelter of a cardboard box, to those sleeping on a friend's floor. Given such wide definition, it is not surprising that estimates of the numbers involved at any one time vary greatly from survey to survey and from one country to another. But regardless of the definition used, there is consensus that the numbers of homeless people in most Western urban areas increased throughout the 1980s and 1990s. This growth was largely accounted for by younger men, families, and ethnic minorities, and reflected wider changes in the social economy—a scarcity of low-cost housing, high unemployment, the erosion of traditional family networks, and downsizing in the organization and delivery of supportive social services. (1) Of all these factors, the shortage of affordable entry-level accommodation is probably the most important. For example, in the United Kingdom there was an 85 per cent decline in the production of new council housing between the mid-1970s and 1980s and a net loss in London alone of 243 000 rental units between 1981 and 1988. (2)

Compared with a domiciled population, homeless people are less likely to have completed basic education, less likely to have ever held employment, and more likely to have experienced parental neglect and abuse in their childhood. (3)

Given the evidence linking homelessness to poverty and social disadvantage, it is hardly surprising that homeless people report higher rates of psychiatric disorder relative to the general population.(4) While rates vary depending on the particular measure of mental illness adopted by each study and by the homeless population being investigated, most report major psychiatric disorder in 30 to 50 per cent of residents of lodging houses and long-stay hostels and up to 60 per cent of those using emergency shelters and sleeping rough. The prevalence of schizophrenia and other psychoses is particularly high amongst the middle-aged residents of long-stay hostels, while depression, generalized anxiety, and impulsive self-harm are more typically encountered in younger runaways and adolescent populations. Alcoholism and drug dependency are present in as many as two-thirds of men and a third of homeless women. Comorbidity of mental illness and substance use disorder is the rule rather than the exception as are the co-occurrence of respiratory disease, infections, trauma, and the physical consequences of poor diet, poor hygiene, and the complications of substance abuse.

The typical pattern of service utilization of this population is one of extremes—bursts of involuntary hospital admissions and compulsory treatment interspersed with long periods of neglect and isolation. Many of those who are found sleeping rough or resident in temporary shelters have found their way to these locations as a conscious effort to avoid contact with health and social care professionals and remain unwilling to be part of any structured rehabilitation programme. The rise in the numbers of mentally ill street homeless people in the United States and the United Kingdom throughout the 1980s was at least partly the consequence of deinstitutionalization. In the United Kingdom, for example, while old long-stay populations were provided with accommodation when the old hospital asylums closed, little thought was given to the needs of the much larger population of 'new chronic' patients who were increasingly caught in a cycle of brief hospital admissions and discharge to inadequately supervised accommodation.

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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