Mental Health System

Incidence and Prevalence of Mental Illness among the Homeless

The 1996 National Survey of Homeless Assistance Providers and Clients was based on a statistical sample of seventy-six metropolitan and non-metropolitan regions, including small cities and rural areas. The survey found that 86 percent of homeless persons had experienced at least one alcohol, drug, or mental health problem in their lifetime, with 57 percent having had problems with mental health, 62 percent with alcohol, and 58 percent with drugs. In the previous month, two-thirds of the homeless persons surveyed had experienced at least one alcohol, drug, or mental health problem; 39 percent had problems with mental health, 38 percent with alcohol, and 26 percent with drugs. The survey also found that onethird of homeless adults suffered at that time from current serious psychiatric illness, including schizophrenia and affective, personality, and character disorders (Burt et al., 1999). Another study of a similar population found that one-third had substance abuse disorders, including 17 percent with dual diagnoses of serious mental illness and chronic substance abuse. Such dual diagnoses pose a challenge to those seeking to develop services that adequately address both needs (Drake et al., 2001).

Mental Health Care for Homeless Persons

During the latter half of the twentieth century, deinstitutionalization, the process of replacing long-stay psychiatric hospitals with smaller, less isolated community-based alternatives substantially changed the way most communities in the United States provided mental health services (Bachrach, 1996). This process of closing down or reducing the size of state hospitals was implemented primarily in the 1970s but continues into the present. The extent of the shift that occurred in the locus of care is illustrated by the change in the resident populations of state and county mental hospitals: From a peak in 1955 at 558,922 patients (339 per 100,000 population), the total had declined by 1998 to 57,151 patients (21 per 100,000) (Mechanic, 1999; Lamb & Bachrach, 2001). Unfortunately, the release of public mental hospital patients most often occurred without alternative community-based mental health services yet in place (Mowbray, Grazier, & Holter, 2002).

Some writers have posited that deinstitutionalization was the primary cause of homelessness from the 1950s into the 1980s (Isaac & Armat, 1990). Several studies have documented that a significant number of patients in mental institutions, particularly in state mental hospitals, were or have been homeless, and that a large proportion of discharged patients became homeless (Lindblom, 1991). However, other research has suggested that several structural factors contributed to the growth in homelessness among individuals with mental illness, including a shortage of affordable housing and a growing proportion of persons [Page 377]living below the poverty rate (O'Flaherty, 1996; Rossi, 1989). Still, it is important to note these latter factors did not come into substantial play until after the first waves of deinstitutionalization had already been largely completed.

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