Mental Illness and Health

The upsurge of homelessness in the United States and other western countries since the late 1970s has stimulated a new level of concern about mental illness in homeless people. In earlier times, the chronic alcoholic stereotype often pervaded discussions of homelessness, leading to negative labels such as “wino” and “skid row bum.” The more recent focus on mental illness in homeless people was occasioned by their high visibility since the 1980s in major American and European cities, and by the public perception that many homeless people were seriously disabled by mental illness. There was concern that these high numbers were a result of the policies of deinstitutionalization that dominated mental health care since the 1970s.

For more than a century, Americans have generally accepted that the care and treatment of people with serious mental illnesses is a public responsibility. Until the middle of the twentieth century, this responsibility was largely met through state mental hospitals, which cared for steadily growing numbers of severely disabled psychiatric patients. The number peaked in 1955, when state and county mental hospitals housed 560,000 patients. Since then, there has been a movement toward treatment in communitybased programs, a trend motivated partly by medical advances and a new philosophy of mental health care, but also by humanitarian and civil rights considerations and the political goal of reducing the huge maintenance costs of public institutions. Deinstitutionalization policies sought to provide care largely on an outpatient basis, with a range of treatment, support, and rehabilitation services for people whose ability to function independently might be severely limited. This task has proved to be costly and complicated. Nevertheless, hundreds of thousands of severely mentally ill people who in a previous era would have been institutionalized indefinitely are now living in community settings.

Community mental health services are provided under local auspices, but unfortunately only a few localities have managed to provide an adequate array of services for the most severely disabled. For some of these people, when family or community supports fail, or when the illness itself hinders good use of available services, homelessness has been the result.