An estimated one in four or five homeless people in the United States suffers from severe mental illness, according to the National Coalition for the Homeless in Washington, DC.

This is about four times the rate of severe mental illness among the nation’s general adult population. Mayors commonly mention mental illness as one of the largest causes of homelessness. (For more information, visit: http://bit.ly/2U0uXZZ.)

Mental illness is especially common among homeless Chicagoans, according to data collected by the University of Illinois Hospital and Health Sciences System.

The health system found that 73% of homeless individuals seen in the hospital and ED are mentally ill and that 38% suffer from severe mental illness.1

“There is a high rate of untreated mental illness on the street,” says Stephen Brown, MSW, LCSW, director of preventive emergency medicine at the University of Illinois Hospital and Health Sciences System.

Half of the patients who visit the hospital’s ED most frequently are chronically homeless, Brown says.

“What we’re beginning to discover is there are sheltered and unsheltered homeless people living on the streets, and many of them are unsheltered because of their severe mental illness,” he explains. “Crisis shelters don’t have the capacity to handle individuals like that.”

New research shows that homeless people with substance use disorders are hospitalized and visit EDs significantly less often when they are provided supportive housing.2

The Better Health Through Housing program, implemented by the university and community partners, helps homeless patients find mental and behavioral health treatment, housing, and medical care. Soon, the program will pair housing with psychiatric services, Brown says.

“We’ll ask individuals if they want to get into treatment, and half might voluntarily comply,” he explains.

Mental and behavioral health problems often overlap with substance use disorders. In those cases, the hospital’s housing program can help patients addicted to alcohol or opioids obtain long-acting injectable drugs to help them stabilize, Brown says.

For example, Sublocade — approved by the FDA in November 2017 — is a monthly buprenorphine injection for medication-assisted treatment of moderate or severe opioid use disorder. Patients who already have been on a stable dose of buprenorphine treatment for seven days are eligible for the injection. (For more information, visit: http://bit.ly/2uyHTqG.)

It is challenging to find enough residential substance use treatment programs, and this is where medication-assisted therapy can help, Brown notes.

For many homeless patients addicted to opioids, the goal is to prevent them from becoming dopesick several times a day. “That’s why they are panhandling all day and why they live on the street — to prevent withdrawal,” he explains.

“The cycle of withdrawal happens within six to eight hours, and there’s no way they can go into a crisis center without their drugs,” Brown adds. “So medication-assisted therapy prevents them from getting dopesick.”

It’s also an alternative to methadone treatment, which is a challenging treatment option for people who lack housing and financial resources, he says.

“We now have drop-in hours [for medication-assisted treatment] at our own clinics, and we’ve had some success in getting homeless people into medication therapy,” Brown says. “One man was off opioids for the first time in 10 years.”

Or, the patients might need and desire psychiatric treatment. But if they lack sustainable housing, they often stop taking their medication, he adds.

The program’s goal is to end this obstacle to better overall health.

“A psychiatric case manager meets with them three to five times a week,” Brown says. “In terms of alignment, we need to have housing as part of our treatment plan so anyone with severe, untreated mental illness can be helped. We can stabilize their mental condition with medication and keep them stable.”

As the Chicago health system’s homeless program has evolved, it has become more involved in the population’s social determinants of health and solutions to these issues.

“When I started the program, I was given a finite task to create a program. As I started doing that, I immediately recognized that this was going to grow and we had to look outward,” Brown explains.

For example, the sheriff’s department is creating an opioid hotspot response to a location where most overdoses occur. “They offer opioid users treatment and bring them to the emergency department, where we give them medication and then navigate them into the treatment they need,” Brown says.

One aspiration is to hire peer recovery support specialists who will connect opioid users into primary care clinics, he adds.

“We are constantly tweaking this program,” Brown says.

REFERENCES

1. Brown S. Better health through housing, a healthcare & housing collaborative: Lessons Learned. Research presented at the Community and Global Health Honors Program, March 12, 2019, Loyola University Medical Center, Maywood, IL.

2. Miller-Archie SA, Walters SC, Singh TP, et al. Impact of supportive housing on substance use-related health care utilization among homeless persons who are active substance users. Ann Epidemiol. 2019;Epub ahead of print.