A new wave of mentally ill people who are homeless appears to be emerging, with new challenges for psychiatrists who work in community settings.
Demographically and clinically distinct from the flood tide of homeless people with serious and persistent mental illness who populated city streets in the 1980s, the emerging class of homeless mentally ill people requires psychiatrists to adapt their current roles within community service agencies to a new and changing reality.
Hunter McQuistion, M.D., an associate clinical professor of psychiatry at the Mount Sinai School of Medicine in New York City, told Psychiatric News that anecdotal evidence from service providers in New York City—as well as data from the city’s shelter system—point to a new class of families and children being displaced from housing because of larger economic trends.
Though this emerging class of homeless is not likely to be characterized predominantly by serious and persistent mental illness—as was the earlier wave of deinstitutionalized patients—they are nevertheless likely to experience significant mental health problems.
"What we are seeing are families, not necessarily with serious psychiatric disorders, but with depression, anxiety, and substance abuse," McQuistion said. "As psychiatrists, we need to understand and respond to that. In the last 20 years, those of us working in the community have focused appropriately on schizophrenia and the severe psychiatric disorders. Now, we need to look at a much larger block of people who may present real issues and an ongoing vulnerability to homelessness because of the collapse of poor communities."
In a report in the May issue of the APA journal Psychiatric Services, McQuistion and colleagues stated that there were 24,517 families in New York’s municipal shelter system on an average day in 2002, a rise of 46.1 percent from 2000. They also cited a survey by the U.S. Conference of Mayors corroborating a similar phenomenon in other cities, with a 14 percent average national yearly rise in homelessness from 1998 through 2002—and a greater increase in homelessness among families with children than among single adults.
McQuistion said that in response to the epidemic of homelessness that struck America’s cities in the 1980s, approaches to the psychiatric care of homeless people with serious mental illness were developed by consensus, with a number of important documents published on the subject by APA. The next step is building greater objective evidence for this consensus.
This process will also be needed for a new, clinically distinct class of homeless people who need mental health services, McQuistion said.
In the Psychiatric Services report, he and colleagues describe the roles that psychiatrists have played in the care of homeless mentally ill people and how those roles have evolved as a result of trends both in services for homeless people and within the profession of psychiatry.
Of overriding importance—regardless of the job title a community psychiatrist might hold—is the function of advocacy. Even at the clinical level, advocacy is crucial since clinicians are invariably called upon to help these patients navigate the public system of benefits and entitlements.
"If you are doing anything at all with this population, you are by definition doing advocacy because this is an underserved population," McQuistion said. "It is theoretically possible to treat patients who are homeless and mentally ill without considering the psychosocial aspects of their presentation. But it would be surprising for a clinician to really ignore that. And because these individuals get services in the public sector, that automatically means navigating systems of care—and that means advocacy."
Advocacy is also inherently part of the work that academic researchers undertake when they seek epidemiological data about a service population.
Psychiatrists who are in administrative positions with service agencies may also find opportunities to advocate for increased funding on behalf of patients. McQuistion acknowledged there may be a tension when it comes to demanding more from funding sources, and many community service agencies are reluctant to bite the hands that feed them.
He suggested, however, that organizations could stand to be bolder from time to time. "Psychiatrists who have administrative roles within these organizations can put these issues on the table with boards of directors and chief executive officers to encourage them to have more of an advocacy function," he said. "It’s a matter of agitating within the organization."
Professional organizations, such as APA, must be advocates for the homeless mentally ill. McQuistion said APA has played a pivotal role in helping to develop task force reports outlining the role of psychiatrists in the care of homeless mentally ill people and helping to develop standards of care.
But he said the organization could do more to collaborate with other organizations—such as the American Psychological Association—in advocating for homeless mentally ill people. "We need to look hard at other professional organizations in order to broaden APA’s advocacy efforts, especially around poverty and homelessness," he said.
McQuistion said he believes the combination of a public health and population-based perspective on health and illness is gaining ground within medicine and medical training—a phenomenon that is driven in part by terrorism-related disaster-planning and relief.
Such a perspective is vital to caring for a population of homeless people with mental illness, he added. Yet residency training in caring for that population is inconsistent, though it has grown dramatically since the 1980s, when there was virtually no formal training.
In the Psychiatric Services paper, he cited unpublished data surveying residency programs that found 51 percent of American psychiatry residencies offered clinical experiences focused on homeless populations. However, only 5.6 percent of the programs responding to the survey rotated all residents through such experiences.
"We don’t have really good information on how methodically residency training programs address the care of homeless mentally ill people, or more generally, a public-sector population," McQuistion said.
Jules Ranz, M.D., director of the public psychiatry fellowship at Columbia University College of Physicians and Surgeons in New York City, agreed. "An increasing number of psychiatrists do go into the public sector, but training for it is still very strongly hospital based and biologically based," he told Psychiatric News. "So very few residents are receiving what we consider to be adequate training in the needs of public patients, especially in community settings."
Nevertheless, Ranz has conducted numerous surveys of community psychiatrists and found revealing trends in job function and satisfaction and a resurgence of interest in community psychiatry. "We have seen among our own alumni psychiatrists moving into these settings," he said. "Community psychiatrists have a sense of possibilities for a challenging role with flexibility and the opportunity to be creative in ways they don’t have in hospital settings."
McQuistion acknowledged that the need to enhance training of residents in public psychiatry is one that competes with other interests that seek inclusion in the residency training curriculum. But he argued that trainees receiving exposure to public-sector patients reap an experience that will benefit them in whatever setting they choose to practice.
"The mentally ill homeless patient, by virtue of his or her experience and psychopathology, needs aggressive engagement on the part of a clinician," he said. "That’s an experience that will serve trainees very well with any type of patient. And because homeless patients are so complex, it helps trainees conceptualize the full biopsychosocial continuum. It’s good training and highly generalizable in terms of acquired skills."
The article, "Challenges for Psychiatry in Serving Homeless People With Psychiatric Disorders," is posted on the Web at http://ps.psychiatryonline.org/cgi/content/abstract/54/5/669. ▪