Transcript Mental Health Services for Homeless in Cork City, Ireland

Mental Health Services for Homeless
in Cork City, Ireland:
Psychiatric Diagnosis; Suicide and
Violence Risk Factors
Dr. Elaine Dunnea, Dr. Maura Dugganb,
Dr. Julie O’Mahonyc
aSenior
Registrar, South Lee Mental Health Service, Cork
University Hospital, Cork, Ireland; bConsultant in Psychiatry,
Adult Homeless Integrated Services, Cork, Ireland;
cSkibbereen Medical Centre, Co. Cork, Ireland
Background
Homeless are those for whom no
accommodation exists, which they could
be reasonably expected to use, or those
who could not be expected to remain in
existing accommodation and are incapable
of providing suitable accommodation for
themselves
Government of Ireland (1988) Housing Act. Irish Statute Book.
The charitable organisation, Simon,
estimates that nationally there are
currently at least 4,176 adults and 1,405
children experiencing homelessness in
Ireland
Despite this, little is formally known about
the extent of the problem and certainly
about its relationship to mental illness
Mental illness & homelessness
Estimates of the prevalence of severe mental disorder
among the homeless in other countries range from 25%50%
Recent guidelines recommend that a detailed
understanding of the mental health needs and priorities
of the population of homeless people should be gained
to provide a guide as to how to allocate available
resources in order to provide care which is relevant to
the requirements of individual patients and their families
A Vision for Change. Department of Health and Children (2006) available at
www.dohc.ie/publications/vision_for_change.html
Suicide and violence
Prevalence rates of suicide in the homeless
population range from 1-3% and, those who
commit suicide have high rates of co-morbidity,
substance misuse, and violence
In the UK, around one third of those convicted
of homicide had a diagnosis of mental disorder
based on life history. 3% of homicide
perpetrators with mental illness were homeless
Appleby L. Department of Health, UK. Safety First: Report of the National
ConfidentiaInquiry into Suicide and Homicide by People with Mental Illness 2001
available at www.dh.gov.uk/en/Publicationsandstatistics
Objectives of this study
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To establish a detailed profile of service users of
the mental health service for homeless in Cork
City, with a particular focus on risk factors for
suicide and violence
To compare this group with those attending a
local General Adult Mental Health Service
Methods
With the approval of the Ethics Committee of the Cork
Teaching Hospitals, information was collected and
recorded from a review of case notes of all service users
of the Mental Health Service for Homeless People in Cork
City
Similar data was gathered from the case notes of service
users attending a Cork General Adult Mental Health
Service
Statistical analysis was carried out using Graphpad Prism
version 5 for windows
Graph Pad Prism version 5.0, Graph Pad Software, San Diego, CA, USA
Results
Approximately 472 individuals availed of
the homeless services in Cork City at the
time of the survey
Homelessness: An Integrated Strategy 2009-2011; www.corkcity.ie
Table 1. Patient Profile of Homeless and
General adult services
(%)
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Number of current patients
(100)
Gender *
Male
Female
Marital status*
Married
(25)
Unmarried
Employment status
Unemployed*
Student
Employed*
Ethnic minority
Homeless
Service n (%)
54 (100)
48 (89)
6 (11)
General Adult
Service n
219
100 (46)
119 (54)
1 (2)
55
53 (98)
164 (75)
52 (96)
2 (4)
0 (0)
4 (7)
149 (68)
14 (6)
56 (26)
7 (3)
*statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001
Figure 1. Age Profile
Homeless service
General Adult service
16-24
16-24
25-34
25-34
35-44
35-44
45-54
45-54
55-64
55-64
>65*
>65*
*statistically significant difference between groups; Fisher’s exact test: p=0.03
Diagnosis (Figure 2)
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There was a significantly higher prevalence of
schizophreniform disorder; personality disorder;
alcohol and drug dependence; and a lower
prevalence of affective disorders in the homeless
service users, though no difference between
groups in relation to either depression or bipolar
affective disorder alone
Homeless patients were significantly more likely
to have a history of alcohol (74% v 27%;
p<0.0001) or drug (61% v 11%; p<0.0001)
misuse
Figure 2. Diagnosis
70
%
60
50
40
30
Homeless
service
20
General Adult
service
10
y
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*statistically significant difference; Χ2: p=0.03(schizophreiform disorder); p<0.0001 (personality
disorder, alcohol dependence, drug dependence)
Risk Factors (Figure 3)
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Factors known to be associated with increased
risk and those which were common in people
who committed suicide and homicide in the UK
are listed in Fig. 3 along with their prevalence in
the groups studied here
Homeless patients were more likely than those
attending the general adult mental health
services to have a history of deliberate self harm
(54% v 21%; p<0.0001) and physical violence
(48% v 10%; p<0.0001)
Figure 3. Factors associated with of
suicide and violence
Unmar r ied*
Unemployed*
Long t er m physical illness
Dual diagnosis*
Hist or y of DSH*
Hist or y of violence*
Dur at ion of sympt oms <1year
Post dischar ge
Recent adver se lif e event s
Family hist or y of suicide
>5 admissions*
Missed last cont act *
Sympt oms at last cont act *
Recent noncompliance*
0
Homeless service
General adult service
20
40
60
%
*statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001
80
100
Service Contact (Figure 3)
There were higher levels of non
compliance and active symptoms in the
homeless group but they also had
significantly more input from
multidisciplinary team members (74% v
37%, p<0.0001) and were seen more
frequently by the consultant psychiatrist
(mean of 3.3 weekly v 10.4 weekly;
p<0.0001)
Conclusions
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The homeless group were significantly more
likely to be male, unemployed, unmarried and
under 65 compared to their general adult
counterparts or compared to adults in the
general population of Cork
Such social isolation and lack of occupation may
exacerbate or maintain symptoms and add to
risk of relapse and suicide
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Severe mental illness has a high prevalence in
the homeless population, with particularly high
levels of psychotic illness and substance
dependence even in comparison to general adult
mental health services
The group of homeless patients also had a high
prevalence of risk factors for suicide and
violence
Poor compliance and severity of illness lead to a
requirement for significant input from
multidisciplinary mental health teams members
Limitations
Data collected for the study was based
solely on case note records. It is possible
that some details may not have been
available leading to an underestimation in
results such as presence of risk factors
Implications
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The profile emerging from this study draws attention to
the complexity of this minority group of mental health
service user
From the findings it is clear that, in addition to the
physical and social needs of any homeless person with
issues such as isolation and lack of occupation, this
group have the additional burden of severe and complex
mental illness, addiction and are at risk of suicide and
possibly violence
It is essential that those most at risk are recognised and
receive appropriate input form well resourced
multidisciplinary teams to ensure there is intensive
treatment of any underlying mental illness as well as
dealing with addiction and social issues in order to
reduce morbidity and risk