Homelessness & mental health

It has now been 13 years since I completed my PhD research on housing for people with psychiatric disability, and policy barriers and enablers to housing for this group. Later that year, in December 2008 the Australian government released its national housing policy, The Road Home, where it confirmed 2 broad COAG goals of halving homelessness and offering supported accommodation to all rough sleepers. Within this policy, mental health issues were recognised as being a cause of homelessness, with a third of clients of the SAAP (homeless) programs and the homeless in inner city areas being mentally ill. The Road Home policy introduced a ‘no exits into homelessness’ from mental health facilities stance.

Just after this time, the number of rough sleepers in Adelaide initially declined before steadily increasing (see Table below). As a result of covid19, large numbers of rough sleepers (e.g. 288 in Adelaide) were housed across the nation (e.g. in hotels), yet his was only a temporary solution, with concerns about ‘what happens next?’

Projects such as Project Zero in Adelaide identify the homelessness who are on the streets and aim to house them, with the ultimate goal of zero street homelessness. However, this is just one form of homelessness, and not the most common type.

Source: Adelaide Zero Project: https://www.dunstan.org.au/adelaide-zero-project/dashboard/

The most common types of homelessness (AIHW, 2020) are:

• People living in severely overcrowded dwellings
• People living in supported accommodation for the homeless
• People temporarily staying with other households
• People living in boarding houses

Some of these definitions of homelessness, for example living in boarding houses, may be permanent accommodation for some groups, e.g. people with a mental illness.

Contributing factors to our homeless population include:

• A decline in affordable housing, including public and social housing
• Domestic and family violence
• People with chronic mental health problems and other disabilities finding it difficult to access housing
• People leaving hospital or the prison system without adequate follow-up or long term housing solutions
• Economic downturn and unemployment

According to the AIHW (2020), recipients of specialist homeless services (SHS) are most likely to have:

• Experienced family and domestic violence
• Have current mental health issues
• Identify as an Aboriginal or Torres Strait Islander.

From 2011–12 to 2019– 20 the number of female clients of specialist homelessness services has increased from 124.4 clients per 10,000 population in 2011–12 to 136.6 in 2019– 20. In total, 60% or almost 174,700 clients were female, and 1/3^rd were under 18 years.

People with chronic mental health problems are particularly vulnerable to homelenessness due to diminishing public resources for public housing, and cash assistance programmes replacing public housing (i.e. rent relief schemes for the private market where people with a chronic mental illness are severely disadvantaged due to stigma and other factors).

Housing affordability and insecure housing tenures have the potential to further compound physical and mental health problems for people with a mental illness. Housing affordability and excessive spending on housing negatively affects mental health (Bryant 2004). Insecure housing also has the potential to compromise the provision and effect of clinical services. There are negative health effects of poor material conditions of a home, inappropriate housing design, certain housing tenures including homelessness, the location of housing and neighborhood factors (Shaw 2004). Housing quality is a significant predictor of psychological distress (Evans, Wells et al. 2000) and poor conditions of a house have been associated with anxiety and depression (MacIntyre et al 2003 in Shaw 2004).  Conversely, studies on the health impact of housing interventions have found a consistent pattern between improvements in housing and better mental health (Evans, Wells et al. 2000; Thomson, Petticrew et al. 2003).

We know that with covid-19, the demands on mental health telephone triage services and Emergency Departments of hospitals has increased significantly, driven by economic and other stressors (there has been a reported 39% increase in mental health presentations to ED at the Royal Adelaide Hospital in South Australia from February 2019 to February 2021). There have also been reported increases in domestic and family violence across the nation (e.g. 10% annual increase in South Australia).

One program for people with chronic mental health problems introduced across countries has been ‘Housing First’. This has four key elements:

• Immediate provision of housing and consumer-driven services.
• Separation of housing and clinical services.
• Providing supports and treatment with a recovery orientation.
• Facilitation of community integration.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679127/

The peak body for homelessness services, Homelessness Australia, which was defunded by the Federal Government in December 2014, has developed principles for Housing First for Australia (adopted 2020): see https://www.homelessnessaustralia.org.au/campaigns/housing-first-australia The Housing First approach has demonstrated effectiveness, both in terms of mental health and wellbeing and housing outcomes. It offers a sustainable, long term solution to the overrepresentation of people with chronic mental health problems (leading to psychiatric disability) within homeless populations: see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679127/