Homeless and mentally ill – a mental healthcare challenge for <scp>E</scp>urope

The study by Stergiopoulos et al. 1 draws the attention to the important issue of cognitive impairments in homeless adults with mental illnesses. The majority of the study participants demonstrated some degree of cognitive impairment, and this was only partly explained by the underlying mental illness. The factors contributing to the development of cognitive impairments in the population of homeless adults are largely unknown but include higher age, lower education, ethnicity and the presence of psychosis, as this study showed. The study was performed in Canada, but its results seem to be generalizable to other industrialized countries including the European countries. Addressing the cognitive impairments in future studies with the aim to improve mental health care for mentally ill homeless persons in Europe will add to the challenge to optimize the quality of mental health care also for socially marginalized groups in Europe. These include not only the homeless, but also the ethnic minority groups, refugees or people with physical or mental handicaps. The rate of mental illness in the homeless population is about 50%, and an additional 25% suffer from a comorbidity of mental illness and substance use problems 2. Rates seem to vary greatly locally and it was recommended to use local surveys and harmonized definitions of homelessness across countries 3. In the European Union, on any given night, approximately 410 000 people are homeless 3. Homeless people with mental illnesses are in need of several essential requirements: housing, social security including work and mental health care. While there are structured programmes with efficiency in improving recovery by providing housing and social security, for example, ‘Housing First’, by and also by Busch-Geertsema 4, 5, the issue of access to mental health care is still open. Reviews showed that case management, assertive community treatment and critical time interventions were effective models of healthcare delivery including the improvement of symptoms of mental disorders, reducing substance use, decreasing psychiatric hospitalizations and increasing out-patient contacts 2, 6. A specific review about homeless young people showed that for this special population, the evidence base was small, and it was concluded that more methodologically sound research was needed to determine which specific interventions were beneficial 7. An important issue besides mental health is general health in the homeless population, given the 5–6 times excess mortality rate, the increased rate of infectious and traumatic disorders, and the undertreatment of common disorders such as hypertension and diabetes 8. Thus, any mental health intervention will also need to address the question of general health care. A final issue is how far cognitive impairments may interfere with help-seeking and mental healthcare service use, and how these barriers can be overcome. Some studies suggest that by addressing cognitive impairments, healthcare service use may be increased 9. Importantly, it is well known that there are specific high-risk periods for becoming homeless, for example, when being released from prison or following treatment in psychiatric facilities, individuals ageing out of the child welfare system and those fleeing violence 3. Prevention programmes would need to identify and address those entering into such high-risk phases of their lives. Taken together, it is evident that mental health in homeless people needs to be addressed by special programmes including case management programmes linking services and assertive outreach programmes. Besides mental health, somatic health, housing and social security need to be parts of innovative comprehensive programmes, which seem to have the highest likelihood given the currently available evidence in this field of mental healthcare research. This is a task which mental healthcare services alone will not be able to accomplish. Socio-economic security, social inclusion and empowerment are additional requirements which can only be achieved if society as a whole, social security services and health insurers collaborate efficiently. On the patient side, trust in services, safety of services and respect by providers are obviously important elements 7. While the study by Stergiopoulos et al. shows that cognitive impairments are an important domain of the psychopathology of many homeless persons and clearly need to be addressed, it is probable that comprehensive approaches including cognitive remediation besides mental and general healthcare, and the provision of social services and housing, are needed to increase the mental health of this especially vulnerable population. One of the aims for European psychiatry will be to identify the most effective elements of such comprehensive programmes, to develop and disseminate such programmes and to provide studies evaluating their implementation in mental health care in Europe. Healthcare providers are advised to address social policies and structural factors which may lead to homelessness 6. One challenge will be to increase the trust of homeless people with mental illness in such services, a process which will also needs to address aspects of high-quality service provision, knowledge about services, and providing experiences of non-coerciveness of mental health service use 10 – this will probably become a central element not just for recruiting those in need of such services, but also to remain in contact. Another challenge will be to ascertain that it is not the poorest of the poor who suffer most from the consequences of the current economic crisis in Europe – homelessness is on the increase in Europe and welfare reforms may endanger the provision of healthcare services to the mentally ill 11 including those who are homeless. The European Union has observed that there are increasing numbers of families, women and children, migrants and members of specific ethnic groups who have increased rates of homelessness (http://ec.europa.eu/social/main.jsp?catId=1061&langId=en; last accessed December 3, 2014). A recent study by the European Commission showed the large variability in service provision and service accessibility between different European countries 12. Obviously, harmonized criteria for homelessness and special services for especially vulnerable groups will be necessary. It will be important for European psychiatrists not only just to monitor such developments, but also to raise their voices if this leads to new mental healthcare requirements. Psychiatry as a medical specialty has a long history of caring for the homeless, providing clinical services and advocacy 13. Homelessness as a mental healthcare challenge will need not only to remain on the agenda of European psychiatry, but to gain increasing attention by psychiatrists and those responsible for developing psychiatry specialty and continuing medical education curricula. What is to be done? One area of action for European psychiatrists will be to establish mental healthcare agendas addressing the factors identified as barriers to mental healthcare for homeless people. Promoting trust in mental healthcare services will take centre stage, and this may involve information programmes for the homeless and barrier-free access to the services. Such initiatives will need sustained funding and should be evaluated regarding their effectiveness.

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