The presence of mental disorders among homeless people has long been recognized.

Homeless
people have high rates of morbidity and mortality while having low rates of health service uptake,
culminating in a high level of unmet need (Power et al., 1999). Some mental disorders, specifically
psychoses, alcohol and drug misuse, depression and personality disorder, are more prevalent
among homeless people when compared with the general population and impoverished housed
people (Abdul et al., 1993; Timms & Balazs, 1997; Zima et al., 1996). Furthermore, homeless
people are more than 34 times more likely to commit suicide (Shaw & Dorling, 1998).
Over the past decade, local, state, and national studies have revealed that 20 to 25 percent of the
homeless population have mental disorders such as schizophrenia, severe and recurrent major
depression, and bipolar disorder (Lehman et al., 1994). Serious mental illnesses disrupt people’s
ability to carry out essential aspects of daily life, such as self-care and household management.
Mental illnesses may also prevent people from forming and maintaining stable relationships or
cause people to misinterpret others’ guidance and react irrationally. This often results in pushing
away caregivers, family, and friends who may be the force keeping that person from becoming
homeless. As a result of these factors and the stresses of living with a mental disorder, people with
mentally illnesses are much more likely to become homeless than the general population (Library
Index, 2009). A study of people with serious mental illnesses seen by California’s public mental
health system found that 15% were homeless at least once in a one-year period (Folsom et al.,
2005). Patients with schizophrenia or bipolar disorder are particularly vulnerable.
Both structural and individual factors contribute to homelessness among people with mental illness
and poor mental health, including lack of safe, affordable housing, as well as potentially disabling
behavioral health issues (O’Hara, 2007). While mental illness may lead to problems that result in
homelessness, it does not appear to be a sufficient risk factor on its own, based on comparisons of
people who are homeless with mental illness and (a) those without mental illness and (b) those
housed with mental illness (Sullivan, Burnam, Koegel, & Hollenberg, 2000). The symptoms
associated with mental illness and substance use disorders may not only contribute to a person’s
vulnerability for homelessness but may also be exacerbated by the experience of homelessness
(O’Hara, 2007). According to the Substance Abuse and Mental Health Services Administration
(2003), lack of resources and fragmented, antiquated mental health service systems exacerbate the
problem of homelessness for people with mental health problems. Homeless people with serious
mental illness find it more challenging to become housed on their own and are at greater risk of
chronic homelessness (U.S. HUD, 2001).

Power, R., French, R., Connelly, J., George, S., Hawes, D., Hinton, T., Klee, H., Robinson, D.,
Senior, J., Timms, P. & Warner, D. (1999) Health, health promotion, and homelessness. British
Medical Journal, 318(7183), 590–592.

Abdul, H.W., Wykes, T. & Stansfeld, S. (1993) The homeless mentally ill: myths and realities.
International Journal of Social Psychiatry, 39(4), 237–254.

Timms, P. & Balazs, J. (1997) ABC of mental health. Mental health on the margins. British
Medical Journal, 315(7107), 536–539.

Zima, B.T., Wells, K.B., Benjamin, B. & Duan, N. (1996) Mental health problems among
homeless mothers: relationship to service use and child mental health problems. Archives of
General Psychiatry, 53(4), 332–338

Shaw, M. & Dorling, D. (1998) Mortality among street youth in the UK. Lancet, 352(9129), 743

Lehman AF, Cordray DS: Prevalence of alcohol, drug, and mental disorders among the homeless:
one more time. Contemporary Drug Problems 20:355-383, 1994Google Scholar

Folsom, D.P., Hawthorne, W., Lindamer, L., Gilmer, T., Bailey, A., Golshan, S., Garcia, P.,
Unützer, J., Hough, R., and Jeste, D.V. “Prevalence and Risk Factors for Homelessness and
Utilization of Mental Health Services Among 10,340 Patients With Serious Mental Illness in a
Large Public Mental Health System.” American Journal of Psychiatry, 162:370-376. Feb. 2005.

Library Index. “The Health of the Homeless – The Mental Health of Homeless People.” 2009.
Available from http://www.libraryindex.com
O’Hara, A. (2007). Housing for people with mental illness: Update of a report to the President’s
New Freedom Commission. Psychiatric Services, 58, 907-913.

Sullivan, G., Burnam, A., Koegel, P., & Hollenberg, J. (2000). Quality of life of homeless persons
with mental illness: Results from the Course-of-Homelessness study. Psychiatric Services, 51,
1135-1141.

U.S. Department of Housing and Urban Development. (2001). A report on worst case housing
needs in 1999: New opportunity amid continuing challenges [Executive summary]. Washington,
DC: Office of Policy Development and Research.
Homelessness is the result of complex interactions among structural factors such as the decreased
availability of low-cost housing, unemployment, lack of social welfare policies, or immigration, and
individual factors of social vulnerability such as physical and mental illness, addiction, loneliness, loss of
social support, or some accumulation of other adverse life events [1,2,3]. The relationship between
homelessness and mental illness has already been discussed. More often, mental illness occurs before
the onset of homelessness, and more rarely during homelessness [11]

Factors found associated with homelessness by one’s social environment and/or adverse life events [15]
are also risk factors for severe psychiatric disorders. A growing body of evidence suggests that adverse
early circumstances, discrimination, experiences of social defeat, powerlessness, and lack of social
support could be an important risk of severe psychiatric disorders [16]. More specifically, family
relationships, as well as disrupted attachment relations, separation from parents in early life, adverse
relationships with parents, or parental communication deviance, have been reported in association with
serious psychopathological disorders [17]. Sexual abuse has been specifically investigated, and a history
of sexual abuse has been linked with psychosis [18].

{{{{1. Firdion J.-M., Marpsat M. A research program on homelessness in France. J. Soc.

Issues. 2007;63:567–588. doi: 10.1111/j.1540-4560.2007.00524.x. [Cross Ref]
2. Philippot P., Lecocq C., Sempoux F., Nachtergael H., Galand B. Psychological research on
homelessness in Western Europe: A review from 1970 to 2001. J. Soc. Issues. 2007;63:483–504.
doi: 10.1111/j.1540-4560.2007.00520.x. [Cross Ref]
3. Shinn M. Homelessness, poverty and social exclusion in the United States and Europe. Eur. J.
Homelessness. 2010;4:19–44.
4. Caton C.L.M., Shrout P.E., Eagle P.F., Opler L.A., Felix A., Dominguez B. Risk factors for
homelessness among schizophrenic men: A case-control study. Am. J. Public
Health. 1994;84:265–270. doi: 10.2105/AJPH.84.2.265. [PMC free article] [PubMed] [Cross
Ref]
5. Babington P.E., Angermeyer M., Azorin J.M., Brugha T., Kilian R., Johnson S., Toumi M.,
Kornfeld Å., EuroSC Research Group The European Schizophrenia Cohort (EuroSC)—A
naturalistic prognostic and economic study. Soc. Psychiatry Psychiatr. Epidemiol. 2005;40:707–
717. doi: 10.1007/s00127-005-0955-5.[PubMed] [Cross Ref]
6. Folsom D.P., Hawthorne W., Lindamer L., Gilmer T., Bailey A., Golshan S., Garcia P.,
Unützer J., Hough R., Jeste D.V. Prevalence and risk factors for homelessness and utilization of
mental health services among 10,340 patients with serious mental illness in a large public mental
health system. Am. J. Psychiatry. 2005;162:370–376. doi:
10.1176/appi.ajp.162.2.370. [PubMed] [Cross Ref]
7. Koegel P., Burman A., Farr R.K. The prevalence of specific psychiatric disorders among
homeless individuals in the inner city of Los Angeles. Arch. Gen. Psychiatry. 1988;45:1085–
1092. doi: 10.1001/archpsyc.1988.01800360033005. [PubMed] [Cross Ref]
8. Kovess V., Mangin L.C. The prevalence of psychiatric disorders and use of care by homeless
people in Paris. Soc. Psychiatry Psychiatr. Epidemiol. 1999;34:580–587. doi:
10.1007/s001270050178. [PubMed][Cross Ref]
9. Fichter M.M., Quadflieg N. Prevalence of mental illness in homeless men in Munich,
Germany: Results from a representative sample. Acta Psychiatr. Scand. 2001;103:94–104. doi:
10.1034/j.1600-0447.2001.00217.x. [PubMed] [Cross Ref]
10. Fazel S., Khosla V., Doll H., Geddes J. The prevalence of mental disorders among the
homeless in Western countries: Systematic review and meta-regression analysis. PLoS
Med. 2008;5:1670–1680. doi: 10.1371/journal.pmed.0050225. [PMC free
article] [PubMed] [Cross Ref]
11. Sullivan G., Burnam A., Koegel P., Hollenberg J. Quality of life of homeless persons with
mental illness: Results from the course-of-homelessness study. Psychiatr. Serv. 2000;51:1135–
1141. doi: 10.1176/appi.ps.51.9.1135. [PubMed] [Cross Ref]
12. Dohrenwend B.P., Levav I., Shrout P.E., Schwartz S., Naveh G., Link B.G., Skodol A.E.,
Stueve A. Socioeconomic status and psychiatric disorders: The causation-selection
issue. Science. 1992;255:946–952. doi: 10.1126/science.1546291. [PubMed] [Cross Ref]
13. Lorant V., Deliège D., Eaton W., Robert A., Philippot P., Ansseau M. Socioeconomic
inequalities in depression: A meta-analysis. Am. J. Epidemiol. 2003;2:98–112. doi:
10.1093/aje/kwf182. [PubMed][Cross Ref]
14. Kessler R.C., Foster C.L., Saunders W.B., Stang P.E. Social consequences of psychiatric
disorders. Am. J. Psychiatry. 1995;152:1026–1032. doi:
10.1176/ajp.152.7.1026. [PubMed] [Cross Ref]
15. Marpsat M., Firdion J.-M. The homeless in Paris: A representative sample survey of users of
services for the homeless. In: Avramov D., editor. Coping with Homelessness: Issues to Be
Tackled and Best Practices in Europe. Ashgate Publishing; Brussels, Belgium: 1998. pp. 221–
251.
16. Bentall R.P., Fernyhough C. Social predictors of psychotic experiences: Specificity and
psychological mechanisms. Schizophr. Bull. 2008;34:1012–1020. doi:
10.1093/schbul/sbn103. [PMC free article][PubMed] [Cross Ref]
17. McKenzie K. How do social factors cause psychotic illnesses? Can. J.
Psychiatry. 2013;58:41–43. doi: 10.1177/070674371305800108. [PubMed] [Cross Ref]
18. Bebbington P.E., Bhugra D., Brugha T., Singleton N., Farrell M., Jenkins R., Lewis G.,
Meltzer H. Psychosis, victimisation and childhood disadvantage: Evidence from the second
British National Survey of Psychiatric Morbidity. Br. J. Psychiatry. 2004;185:220–226. doi:
10.1192/bjp.185.3.220. [PubMed][Cross Ref]}}}}}}}}}}}}}}}}}}
Serious mental illnesses disrupt people’s ability to carry out essential aspects of daily life, such as self
care and household management. Mental illnesses may also prevent people from forming and
maintaining stable relationships or cause people to misinterpret others’ guidance and react irrationally.
This often results in pushing away caregivers, family, and friends who may be the force keeping that
person from becoming homeless. As a result of these factors and the stresses of living with a mental
disorder, people with mentally illnesses are much more likely to become homeless than the general
population (Library Index, 2009). A study of people with serious mental illnesses seen by California’s
public mental health system found that 15% were homeless at least once in a one-year period (Folsom
et al., 2005). Patients with schizophrenia or bipolar disorder are particularly vulnerable.((((( Folsom, D.P.,
Hawthorne, W., Lindamer, L., Gilmer, T., Bailey, A., Golshan, S., Garcia, P., Unützer, J., Hough, R., and
Jeste, D.V. “Prevalence and Risk Factors for Homelessness and Utilization of Mental Health Services
Among 10,340 Patients With Serious Mental Illness in a Large Public Mental Health System.” American
Journal of Psychiatry, 162:370-376. Feb. 2005.

Library Index. “The Health of the Homeless – The Mental Health of Homeless People.” 2009. Available
from http://www.libraryindex.com))))

Both structural and individual factors contribute to homelessness among people with mental illness and
poor mental health, including lack of safe, affordable housing, as well as potentially disabling behavioral
health issues (O’Hara, 2007). While mental illness may lead to problems that result in homelessness, it
does not appear to be a sufficient risk factor on its own, based on comparisons of people who are
homeless with mental illness and (a) those without mental illness and (b) those housed with mental
illness (Sullivan, Burnam, Koegel, & Hollenberg, 2000). The symptoms associated with mental illness and
substance use disorders may not only contribute to a person’s vulnerability for homelessness but may
also be exacerbated by the experience of homelessness (O’Hara, 2007). According to the Substance
Abuse and Mental Health Services Administration (2003), lack of resources and fragmented, antiquated
mental health service systems exacerbate the problem of homelessness for people with mental health
problems. Homeless people with serious mental illness find it more challenging to become housed on
their own and are at greater risk of chronic homelessness (U.S. HUD, 2001). Between 150,000 and
200,000 people with disabilities, including mental illness, experience chronic homelessness. Meta-
analysis of 16 epidemiological studies of people in the United States without homes revealed the
prevalence of mental disorders for any Axis I disorder to be 43%; for a severe Axis I disorder, 18%; and
for a lifetime severe Axis I disorder, 32% (Lehman & Cordray, 1993). More recent estimates of mental
disorders among people living without homes range up to over 40% (Burt, 2001; Fazel, Khosla, Doll, &
Geddes, 2008), with a wide variety of symptoms of mental disorders and diagnosed mental illnesses
present, including schizophrenia and other psychoses, mood and anxiety symptoms, paranoia, and
obsessive compulsive symptoms and disorders including posttraumatic stress disorder (PTSD) (Connolly,
CobbRichardson, & Ball, 2008; Olfson, Mechanic, Hansell, Boyer, & Walkup, 1999). At-risk youths living
without homes also have problems with mental health, including mood disorders, suicide attempts, and
PTSD (Cauce et al., 2000; McCaskill, Toro, & Wolfe, 1998; Powers, Eckenrode, & Jaklitsch, 1990; Rew,
Thomas, Horner, Resnick, & Beuhring, 2001; RotheramBorus, 1993). PTSD affects as many as one third
of adolescents without homes (Whitbeck, Hoyt, Johnson, & Chen, 2007), as does the co-occurrence of
depression and anxiety symptoms with PTSD (Gwadz, Nish, Leonard, & Strauss, 2007). Among 14–25-
year-old youths experiencing homelessness, 82% reported psychological symptoms including depression
and anxiety (sometimes severe and chronic) and aggression; 43% reported having attempted suicide
(Klee & Reid, 1998).
ABDUL, H.W., WYKES, T. & STANSFELD, S. (1993) The homeless mentally ill: myths and realities.
International Journal of Social Psychiatry, 39(4), 237–254. ADSHEAD, G. (1998) Psychiatric staff as
attachment figures. Understanding management problems in psychiatric services in the light of
attachment theory. British Journal of Psychiatry, 172, 64–69. APPLEWHITE, S.L. (1997) Homeless
veterans: perspectives on social services use. Social Work, 42(1), 19–30. BHUGRA, D. (2000)
Homelessness and Mental Health. Cambridge: Cambridge University Press. DE ROSA, C.J.,
MONTGOMERY, S.B., KIPKE, M.D., IVERSON, E., MA, J.L. & UNGER, J.B. (1999) Service utilization among
homeless and runaway youth in Los Angeles, California: rates and reasons. Journal of Adolescent Health,
24(6), 449–458. DEPARTMENT OF HEALTH (1999) The National Service Framework for Mental Health.
London: Department of Health. DEPARTMENT OF HEALTH (2000) The NHS Plan. London: Department of
Health. GRENIER, P. (1997) Still dying for a home: an update of Crisis’ 1992 investigation into the links
between homelessness, health and mortality. London: CRISIS. HODNICKI, D.R., HORNER, S.D. & BOYLE,
J.S. (1992) Women’s perspectives on homelessness. Public Health Nursing, 9(4), 257–262. LINDSEY, E.
(1998) Service providers’ perceptions of factors that help or hinder homeless families. Families in
Society, 79(2), 160–172. MAYS, N. & POPE, C. (1995) Rigour and qualitative research. British Medical
Journal, 311(6997), 109–112. POPE, C., ZIEBLAND, S. & MAYS, N. (2000) Qualitative research in health
care. Analysing qualitative data. British Medical Journal, 320(7227), 114–116. POWER, R., FRENCH, R.,
CONNELLY, J., GEORGE, S., HAWES, D., HINTON, T., KLEE, H., ROBINSON, D., SENIOR, J., TIMMS, P. &
WARNER, D. (1999) Health, health promotion, and homelessness. British Medical Journal, 318(7183),
590–592. REID, P. (1999) Young homeless people and service provision. Health and Social Care in the
Community, 7(1), 17–24. SHAW, M. & DORLING, D. (1998) Mortality among street youth in the UK.
Lancet, 352(9129), 743 STYRON, T.H. (1997) Understanding the experience of family homelessness in the
context of single mothers’ lives. PhD thesis. University of Massachusetts Amherst. SUSNICK, L. (1992)
Stigma, fear and dreams: an interview-observation study of person who are homeless and mentally ill
and their service providers. PhD thesis. Gallaudet University, Washington. TIMMS, P. & BALAZS, J. (1997)
ABC of mental health. Mental health on the margins. British Medical Journal, 315(7107), 536–539.
VANCE, D. (1994) Barriers to use of services by older homeless people. Psychological Reports, 75(3 Pt 1),
1377–1378. VANCE, D. (1995) Barriers and aids in conducting research with older homeless individuals.
Psychological Reports, 76(3 Pt 1), 783–786. ZIMA, B.T., WELLS, K.B., BENJAMIN, B. & DUAN, N. (1996)
Mental health problems among homeless mothers: relationship to service use and child mental health
problems. Archives of General Psychiatry, 53(4), 332–338