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Housing the Homeless Mentally

ill: A Longitudinal Study of

a Treatment Approach
Frank R. Lipton, M.D. care to the chronic mentally ill. For source of income. They usually
Suzanne Nutt, M.P.H. many individuals living with family lack medical insurance and receive
Albert Sabatini, M.D. or friends or in other supportive little or no medical or psychiatric
settings, deinstitutionalization has care.
In a one-year study of 49 home- succeeded. However, for many of These findings have prompted
less chronic mentally ill patients, the chronic mentally ill discharged advocates for the homeless mental-
the subjects, selectedat admission into the community, the alterna- ly ill to recommend development
f or inpatient treatment, were tive care system we created-or of a mental health system with the
randomly assigned to one of two failed to create-has led to destitu- capacity to provide the chronic pa-
groups. One group was placed in tion, recidivism, criminalization, tient, whether homeless or domi-
an experimental residential and homelessness (1). ciled, with a comprehensive social
treatment programfoiowing dis- Research on the chronically ill support system. A major recom-
charge, and the other group re- homeless has focused primarily on mendation of the American Psy-
ceived standird postdischarge describing the sociodemographic chiatnic Association’s task force on
care. Subjects were interviewed and clinical characteristics of this the homeless mentally ill was for
every four months during the population (2,3). Recent cross-sec- the development of a continuum
year as well as at index hospital- tional studies have demonstrated of supportive residential programs
ization and discharge. Although that while the homeless are a het- (11,12).
the study remains exploratory erogeneous group, significant Studies of chronic patients who
due to the small sample size and numbers of individuals suffer from are not homeless have demonstrat-
case attrition, the authors found major mental illnesses, most com- ed that residential programs can
that compared with the control monly schizophrenia, major affec- increase patients’ stay in the com-
group, the subjects in the residen- tive disorders, and severe person- munity as well as improve their
tial treatment program spent sig- ality disorders. Alcoholism and quality of life compared with pro-
ns’icantIy more nights in ade- drug abuse often complicate the grams offering standard forms of
quate shelter, spent fewer nights clinical picture (4-9). care, such as long-term hospitaliza-
in hospitals or undomiciled, and This population has also been tion and traditional community-
were more satisfied with and reported to back a social margin based aftercare (1 2-1 5). However,
committed to their living ar- and to have inadequate social net- little attention has been given to
rangements. works (1,5,10). Homeless individ- the longitudinal interaction be-
tmis have little if any contact with tween homelessness, mental ill-
Deinstitutionalization may be family, friends, or social service ness, and the efficacy of treatment
viewed as an ongoing experiment agencies and are frequently unem- interventions, and we are not
in providing alternative forms of pboyed or without an apparent aware of any studies examining the
effectiveness of residential treat-
Dr. Lipton is currently clinical ical director of the department ment for the homeless mentally ill.
assistant professor of psychiatry, of psychiatry at Bellevue Hospi- This paper describes a one-year
Ms. Nutt is clinical instructor of tal Center. This study was con- study, begun in 1983, that com-
psychiatry, and Dr. Sabatini is ducted when Dr. Lipton was di- pared homeless patients who were
associate professor of clinical rector of psychiatric emergency assigned to a residential treatment
psychiatry at the New York services and Ms. Nutt was statis- program after discharge from inpa-
University Medical Center. Dr. tician in the biometrics depart- tient care with homeless patients
Lipton is also deputy commis- ment at Bellevue Hospital Cen- for whom standard postdischarge
sioner of the New York City ter. Dr. Lipton’s address is Of- planning and treatment were ar-
Human Resources Administra- fice of Psychiatry, Human ranged.
tion. Ms. Nutt is acting coordi- Resources Administration, 5th The study was initiated when 25
nator of Empire Blue Cross and Floor, 311 Broadway, New rooms became available at the
Blue Shield. Dr. Sabatini is med- York, New York 10007. opening of St. Francis Residence

40 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry

II, giving the authors a rare oppor- ning begins immediately upon ad- of I 7 is typical
. of recently admit-
tunity to conduct an experimental mission, it was necessary to select ted psychiatric inpatients. This in-
study of residential treatment for the subjects in the emergency strument was selected because it is
the homeless. The St. Francis Resi- room. Fifty-two patients present- ahistorical and does not depend on
dence is a nonprofit permanent ing to the Bellevue Hospital psy- subjects’ reliability or on contribu-
supportive housing program bocat- chiatric emergency service who tions by other informants.
ed in a renovated single-room-oc- were homeless, chronic mentally A questionnaire was used to
cupancy hotel in New York City ill, and in need of inpatient psychi- gather information on the physical
(16). Through its linkages with attic treatment were randomly as- adequacy of subjects’ housing ar-
city, state, and voluntary agencies, signed to the experimental and the rangements and subjects’ satisfac-
the residence provides an integrat- control groups. Homelessness was tion with them, utilization of inpa-
ed and comprehensive array of defined as sleeping in a public tient and outpatient psychiatric
services to chronic mentally ill pa- place, such as a street, shelter, or and social services, use of psycho-
tients who are homeless or at risk transportation terminal, or in some tropic medication, daily activities,
of becoming homeless. In addition other location perceived to be income, number of nights spent in
to a furnished room, the program temporary by the patient. Chronic shelters or on the streets, and fre-
offers individualized case manage- mental illness was defined accord- quency of contact with family and
ment, coordination of public assist- ing to the St. Francis Residence’s the police.
ance or Social Security benefits, admission requirements as any ma- Caton and associates’ rating
medication monitoring, money jor psychiatric diagnosis, excluding scales ( I 8) were used to rate the
management, meals, activity thera- mental retardation, organic brain physical condition of patients’ liv-
py, and, when appropriate, refer- syndrome, or substance abuse, ing arrangements and patients’ sat-
rals to psychosocial and rehabilita- having a duration of at least six isfaction with and commitment to
tion programs. Through a collabo- months. these arrangements. These scales
rative relationship with Bellevue were modified to allow interview-
To be included in the study,
Hospital, on-site psychiatric treat- subjects had to have been home- ers to rate a hospital, shelter, or
ment is provided, and hospital ad- less continuously for at least three street environment. Hospitals
missions are facilitated when clini- were rated as physically adequate
months before admission. Home-
cally indicated. less patients who had been in a although some subjects did not
psychiatric hospital at any time express satisfaction with their liv-
Methods in the three months before the ing arrangements in hospitals. The
Given the lack of knowledge about best living arrangements, rated 1,
study admission but who had been
residential treatment of the home- were those with functioning utili-
homeless for at least three months
less chronic mentally ill and the before that earlier admission was
ties and no overcrowding or secur-
dearth of research methods appro- ity problems. The poorest arrange-
eligible to be included. Subjects
priate for the study of this popula- ments, rated 5, lacked utilities or
with serious criminal histories or
tion, it was challenging to define recent episodes of violent or sm- had inadequate utilities, were
and operationalize meaningful out- cidal behavior were excluded. overcrowded, or had serious secur-
come measures. Three major ity problems. If subjects expressed
hypotheses were posed. It was hy- Informed consent was obtained satisfaction with and commitment
pothesized, first, that it would be from all subjects. Experimental to their living arrangements, their
feasible to place homeless chronic subjects were placed at the St. response was scored 1 whereas

patients in long-term supportive Francis Residence at discharge,

extreme dissatisfaction and desire
housing and, second, that patients’ while control subjects received for an alternative setting was
routine discharge planning. Each
quality of life would be better im- scored 4.
proved by long-term residential subject was followed for one calen- Life table analysis was used to
placement than by standard post- dar year from the date of admis- examine further the study groups’
discharge care. For purposes of the sion to the study. Interviews were patterns of homelessness during
study, improved quality of life was conducted every four months dur- the follow-up period. Life table
indicated by a reduction of nights ing the study year as well as at analysis is a useful method for cx-
spent undomiciled or hospitalized index admission and discharge. amining longitudinal outcome
as well as by an improvement in Survey instruments. Psychiatric from a treatment because data
the physical living environment status was examined using the from all patients are incbuded
and in patient satisfaction with and Structured Clinical Interview regardless of the amount of time
commitment to their living ar- (SCI) (17), a standardized psychiat- that each subject is followed. This
rangements. Third, it was pro- ric interview that yields an illness approach provides a more precise
posed that residential treatment severity score and ten symptom estimate than those made at a sin-
would reduce the severity of pa- subarea scores. An SCI severity gle point in time as monthly esti-
tients’ psychopathology. score of zero indicates absence of mates of risk are calculated con-
Subjects. Since discharge plan- psychopathology. A severity score trolling for case attrition due to

Hospital and Community Psychiatry January 1988 Vol. 39 No. 1 41

subjects, becoming homeless or
Table 1
lost to follow-up (19).
DSM-1II diagnosis at index admission, by study group’
Interviewers were mental health
professionals who were trained on Experimental Control
all study instruments and who group group
scored reliability coefficients of
Diagnosis N % N %
greater than .80 on the SC! when
compared with a reliable trainer. Schizophrenic disorders 20 76 20 88
Affective disorders 1 4 0 0
Results Personality disorders 2 8 2 8
Of the 52 patients selected for the Other psychotic disorders 3 12 1 4
study, 49 were followed during the I 2196 df=3, ns
study year. Three control subjects
were dropped from the study dur-
ing the index hospitalization when groups had mean SCI severity We attempted to locate the sub-
screening identified histories of scores of 1 .07 and 1 .49, respec- jects who could not be interviewed
significant substance abuse, vio- tively. The lack of a statistically by consulting any agency or mdi-
lence, or criminal behavior. significant difference on this van- vidual with whom they were
Tests for homogeneity of ex- able must be interpreted cautious- known to have been in contact.
perimental and control subjects’ ly since the control group received Some of the experimental and con-
sociodemographic and psychiatric ongoing psychiatric care during trol subjects who could not be
characteristics at index admission their extended index hospitaliza- interviewed at 1 2 months had been
and discharge did not reveal any tions and may not have exhibited interviewed at earlier follow-up
statistically significant differences. levels of psychopathology typical periods, but the data derived from
The mean age of subjects was 37 of discharged patients receiving these interviews are not included
years. Sixty-five percent were standard care in the community. In in Table 2.
male. Twenty-two percent were addition, a more extended follow- Extent of hospitalization. A
brought to the emergency room by up period may be required before statistically significant difference
police, 1 5 percent came by ambu- it is possible to determine the ef- between the two groups was de-
lance, and 63 percent came alone fect of a treatment modality on tected in the proportion of the
or with friends or family members. outcome in schizophrenics. study year spent in a psychiatric
Seventy-one percent were admit- Discharge placement. Upon in- hospital (Table 2). Experimental
ted involuntarily, and 29 percent dex discharge, 26 percent of the subjects spent a mean of 55 nights,
were admitted voluntarily. Mean control group refused all discharge or 1 5 percent of the study year, in
duration of the most recent epi- placement assistance, 26 percent a hospital, compared with a mean
sode of homelessness was 21.1 were discharged to a shelter, 17 of 168 nights, or 46 percent of the
months. There was no association percent were placed in an adult year, for control subjects (t=3.74,
between length of homelessness home, 22 percent were transferred df=20, p<.OO1). This difference
and acceptance of placement in the to a state hospital, 4 percent were was greatest for the index hospital-
residential program. discharged in the custody of a ization at Bellevue, with the ex-
Illness severity scores. At index friend, and 4 percent received an perimental subjects having a mean
admission and index discharge unspecified disposition. All experi- length of stay of 22 nights com-
there were no significant differ- mental subjects initially accepted pared with 52 nights for the con-
ences between groups in the SCI placement at the St. Francis Resi- trol subjects (t=2.56, df=47,
illness severity scores or the types dence. p<.O5).
of symptomatobogy; both experi- Residential status. Twelve This difference in length of stay
mental and control subjects exhib- months after the study admission, was greater when nights trans-
ited severe psychopathology. The 69 percent of the experimental ferred to a state hospital were in-
average SC! scores at admission group were living in permanent cluded in the index stay. Experi-
were 1 .8 1 for the experimental housing, 8 percent were in an mental subjects had a mean total
group and 1.88 for the control acute care hospital, 8 percent were length of stay of 22 nights and
group. At discharge the scores in a state hospital, and 1 5 percent control subjects a mean total
were .80 and .85, respectively. No could not be interviewed. At this length of index stay of 97 nights
difference in admission diagnoses same time, 30 percent of the con- (t=3.96, df=l5, p<.OO1). This
was detected between groups (Ta- trol group were in permanent finding is particularly noteworthy
ble 1). housing, 8 percent were homeless, because subjects were selected at
Both groups showed severe 1ev- 4 percent were in an acute care random, suggesting that the differ-
els of psychopathology throughout hospital, 22 percent were in a state ence in length of stay can be attrib-
the study year. After 12 months, hospital, and 35 percent could not uted to the availability of the inter-
the experimental and control be interviewed. vention and not to the subjects’

42 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry

months in the community. This
Table 2
group had a 40 percent chance of
Mean percentage of nights during the study year spent by subjects in three types of
having 30 or more consecutive
living arrangements
nights of homelessness during that
Experimental Contr ol period, but no risk for the remain-
. . group nights group nights der of the year.
Quality of living arrange-
arrangement M% SD N’ M% SD N’ t2 df p
ments. The groups differed signifi-
Total year cantly in interviewers’ ratings of
Permanent the objective adequacy of subjects’
housing 79 26 20 33 36 14 4.32 32 .0001 living arrangements. Experimental
Homeless 5 2 1 20 20 32 15 1.78 33 ns subjects’ living arrangements were
Hospital3 15 17 21 46 30 15 3.74 34 .001 rated as adequate, with a mean
score of 1.2 1 at 12 months, and
controls’ arrangements were rated
Homeless 6 22 20 46 51 13 2.62 31 .019
as fair, with a mean score of 1.97
I Subjects who could be interviewed at 12 months and had complete data on number of (t=2.5, df=33, p<.0l5).
nights in hospital, number of nights homeless, and number of nights in permanent housing These results were confirmed by
2 Two-tailed test
the subjects’ ratings. The experi-
3 Includes index stay and nights rehospitalized
mental group, with a mean score of
1.63 at 12 months, indicated that
psychiatric status or other charac- homelessness during the study on average they were satisfied with
teristics. year. During the entire year, ex- and committed to their housing
No difference was found in the perimental subjects had a 1 3 per- arrangements. At 12 months the
mean number or length of read- cent chance of having 30 or more controls’ mean rating of their living
missions to psychiatric hospitals. consecutive homeless nights, com- arrangements was 2.87, indicating
This lack of difference should be pared with 39 percent for the con- that on average they perceived in-
interpreted carefully because con- trols (287.46, df=l, p<.Ol). Ex- adequacies and desired an alterna-
trol subjects spent a significant perimental subjects had a 10 per- tive (t3.68, df=32, p<.OO1).
portion of the study year in the cent chance of becoming homeless
index hospitalization, and there- on a long-term basis during their Discussion
fore spent less time than experi- first month in the community, and Despite its experimental design,
mental subjects in the community a 3 percent chance during the rest this study remains exploratory in
at risk of being rehospitalized. of the study year. In contrast, the its conclusions about the efficacy
Episodes ofbomelessness. There controls’ period of greatest risk of residential treatment for the
was no significant difference be- extended over their first four homeless mentally ill. Study re-
tween the two groups in the pro-
portion of the total study year Figure 1
spent undomiciled (Table 2). Probability of not having 30 or more consecutive nights homeless postdischarge
However, when this analysis was (N=49)’
repeated for the proportion of
nights spent homeless after the in-
dex discharge, a difference was de- 0.9 \ _#{149}........

tected. The experimental subjects

were homeless for a mean of 6
percent of nights after discharge, .

compared with 46 percent for the I

controls (t=2.6, df=l5, p<Ol9).

This comparison
test of the impact
is a more precise
of the experi-
mental intervention as it compares
the two groups’ experience in the 0.3 Experimenta1s(N26)#{149}#{149}#{149}#{149}S
community and is not confounded Controls (N23)

by inclusion of patients who had 8 0.2

not been discharged from the in- 0.1

dex hospitalization.
As Figure 1 indicates, experi- 0.0 -
0 1 2 3 4 5 6 7 8 9 10 11 12
mental subjects had a significantly
greater chance than the controls of
not having an extended period of I Subjects who could not be interviewed are assumed to have become homeless.

Hospital and Community Psychiatry January 1988 Vol. 39 No. 1 43

suits must be interpreted in light of work of support services that can and can increase patients’ commit-
a number of anticipated and unan- break the costly and inhumane cy- ment to those arrangements.
ticipated limitations. cle of homebessness and hospital- The results do not support the
The objective of comparing resi- ization. hypothesis that the intervention
dential treatment with standard Results provide support for two reduces severity of psychopathobo-
community-based care was con- of the three study hypotheses. gy. The lack of a difference on this
founded by the controls’ unexpect- First, the study demonstrates that outcome measure may be due to
edly bong index hospitalizations. it is feasible to place homeless the limited sample size, lost con-
This finding is itself valuable, but chronic mentally ill patients in a trol cases, or the large proportion
this characteristic of the control residential treatment setting. All of the study year control subjects
group limits our understanding of subjects who were offered a room spent in the hospital receiving psy-
the effect of the study interven- at the residence accepted it initial- chiatric treatment. Despite these
iion. We do not consider the con- by, and at the end of the study year limitations, this study indicates
trol group’s experience to repre- 69 percent of these subjects were that it is possible to maintain
sent outcome from typical commu- still permanently housed. Al- homeless patients in the communi-
nity-based care. Sampling from a though this conclusion may seem ty despite significant levels of psy-
nonhospital or discharged popula- self-evident, professional and lay chiatric symptomatology, suggest-
tion would eliminate this problem. literature has suggested that many ing that homelessness is less a man-
Another unanticipated concern homeless individuals resist compbi- ifestation of the patient’s illness
resulted from the extent of sub- ance with treatment plans or are than a socioeconomic status arising
jects’ unreliable reporting on use unwilling to accept the services from the gaps and barriers within
of medication and social and psy- offered to them, implying that they our health care delivery system.
chiatric services, and on activities are homeless by choice (2). Study results indicate that many
of daily living. As other investiga- Second, it appears that residen- patients can benefit from a com-
tors have observed, this limitation tial treatment can improve pa- prehensive long-term care arrange-
must be overcome before we can tients’ quality oflife. The availabil- ment such as that provided by the
identify service characteristics that ity of a room at the residence St. Francis Residence. Although
are related to positive outcome reduced subjects’ index length of this study does not identify the
from treatment (2). stay in the hospital as well as the specific components of the pro-
An anticipated limitation was total amount of time spent in the gram that make it effective, we
the case attrition, particularly hospital during the study year. speculate that adequate support
among the control subjects. When This finding has economic implica- systems for these patients should
we began, we were not certain that tions since there is a difference of include outreach services, shelter,
it would be feasible to follow this approximately $500 per day be- residential alternatives, financial
population, but we suggest that it tween the cost of residential and assistance, health care, hospital
is possible to minimize loss of sub- hospital treatment. services, rehabilitative programs,
jects through collaborative rela- Interpretatjon of study results and case management (1). In addi-
tionships between researchers and on rehospitalization is difficult due tion, like other investigators
service providers. to the factors discussed above. It is (20,2 1), we propose that service
The limited sample size may be a possible that if the subjects who systems must feature linkage,
factor in the nonsignificant results could not be interviewed were do- meaningfulness, and flexibility to
on some outcome variables, such ing poorly, a difference in the pre- assure effective care.
as psychiatric status. The sample dicted direction might have been With the fragmentation of fund-
size also limits the kind of conclu- detected. The experimental pro- ing and service delivery so preva-
sions that can be made about pa- gram significantly reduced the lent, we propose that linkage is
tient characteristics associated with number of homeless nights spent one of the primary strategies
good and poor outcome. Further in the community after the index through which a comprehensive,
research using larger sample sizes discharge, the risk of becoming continuous, and integrated system
and a broader range of variables is chronically homeless, and the can be constructed. Linkage must
needed. length of time immediately post- be actualized on multiple levels in
Despite its limitations, this study discharge during which a patient is both horizontal and vertical direc-
provides preliminary support for at greatest risk of becoming home- tions. Patients must be linked to
the development of a continuum less. During this high-risk period it appropriate services; programs
of residential and treatment serv- is critical to provide intensive sup- must be linked to an array of com-
ices for the homeless mentally ill. portive services. Results from the munity resources; and service sys-
In addition, it begins to document objective and subjective assess- tems must be interrelated. Such
longitudinally the course of com- ments of living arrangements indi- linkage will permit interdigitation
*nunity-based care for this popula- cate that a residential treatment of funding mechanisms as well as
tion, and our findings suggest that program can improve the physical comprehensive service delivery
it is possible to configure a net- conditions in which patients live (22).

44 January 1988 Vol. 39 No. 1 Hospital and Community Psychiatry

Similarly services and treatment access to humane treatment, we Homeless: Urban Psychiatry’s Chal-

plans must be perceived by pa- have restricted their lives to a per- lenge. Edited by Jones BE. Washing-
ton, DC, American Psychiatric Press,
tients as relevant and meaningful petual search for survival.
to their needs (20,2 1). The authors Deinstitutionalization was envi- 8. Roth D, Bean GJ: New perspectives
believe that if assistance is de- sioned as a process through which on homelessness: findings from a state-
signed with this principle in mind, patients could be cared for in the wide epidemiological study. Hospital
and Community Psychiatry 87:712-
patients are more apt to accept community. This study suggests
719, 1986
services and comply with treat- that the principles underlying the 9. Barrow 5, Lovell AM: Evaluation of
ment. This point is illustrated by policy were not wrong. It is possi- Project Reach Out 1981-1982. New
the fact that although 7 1 percent of bbe to maintain patients in the York, New York State Psychiatric In-
stitute, 1982
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10. Segal SP, Baumohl J: Engaging the
ted to the index hospitalization in- hensive and integrated resources disengaged: proposals on madness and
voluntarily, they all accepted resi- exist. By pursuing community psy- vagrancy. Social Work 25:358-365,
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recommendations, in The Homeless
more than simply meaningful; they acknowledging our limitations, we
Mentally Iii. Edited by Lamb HR.
must also provide the patient with can develop a mental health care Washington, DC, American Psychiat-
a sense of decency, security, and system with the capacity to make nc Association, 1984
dignity. We suggest that it is not deinstitutionalization a viable actu- 12. Stein LI, Test MA (eds): Alternatives
meaningful, humane, or ,therapeu- ality rather than a discarded social to Mental Hospital Treatment. New
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ter in an overcrowded facility use of a mid-Manhattan hotel as a
where clients prey upon those Acknowledgments support system. Community Mental
even more unfortunate than them- HealthJournal 12:76-83, 1977
The authors gratefully acknowledge 14. Fairweather GW: The prototype lodge
selves. the contributions of Anne Hardesty, society: instituting group process prin-
The configuration of the service Ph.D., Gary Gulbenkian, Adam ciples. New Directions for Mental
delivery system must be malleable Smith, Lou Cuoco, Peter Micheels, Health Services 7:13-32, 1980
enough to accommodate patients Rose Occhino, the clinical staff of the 15. Cutler DL, Beigel Al: A church-based
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Hospital and Community Psychiatry January 1988 Vol. 39 No. 1 45