Psychiatric morbidity and health service use among attendees at a winter shelter

AIMS AND METHOD

Homelessness is associated with raised psychiatric morbidity.Case records for 597 consecutive attendees at a winter sheltermedical service were retrospectively reviewed to assess routinerecording of psychiatric morbidity and to examine associationsbetween current psychiatric symptoms and health service use.

RESULTS

Previous psychiatric morbidity was recorded in 36.0% of attendees, including 20.4% with comorbid substance misuse. Current psychiatricmorbidity was recorded in 31.3% of attendees, and was associatedwith reduced total medication prescription, increased referralto other services and increased re-presentation to the sheltermedical service.

CLINICAL IMPLICATIONS

Psychiatric morbidity was frequently recorded in this population.Current psychiatric symptoms were associated with increasedhealth service use. Improved training of shelter staff shouldbe instituted to increase engagement with mainstream mentalhealth services.

Introduction

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Introduction

Studies from around the world have repeatedly shown rates ofdepression, anxiety, substance misuse and psychosis which areseveral times higher in the homeless than in housed populations (Koegel et al, 1988; Fichter & Quadflieg, 2001; Han et al, 2003).Data from the UK suggest that 70-80% of homeless people haveat least one lifetime psychiatric diagnosis, 30-50% reportacute psychological distress and at least 20% show comorbidsubstance misuse and mental illness (Scott, 1993).

However, the impact of mental disorder on the provision of overall healthcare to this population is less clear. This study aimedto assess recording of psychiatric morbidity among attendeesat the medical centres of open access winter shelters run bythe homelessness charity Crisis. It also examined associationsbetween the presence of current psychiatric symptoms and treatmentreceived.

Method

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Method

The Crisis Open Christmas is a group of open access winter shelters available in London over the Christmas week, attended mainlyby those living on the streets or in insecure accommodationsuch as hostels (see http://www.crisis.org.uk/coc). The sheltermedical centres are staffed by volunteer clinicians and provide emergency medical care, primary healthcare and health education.Attendees are initially triaged by nurses, who use a standardisedmedical form to record demographic and housing information,usual sources of healthcare, past medical and psychiatric history(specifically including asthma, diabetes, hypertension, tuberculosis,fits, alcohol misuse, drug misuse and mental health problems),smoking status, current medications and drug allergies. In addition,the presenting complaint is detailed. Definitive assessmentand treatment is provided by the most appropriate member ofthe clinical team, for instance a physician, psychiatrist ornurse.

During November 2003, as part of a strategy to improve assessmentand management of psychiatric disorder within the Crisis OpenChristmas, medical records for attendees at the 2002 Crisismedical centres were examined. All attendees who had seen adoctor or nurse were eligible for inclusion in the study. Thosewho left the medical centre before details of the presenting complaint had been recorded were excluded.

Demographic information and data on reported lifetime and currentmental health problems and substance misuse were extractedfrom the medical records. Details of illicit drugs used andprevious psychiatric diagnoses were not required by the assessmentschedule, but were often recorded by clinicians or could beinferred from reported medication. Where the current presentation included signs or symptoms of psychiatric illness or substancemisuse, symptom type and diagnosis given were noted.

Outcomes of the consultation were defined as:

immediate treatment offered
referral to shelter substancemisuse team
acute referral to external medical, surgical orpsychiatricfacility
later re-presentation to shelter medicalservice.

These outcomes were compared between those with and those withoutcurrent psychiatric symptoms, using ${chi}$ ² tests to assess the statistical significance of findings. All data were analysed using SPSSversion 10 for Windows.

Results

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Results

Of 649 attendees, 597 (92.0%) were eligible for inclusion, and52 (8.0%) were excluded because they left before their presentingcomplaint had been recorded; 202 (33.8%) attended more thanonce. The mean age of attendees was 40 years (range 16-78,s.d.=12.9) and 83.8% of attendees were male. Data on ethnicitywere absent in 28.8%; of those remaining, 85.6% identified themselvesas British or White. Out of 597 attendees, 51.1% defined themselves as rough sleepers, 13.8% lived in hostels and 21.1% were housed.

Physical health
Reported physical illness was common, including 17.6% with registered disability, 26.0% asthma, 14.3% fits, 13.2% hypertension, 4.8%diabetes and 4.1% tuberculosis. Smoking was reported by 74.6%.At least one usual source of healthcare was reported by 75.4%of attendees, including 58.3% from a general practitioner orprimary healthcare team for the homeless. There were 414 (69.3%)who gave information on current medication, of whom 198 (47.8%)were taking medication for physical health problems, 107 (25.8%)for mental health problems and 152 (36.7%) were taking no medication.

Past psychiatric history
Information on previous mental illness, excess alcohol use andillicit drug use was missing for 13.2, 10.7 and 12.2% of attendeesrespectively. Of the remainder, 209 (39.1%; 95% CI 35.0-43.3)reported excess alcohol use, 186 (35.4%; CI 31.3-39.5) illicitdrug use and 187 (36.0%; CI 31.9-40.2) mental health problems.Of the 506 for whom information was available on all three, 103 (20.4%; CI 16.9-23.9) reported comorbid substance misuseand mental health problems. Details of specific drugs recorded(n=127) and psychiatric history (n=128) are given in Table 1.

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Table 1. Details of lifetime drug misuse (n=127) and past psychiatric history (n=128)

There were 107 attendees (25.8% of those giving informationon medication) who reported currently prescribed psychotropicmedication, including 26 using antipsychotics (6.3%); 47 (7.9%)were recorded as known to psychiatric or substance misuse services,although this information was not routinely requested.

Current symptoms and association with outcomes
There were 187 attendees (31.3%, 95% CI 27.6-35.0) who had current psychiatric signs or symptoms recorded during at least oneconsultation. As shown in Table 2, both presenting complaintsand diagnoses given in these attendees were predominantly relatedto physical disorder or substance misuse. Diagnosis of depressionand anxiety was unusual.

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Table 2. Presenting symptoms (n=187) and diagnoses given (n=137)

Table 3 shows highly significant associations between currentpsychiatric morbidity and outcome of the Crisis Open Christmasconsultation. These include increases in initial non-pharmacologicalmanagement (assessment and reassurance, healthcare advice, orreferral to shelter Samaritan service), referral to the sheltersubstance misuse team, referrals to hospital (medical and psychiatric)and re-presentation to the shelter medical centre. Overall,this represents an increased use of healthcare resources.

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Table 3. Outcome according to presence of current psychiatric morbidity

Discussion

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Discussion

This large, cross-sectional study is unusual in focusing onpsychiatric morbidity routinely recorded during primary careconsultations among a predominantly homeless population. Recordedprevalence of both lifetime and current psychiatric morbiditywas high, and current symptoms were associated with increasedhealth service use.

Recorded rates of lifetime and current psychiatric morbidityin this study are comparable to those seen in previous researchusing self-report measures (Scott, 1993; Gill et al, 1996), although use of observer report, longitudinal measures anddiagnostic instruments is known to be associated with higherrecorded rates of disorder in this population (Goldfinger et al, 1996).As in other studies (Bridges & Goldberg, 1985; Feldman et al, 1987), many attendees with psychiatric morbidity presented with physicalsymptoms or acute problems related to substance misuse. Depressionand anxiety were rarely diagnosed, and a diagnosis of substancemisuse was frequently not followed by referral to substancemisuse services, suggesting that important opportunities forintervention were missed.

Overall, few psychotropic medications were prescribed, as theCrisis Open Christmas medical service does not dispense benzodiazepines,atypical antipsychotics or antidepressants. Given the knownassociation between physical and psychological morbidity inthe homeless (Gill et al, 1996; Desai & Rosenheck, 2005), the association between current psychiatric morbidity and reducedoverall medication prescription at the Crisis Open Christmasis surprising. However, increased rates of both acute referraloutside the shelter and re-presentation within the shelterdemonstrate that the high level of health need typically foundin homeless people with mental illness is associated with increased health service use, particularly for acute services (Stein & Gelberg, 1997).

Although the large sample size and small number of attendeesexcluded because of lack of information are important strengthsof the study, there are also some limitations. As a retrospectivestudy, it relied on good-quality data having been collectedduring routine clinical practice, and levels of missing datawere of concern for some items. No diagnostic measures wereused, and the true prevalence of psychiatric disorder in thesample is therefore unknown. The unusual service context ofthe study also means that generalisation may be difficult,although the demographic similarity between this and previoussamples of homeless people in Britain is encouraging. Finally,since these data are cross-sectional, the impact of the high incidence and remission rates of mental illness in the homelessis unclear (Fichter & Quadflieg, 2005). Further longitudinaldata are therefore essential to inform service planning.

Although previous studies have explored both clinical and economicaspects of different models of service provision for homelesspeople with mental illness (Rosenheck, 2000), the challengeof creating an initial engagement with services remains. Inthis context, opportunities to identify and treat mental healthproblems must be taken whenever possible. Interventions withinthe shelter environment have the potential to increase engagementwith mainstream services (Bradford et al, 2005), and thisis particularly important for the Crisis Open Christmas, whichoperates for only 1 week per year. The impact of mental healthtraining for shelter staff has received little attention (Vamvakas & Rowe, 2001), but this study suggests that improved training of Crisis staffin the detection and management of mental health problems shouldbe instituted, and its impact be systematically evaluated.Such training should aim to increase engagement with mainstreammental health services as the first step towards reducing theburden of psychiatric morbidity in this vulnerable group.

Acknowledgments

I thank Roger Williams and other Crisis staff for their support.The findings were presented as a poster at the 2004 AnnualMeeting of the General and Community Faculty of the Royal Collegeof Psychiatrists and won the trainee research prize. ProfessorMartin Prince and Dr Rajesh Mohan offered advice on earlierversions of this paper.

References

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