Association of homelessness and psychiatric hospital readmission-a retrospective cohort study 2016-2020.

BACKGROUND: A large proportion of adult psychiatric inpatients experience homelessness and are often discharged to unstable accommodation or the street. It is unclear whether homelessness impacts psychiatric hospital readmission. Our primary objective was to examine the association between homelessness and risk for 30-day and 90-day readmission following discharge from a psychiatric unit at a single urban hospital. METHODS: A retrospective cohort study involving health administrative data among individuals (n = 3907) in Vancouver, Canada with an acute psychiatric admission between January 2016 and December 2020. Participants were followed from the date of index admission until censoring (December 30, 2020). Homelessness was measured at index admission and treated as a time-varying exposure. Adjusted Hazard Ratios (aHRs) of acute readmission (30-day and 90-day) for psychiatric and substance use disorders were estimated using multivariable Cox proportional hazards regression. RESULTS: The cohort comprised 3907 individuals who were predominantly male (61.89%) with a severe mental illness (70.92%), substance use disorder (20.45%) and mean age of 40.66 (SD, 14.33). A total of 686 (17.56%) individuals were homeless at their index hospitalization averaging 19.13 (21.53) days in hospital. After adjusting for covariates, patients experiencing homelessness had a 2.04 (1.65, 2.51) increased rate of 30-day readmission and 1.65 (1.24, 2.19) increased rate of 90-day readmission during the observation period. CONCLUSIONS: Homelessness was significantly associated with increased 30-day and 90-day readmission rates in a large comprehensive sample of adults with mental illness and substance use disorders. Interventions to reduce homelessness are urgently needed. QUESTION: Is homelessness associated with risk for 30-day and 90-day psychiatric hospital readmission? FINDINGS: In this retrospective cohort study of 3907 individuals, homelessness at discharge was associated with increased 30-day and 90-day psychiatric readmission. MEANING: Housing status is an important risk factor for hospital readmission. High-quality interventions focused on housing supports have the potential to reduce psychiatric readmission.

Multivariable modelling of factors associated with criminal convictions among people experiencing homelessness and serious mental illness: a multi-year study.

People experiencing homelessness and serious mental illness exhibit high rates of criminal justice system involvement. Researchers have debated the causes of such involvement among people experiencing serious mental illness, including what services to prioritize. Some, for example, have emphasized mental illness while others have emphasized poverty. We examined factors associated with criminal convictions among people experiencing homelessness and serious mental illness recruited to the Vancouver At Home study. Participants were recruited between October 2009 and June 2011. Comprehensive administrative data were examined over the five-year period preceding study baseline to identify risk and protective factors associated with criminal convictions among participants (n = 425). Eight variables were independently associated with criminal convictions, some of which included drug dependence (RR = 1.53; P = 0.009), psychiatric hospitalization (RR = 1.44; P = 0.030), an irregular frequency of social assistance payments (compared to regular payments; 1.75; P < 0.001), and prior conviction (RR = 3.56; P < 0.001). Collectively, findings of the present study implicate poverty, social marginalization, crises involving mental illness, and the need for long-term recovery-oriented services that address these conditions to reduce criminal convictions among people experiencing homelessness and serious mental illness.

The association between experiencing homelessness in childhood or youth and adult housing stability in Housing First.

BACKGROUND: Researchers have pointed out the paucity of research investigating long-term consequences of experiencing homelessness in childhood or youth. Limited research has indicated that the experience of homelessness in childhood or youth is associated with adverse adjustment-related consequences in adulthood. Housing First (HF) has acknowledged effectiveness in improving housing outcomes among adults experiencing homelessness and living with serious mental illness, although some HF clients struggle with maintaining housing. The current study was conducted to examine whether the experience of homelessness in childhood or youth increases the odds of poorer housing stability following entry into high-fidelity HF among adults experiencing serious mental illness and who were formerly homeless. METHODS: Data were drawn from the active intervention arms of a HF randomized controlled trial in Metro Vancouver, Canada. Participants (n = 297) were referred to the study from service agencies serving adults experiencing homelessness and mental illness between October 2009 and June 2011. The Residential Time-Line Follow-Back Inventory was used to measure housing stability. Least absolute shrinkage and selection operator was used to estimate the association between first experiencing homelessness in childhood or youth and later housing stability as an adult in HF. RESULTS: Analyses indicated that homelessness in childhood or youth was negatively associated with experiencing housing stability as an adult in HF (aOR = 0.53; 95% CI = 0.31-0.90). CONCLUSIONS: Further supports are needed within HF to increase housing stability among adult clients who have experienced homelessness in childhood or youth. Asking clients about the age they first experienced homelessness may be of clinical utility upon enrollment in HF and may help identify support needs related to developmental experiences. Results further emphasize the importance of intervening earlier in life in childhood and youth before experiencing homelessness or before it becomes chronic. Findings also contribute to a limited knowledge base regarding the adverse long-term consequences of childhood and youth homelessness. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN57595077 and ISRCTN66721740 . Registered on October 9, 2012.

Gender differences among Indigenous Canadians experiencing homelessness and mental illness.

BACKGROUND: Indigenous people are over represented among homeless populations worldwide and the prevalence of Indigenous homelessness appears to be increasing in Canadian cities. Violence against Indigenous women in Canada has been widely publicized but has not informed the planning of housing interventions. Despite historical policies leading to disenfranchisement of Indigenous rights in gender-specific ways, little is known about contemporary differences in need between homeless Indigenous men and women. This study investigated mental health, substance use and service use among Indigenous people who met criteria for homelessness and mental illness, and hypothesized that, compared to men, women would have significantly higher rates of trauma, suicidality, substance dependence, and experiences of violence. METHODS: This study was conducted using baseline (pre-randomization) data from a multi-site trial. Inclusion in the current analyses was restricted to participants who self-reported Indigenous ethnicity, and combined eligible participants from Vancouver, BC and Winnipeg, MB. Logistic regression analyses were used to model the independent associations between gender and outcome variables. RESULTS: In multivariable regression models among Indigenous participants (n = 439), female gender was predictive of meeting criteria for PTSD, multiple mental disorders, current high suicidality and current substance dependence. Female gender was also significantly associated with reported physical (AOR: 1.52, 95% CI = 1.10-2.23) and sexual (AOR: 6.31, 95% CI = 2.78-14.31) violence. CONCLUSIONS: Our analyses of Indigenous men and women who are homeless illustrate the distinct legacy of colonization on the experiences of Indigenous women. Our findings are consistent with the widely documented violence against Indigenous women in Canada. Housing policies and services are urgently needed that take Indigenous historical contexts, trauma and gender into account. TRIAL REGISTRATION: This trial has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374 ; ISRCTN57595077 ; ISRCTN66721740 .

Temporal associations between medication adherence for patients with schizophrenia and opioid dependence: A 17-year Canadian Cohort Study.

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained <0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

Indigenous and non-Indigenous people experiencing homelessness and mental illness in two Canadian cities: A retrospective analysis and implications for culturally informed action.

OBJECTIVES: Indigenous people in Canada are not only over-represented among the homeless population but their pathways to homelessness may differ from those of non-Indigenous people. This study investigated the history and current status of Indigenous and non-Indigenous people experiencing homelessness and mental illness. We hypothesised that compared with non-Indigenous people, those who are Indigenous would demonstrate histories of displacement earlier in life, higher rates of trauma and self-medication with alcohol and other substances. DESIGN AND SETTING: Retrospective data were collected from a sample recruited through referral from diverse social and health agencies in Winnipeg and Vancouver. PARTICIPANTS: Eligibility included being 19 years or older, current mental disorder and homelessness. MEASURES: Data were collected via interviews, using questionnaires, on sociodemographics (eg, age, ethnicity, education), mental illness, substance use, physical health, service use and quality of life. Univariate and multivariable models were used to model the association between Indigenous ethnicity and dependent variables. RESULTS: A total of 1010 people met the inclusion criteria, of whom 439 self-identified as Indigenous. In adjusted models, Indigenous ethnicity was independently associated with being homeless at a younger age, having a lifetime duration of homelessness longer than 3 years, post-traumatic stress disorder, less severe mental disorder, alcohol dependence, more severe substance use in the past month and infectious disease. Indigenous participants were also nearly twice as likely as others (47% vs 25%) to have children younger than 18 years. CONCLUSIONS: Among Canadians who are homeless and mentally ill, those who are Indigenous have distinct histories and current needs that are consistent with the legacy of colonisation. Responses to Indigenous homelessness must be developed within the context of reconciliation between Indigenous and non-Indigenous Canadians, addressing trauma, substance use and family separations. TRIAL REGISTRATION NUMBER: ISRCTN42520374, ISRCTN57595077, ISRCTN66721740.

Association of Methadone Treatment With Substance-Related Hospital Admissions Among a Population in Canada With a History of Criminal Convictions.

Importance: People with criminal histories experience high rates of opioid dependence and are frequent users of acute health care services. It is unclear whether methadone adherence prevents hospitalizations. Objective: To compare hospital admissions during medicated and nonmedicated methadone periods. Design, Setting, and Participants: A retrospective cohort study involving linked population-level administrative data among individuals in British Columbia, Canada, with provincial justice contacts (n= 250 884) and who filled a methadone prescription between April 1, 2001, and March 31, 2015. Participants were followed from the date of first dispensed methadone prescription until censoring (date of death, or March 31, 2015). Data analysis was conducted from May 1 to August 31, 2018. Exposures: Methadone treatment was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analyzed as a time-varying exposure. Main Outcome and Measures: Adjusted hazard ratios (aHRs) of acute hospitalizations for any cause and cause-specific (substance use disorder [SUD], non-substance-related mental disorders [NSMDs], and medical diagnoses [MEDs]) were estimated using multivariable Cox proportional hazards regression. Results: A total of 11 401 people (mean [SD] age, 34.9 [9.4] years; 8230 [72.2%] men) met inclusion criteria and were followed up for a total of 69 279.3 person-years. During a median follow-up time of 5.5 years (interquartile range, 2.8-9.1 years), there were 19 160 acute hospital admissions. Dispensed methadone was associated with a 50% lower rate of hospitalization for any cause (aHR, 0.50; 95% CI, 0.46-0.53) during the first 2 years (≤2.0 years) following methadone initiation, demonstrating significantly lower rates of admission for SUD (aHR, 0.32; 95% CI, 0.27-0.38), NSMD (aHR, 0.41; 95% CI, 0.34-0.50), and MED (aHR, 0.57; 95% CI, 0.52-0.62). As duration of time increased (2.1 to ≤5.0 years; 5.1 to ≤10.0 years), methadone was associated with a significant but smaller magnitude of effect: SUD (aHR, 0.43; 95% CI, 0.36-0.52; aHR, 0.47; 95% CI, 0.37-0.61), NSMD (aHR, 0.51; 95% CI, 0.41-0.64; aHR, 0.60; 95% CI, 0.47-0.78), and MED (aHR, 0.71; 95% CI, 0.65-0.77; aHR, 0.85; 95% CI, 0.76-0.95). Conclusions and Relevance: In this study, methadone was associated with a lower rate of hospitalization among a large cohort of Canadian individuals with histories of convictions and prevalent concurrent health and social needs. Practices to improve methadone adherence are warranted.

Methadone maintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada.

BACKGROUND: Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. METHODS AND FINDINGS: We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23-0.33]) and external (AHR 0.41 [95% CI 0.33-0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13-0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30-0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. CONCLUSIONS: Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.

Continuity of Care among People Experiencing Homelessness and Mental Illness: Does Community Follow-up Reduce Rehospitalization?

OBJECTIVE: To examine whether timely outpatient follow-up after hospital discharge reduces the risk of subsequent rehospitalization among people experiencing homelessness and mental illness. DATA SOURCES: Comprehensive linked administrative data including hospital admissions, laboratory services, and community medical services. STUDY DESIGN: Participants were recruited to the Vancouver At Home study based on a-priori criteria for homelessness and mental illness (n = 497). Logistic regression analysis was used to assess the relationship between outpatient care within 7 days postdischarge and subsequent rehospitalization over a 1-year period. DATA EXTRACTION: Data were extracted for a consenting subsample of participants (n = 433) spanning 5 years prior to study enrollment. PRINCIPAL FINDINGS: More than half of the eligible sample (53 percent; n = 128) were rehospitalized within 1 year following an index hospital discharge. Neither outpatient medical services nor laboratory services within 7 days following discharge were associated with a significantly reduced likelihood of rehospitalization within 2 months (AOR = 1.17 [CI = 0.94, 1.46]), 6 months (AOR = 1.00 [CI = 0.82, 1.23]) or 12 months (AOR = 1.24 [CI = 1.02, 1.52]). CONCLUSIONS: In contrast to evidence from nonhomeless samples, we found no association between timely outpatient follow-up and the likelihood of rehospitalization in our homeless, mentally ill cohort. Our findings indicate a need to address housing as an essential component of discharge planning alongside outpatient care.

The effect of Housing First on adherence to methadone maintenance treatment.

BACKGROUND: Opioid overdose deaths have become a public health crisis in North America, and those who are homeless are particularly vulnerable. Methadone maintenance treatment (MMT) may prevent overdose and death among homeless people with opioid dependence, but suboptimal medication adherence is a common limitation. Previous research found that Housing First (HF) increases antipsychotic medication adherence among formerly homeless people. However, no experimental trials have examined whether HF has a significant impact on MMT adherence. We examined the intervention effect of HF on MMT adherence in a randomized sample of homeless adults experiencing mental illness and opioid dependence in Vancouver, Canada. METHODS: Comprehensive administrative and self-reported data from homeless adults living with serious mental illness recruited to the Vancouver At Home study were analyzed. Only methadone recipients were included (n = 97). The medication possession ratio (MPR) was utilized as the measure of adherence, and relevant data were obtained from provincial administrative pharmacy records. Study arms were HF and treatment as usual (TAU). Student t-tests were used to test for differences in MMT MPR between HF and TAU. RESULTS: No significant differences were observed in MMT MPR between participants in HF and TAU (0.52 vs. 0.57, p = 0.559) in the post-randomization period. CONCLUSION: HF was not associated with significantly different MMT MPR compared to TAU. Additional interventions are indicated as HF alone was insufficient to facilitate improved MMT adherence among formerly homeless adults experiencing concurrent opioid dependence and serious mental illness.

Associations between methadone maintenance treatment and crime: a 17-year longitudinal cohort study of Canadian provincial offenders.

AIMS: To estimate and test the difference in rates of violent and non-violent crime during medicated and non-medicated methadone treatment episodes. DESIGN, SETTING AND PARTICIPANTS: The study involved linkage of population level administrative data (health and justice) for all individuals (n = 14 530) in British Columbia, Canada with a history of conviction and who filled a methadone prescription between 1 January 1998 and 31 March 2015. Methadone maintenance treatment was the primary independent variable and was treated as a time-varying exposure. Each participant's follow-up (mean: 8 years) was divided into medicated (methadone was dispensed) and non-medicated (methadone was not dispensed) periods with mean durations of 3.3 and 4.6 years, respectively. MEASUREMENTS: Socio-demographics of participants were examined along with the main outcomes of violent and non-violent offences. FINDINGS: During the first 2 years of treatment (≤ 2.0 years), periods in which methadone was dispensed were associated with a 33% lower rate of violent crime [0.67 adjusted hazard ratio (AHR), 95% confidence intervals (CI) = 0.59, 0.76] and a 35% lower rate of non-violent crime (0.65 AHR, 95% CI = 0.62, 0.69) compared with non-medicated periods. This equates to a risk difference of 3.6 (95% CI = 2.6, 4.4) and 37.2 (95% CI = 33.0, 40.4) fewer violent and non-violent offences per 100 person-years, respectively. Significant but smaller protective effects of dispensed methadone were observed across longer treatment intervals (2.0 to ≤ 5.0 years, 5.0 to ≤ 10.0 years). CONCLUSIONS: Among a cohort of Canadian offenders, rates of violent and non-violent offending were lower during periods when individuals were dispensed methadone compared with periods in which they were not dispensed methadone.

Adherence to Antipsychotic Medication and Criminal Recidivism in a Canadian Provincial Offender Population.

Preliminary evidence suggests that adherence to antipsychotic medication reduces criminal recidivism among patients diagnosed with schizophrenia. However, existing studies operationalize antipsychotic adherence as a binary variable (usually using a threshold of ≥80%), which does not reflect the prevalence of suboptimal adherence in real-world settings. The purpose of the current analysis was to investigate the association between successive ordinal levels of antipsychotic adherence and criminal recidivism in a well-defined sample of offenders diagnosed with schizophrenia (n = 11462). Adherence was measured using the medication possession ratio (MPR) and analyzed as a time-dependent covariate in multivariable regression models. Data were drawn from linked, comprehensive diagnostic, pharmacy and justice system records, and individuals were followed for an average of 10 years. Adjusted rate ratios (ARR) and confidence intervals (CI) are reported. Overall mean MPR was 0.41. Increasing levels of antipsychotic adherence were not associated with progressively lower rates of offending. However, when compared to the reference group (MPR ≥ 80%) all lower adherence levels were significantly associated (P < .001) with increased risk of violent (ARR = 1.58; 95% CI = 1.46-1.71) and nonviolent (ARR = 1.41; 95% CI = 1.33-1.50) offenses. Significance was replicated in separate sensitivity analyses. Previously published studies reporting reductions in crime may have been influenced by antipsychotic adherence ≥80%. Binary operationalization of adherence is an inaccurate predictor of recidivism. Future research addressing functional outcomes of antipsychotic adherence should conceptualize adherence as an incremental independent variable.

A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats.

OBJECTIVE: No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU). METHODS: Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports. RESULTS: Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU. CONCLUSION: HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes. REGISTRATION: Current Controlled Trials: ISRCTN57595077.

Recruitment and retention of homeless individuals with mental illness in a housing first intervention study.

BACKGROUND: Homeless individuals with mental illness are challenging to recruit and retain in longitudinal research studies. The present study uses information from the Vancouver site of a Canadian multi-city longitudinal randomized controlled trial on housing first interventions for homeless individuals. We were able to recruit 500 participants and retain large number of homeless individuals with mental illness; 92% of the participants completed the 6-month follow up interview, 84% the 24-month follow up, while 80% completed all follow-up visits of the study. PURPOSE: In this article, we describe the strategies and practices that we considered as critical for successful recruitment and retention or participants in the study. METHODS: We discuss issues pertaining to research staff hiring and training, involvement of peers, relationship building with research participants, and the use of technology and social media, and managing challenging situations in the context of recruitment and retention of marginalized individuals. CONCLUSIONS: Recruitment and retention of homeless participant with mental illness in longitudinal studies is feasible. It requires flexible, unconventional and culturally competent strategies. Longitudinal research projects with vulnerable and hidden populations may benefit from extensive outreach work and collaborative approaches that are based on attitudes of mutual respect, contextual knowledge and trust.

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness.

BACKGROUND: Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. MATERIAL AND METHODS: Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. RESULTS: Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051). CONCLUSIONS: The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.

Housing First Improves Adherence to Antipsychotic Medication Among Formerly Homeless Adults With Schizophrenia: Results of a Randomized Controlled Trial.

Adherence to antipsychotic medication is a significant challenge among homeless patients. No experimental trials have investigated the impact of Housing First on adherence among patients with schizophrenia. We investigated whether Housing First in congregate and scattered-site configurations resulted in superior adherence compared to usual care. Adult participants (n = 165) met criteria for homelessness, schizophrenia, and initiation of antipsychotic pharmacotherapy prior to recruitment to an unblinded, 3-arm randomized controlled trial in Vancouver, Canada. Randomization arms were: congregate Housing First (CHF) with on-site supports (including physician and pharmacy services); scattered-site Housing First (SHF) with Assertive Community Treatment; or treatment as usual (TAU) consisting of existing services. Participants were followed for an average of 2.6 years. Adherence to antipsychotic medication was measured using the medication possession ratio (MPR), and 1-way ANOVA was used to compare outcomes between the 3 conditions. Data were drawn from comprehensive pharmacy records. Prior to randomization, mean MPR among participants was very low (0.44-0.48). Mean MPR in the follow-up period was significantly different between study arms (P < .001) and approached the guideline threshold of 0.80 in SHF. Compared to TAU, antipsychotic adherence was significantly higher in SHF but not in CHF. The results demonstrate that further implementation of SHF is indicated among homeless people with schizophrenia, and that urgent action is needed to address very low levels of antipsychotic adherence in this population (trial registration: ISRCTN57595077).

Housing First and Unprotected Sex: A Structural Intervention.

UNLABELLED: Elevated prevalence estimates of sexually transmitted infections and sexual risk behaviors have commonly been reported among homeless and precariously housed adults. Research has increasingly recognized the importance and impact of structural factors, such as housing, on risk behaviors. Several researchers have argued that supported housing interventions, such as Housing First (HF), may contribute to reductions in sexual risk behavior. The present study is the first analysis of a randomized controlled trial to examine the effect of HF on unprotected sex among formerly homeless and marginally housed adults with mental illness and complex comorbidities. METHODS: Generalized estimating equations were used to examine between-group differences in unprotected sex. RESULTS: Compared with treatment as usual, no association was found between HF and unprotected sex over the 24 months of follow-up. Several other variables were significantly and independently associated with unprotected sex. CONCLUSION: Results suggest that further interventions are needed to reduce unprotected sex among homeless and unstably housed individuals with mental illness.

Food Insecurity among Homeless Adults with Mental Illness.

BACKGROUND: The prevalence of food insecurity and food insufficiency is high among homeless people. We investigated the prevalence and correlates of food insecurity among a cohort of homeless adults with mental illness in Vancouver, British Columbia, Canada. METHODS: Data collected from baseline questionnaires in the Vancouver At Home study were analysed to calculate the prevalence of food insecurity within the sample (n = 421). A modified version of the U.S. Department of Agriculture's Adult Food Security Survey Module was used to ascertain food insecurity. Univariable and multivariable logistic regression were used to examine potential correlates of food insecurity. RESULTS: The prevalence of food insecurity was 64%. In the multivariable model, food insecurity was significantly associated with age (adjusted odds ratio [aOR] = 0.97; 95% CI: 0.95-0.99), less than high school completion (aOR = 0.57; 95% CI: 0.35-0.93), needing health care but not receiving it (aOR = 1.65; 95% CI: 1.00-2.72), subjective mental health (aOR = 0.97; 95% CI: 0.96-0.99), having spent over $500 for drugs and alcohol in the past month (aOR = 2.25; 95% CI: 1.16-4.36), HIV/AIDS (aOR = 4.20; 95% CI: 1.36-12.96), heart disease (aOR = 0.39; 95% CI: 0.16-0.97) and having gone to a drop-in centre, community meal centre or program/food bank (aOR = 1.65; 95% CI: 1.01-2.68). CONCLUSIONS: The prevalence of food insecurity was extremely high in a cohort with longstanding homelessness and serious mental illness. Younger age, needing health care but not receiving it, poorer subjective mental health, having spent over $500 for drugs and alcohol in the past month, HIV/AIDS and having gone to a drop-in centre, community meal centre or program/food bank each increased odds of food insecurity, while less than high school completion and heart disease each decreased odds of food insecurity. Interventions to reduce food insecurity in this population are urgently needed.

Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill.

BACKGROUND: Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population. METHODS: Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness. RESULTS: Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations (PABAK: 0.77; 95 % confidence interval (CI) = 0.71, 0.83), multiple psychiatric hospitalizations (PABAK = 0.50, 95 % CI = 0.41, 0.59), emergency department visits (PABAK: 0.77; 95 % CI = 0.71, 0.83), jail (PABAK: 0.74; 95 % CI = 0.68, 0.81), and income assistance (PABAK: 0.82; 95 % CI = 0.76, 0.87). Significant differences in under versus over reporting were also found. CONCLUSIONS: People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions. ISRCTN registry: 57595077 (Vancouver at Home Study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual); and 66721740 (Vancouver at Home study: Housing First plus Intensive Case management versus treatment as usual).

A 10-year retrospective analysis of hospital admissions and length of stay among a cohort of homeless adults in Vancouver, Canada.

BACKGROUND: Homelessness is associated with a very high prevalence of substance use and mental disorders and elevated levels of acute health service use. Among the homeless, little is known regarding the relative impact of specific mental disorders on healthcare utilization. The aim of the present study was to examine the association between different categories of diagnosed mental disorders with hospital admission and length of stay (LOS) in a cohort of homeless adults in Vancouver, Canada. METHODS: Participants were recruited as part of an experimental trial in which participants met criteria for both homelessness and mental illness. Administrative data were obtained (with separate consent) including comprehensive records of acute hospitalizations during the 10 years prior to recruitment and while participants where experiencing homelessness. Generalized Estimating Equations were used to estimate the associations between outcome variables (acute hospital admissions and LOS) and predictor variables (specific disorders). RESULTS: Among the eligible sample (n = 433) 80 % were hospitalized, with an average of 6.0 hospital admissions and 71.4 days per person during the 10-year observation period. Of a combined total 2601 admissions to hospital, 1982 were psychiatric and 619 were non-psychiatric. Significant (p <0.001) independent predictors of hospital admission and LOS included a diagnosis of schizophrenia or bipolar disorder, as well as high (≥32 service contacts) non-psychiatric medical service use in the community. CONCLUSIONS: Our results demonstrate that specific mental disorders alongside high non-psychiatric service use were significantly associated with hospital admission and LOS. These findings suggest the importance of screening within the homeless population to identify individuals who may be at risk for acute illness and the implementation of services to promote recovery and prevent repeated hospitalization. TRIAL REGISTRATION: ISRCTN57595077 ; ISRCTN66721740.