International evidence on lived experiences of trauma during homelessness and effects on mental health including substance use: a co-produced qualitative systematic review.

BACKGROUND: Trauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use. METHODS: In this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist. FINDINGS: We included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances. INTERPRETATION: Further evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation. FUNDING: National Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.

Evaluation of a Pathway team for homeless mental health in-patients.

AIMS AND METHOD: The Pathway model is an enhanced care coordination model for homeless people in hospital. We aimed to evaluate the first attempt to apply it on psychiatric wards, which started in 2015 in South London. We developed a logic model which expressed how the Pathway approach might work. Two predictions from this model were tested, using propensity scores and regression to estimate the effect of the intervention among people who were eligible for it. RESULTS: The Pathway team theorised that their interventions would reduce length of stay, improve housing outcomes and optimise the use of primary care - and, more tentatively, reduce readmission and emergency presentations. We were able to estimate effects on length of stay (-20.3 days; 95% CI -32.5 to -8.1; P = 0.0012) and readmission (a non-significant reduction). CLINICAL IMPLICATIONS: The marked reduction in length of stay, explicable in terms of the logic model, constitutes preliminary support for the Pathway model in mental health services.

Impact on the use and cost of other services following intervention by an inpatient pathway homelessness team in an acute mental health hospital.

BACKGROUND: Mental illness in people experiencing homelessness is common and a key reason for attendance at emergency departments and admission to hospital. AIMS: This paper describes how the KHP Pathway homeless team impacted use and cost of health and wider services. The Pathway model had never been adopted by a mental health hospital, and there had never been an economic analysis to evaluate service use before and after intervention. METHOD: Service use was measured using an adapted version of the Client Service Receipt Inventory (CSRI) with a simple before and after design at admission, 3 months and 6 months after discharge from hospital. RESULTS: During the first 3-month follow-up, over half the participants saw a GP, with an increase in the proportion seeing a psychiatrist, social worker and a mental health nurse. Attendance at emergency departments was substantially lower than at baseline. The mean total service cost was £818 at base line and £414 at 3 months. CONCLUSIONS: The adapted version of the CSRI demonstrates that patients seen by the Pathway Homelessness Team were supported to use community and scheduled health and care services. The service overcomes barriers, frequently experienced by people experiencing homelessness, in accessing support and community healthcare in the UK.