Yoga as an Add-on Therapy in Parkinson's Disease: A Single Group Open-label Trial.

OBJECTIVE: We aimed to evaluate the effect of yoga on motor and non-motor symptoms and cortical excitability in patients with Parkinson's disease (PD). METHODS: We prospectively evaluated 17 patients with PD at baseline, after one month of conventional care, and after one month of supervised yoga sessions. The motor and non-motor symptoms were evaluated using the Unified Parkinson's disease Rating Scale (motor part III), Hoehn and Yahr stage, Montreal Cognitive Assessment, Hamilton depression rating scale, Hamilton anxiety rating scale, non-motor symptoms questionnaire and World Health Organization quality of life questionnaire. Transcranial magnetic stimulation was used to record resting motor threshold, central motor conduction time, ipsilateral silent period (iSP), contralateral silent period (cSP), short interval intracortical inhibition (SICI), and intracortical facilitation. RESULTS: The mean age of the patients was 55.5 ± 10.8 years, with a mean duration of illness of 4.0 ± 2.5 years. The postural stability of the patients significantly improved following yoga (0.59 ± 0.5 to 0.18 ± 0.4, p = 0.039). There was a significant reduction in the cSP from baseline (138.07 ± 27.5 ms) to 4 weeks of yoga therapy (116.94 ± 18.2 ms, p = 0.004). In addition, a significant reduction in SICI was observed after four weeks of yoga therapy (0.22 ± 0.10) to (0.46 ± 0.23), p = 0.004). CONCLUSION: Yoga intervention can significantly improve postural stability in patients with PD. A significant reduction of cSP and SICI suggests a reduction in GABAergic neurotransmission following yoga therapy that may underlie the improvement observed in postural stability. CLINICALTRIALSGOV IDENTIFIER: CTRI/2019/02/017564.

Effects of yoga on impulsivity in patients with and without mental disorders: a systematic review.

BACKGROUND: Yoga can be used as a complementary intervention to conventional treatments, whether pharmacological or non-pharmacological. Sustained practice of yoga can generate a series of benefits for individuals' quality of life and improve their physical fitness. OBJECTIVE: To investigate the potential effects of yoga as an adjunct intervention in conditions involving impulse control issues, such as attention deficit hyperactivity disorder (ADHD), borderline personality disorder, bipolar affective disorder, and substance use disorders. METHODS: We performed a systematic review of placebo-controlled, randomized trials of yoga in patients with impulsivity. PubMed, Web of Science, and Science Direct databases were searched for trials published up to January, 2023. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. RESULTS: Out of 277 database results, 6 RCT were included in this systematic review. To assess the level of attention and impulsiveness, the following scales were analyzed: Barratt Impulsiveness, UPPS-P Impulsive Behavior scale, Conners' Continuous Performance Test IIª and Conners' Parent Rating Scale-Revised: Long. CONCLUSIONS: Yoga didn't have a significant improvement in impulsivity when compared to placebo. There are many tools to assess impulsivity, but they mean different concepts and domains consisting in a weakness on comparison of yoga effects. PROSPERO REGISTRATION: CRD42023389088.

Yoga and psychiatric disorders: a review of biomarker evidence.

Traditionally, yoga has been used as a means for spiritual growth but over the past two decades or so its therapeutic benefits in psychiatric disorders have been scientifically explored. Yoga has been shown to be useful as a mono-therapy in mild to moderate depression and as an adjuvant in several psychiatric disorders including schizophrenia, anxiety disorders, substance use disorders and Mild Cognitive Impairment. Furthermore, systematic attempts have been made to understand the biological correlates of yoga in these psychiatric disorders. Given that no psychiatric disorder has strong and established biomarkers, it is interesting that preliminary research has demonstrated significant changes in certain important biomarkers following regular yoga practice. In this brief review, we provide an update on the effects of yoga on biochemical, neuro-physiological and neuro-imaging related bio-markers in psychiatric disorders. Although findings and trends are promising, much more research is warranted to establish a definite biological basis for yoga in psychiatry.

Development, Validation, and Feasibility Testing of a Yoga Module for Opioid Use Disorder.

CONTEXT: Opioid use disorder (OUD) involves excessive use of opioids-such as heroin, morphine, fentanyl, codeine, oxycodone, and hydrocodone-leading to major health, social, and economic consequences. Yoga lifestyle interventions have been found to be useful as adjunct therapies in management of substance use disorders and chronic pain conditions. OBJECTIVE: The research team intended to develop, validate, and test for feasibility a yoga program for OUD patients that could reduce opiate withdrawal symptoms-such as pain, fatigue, low mood, anxiety and sleep disturbances-and cravings associated with drugs. DESIGN: The research team first performed a literature review of traditional and contemporary yoga texts, such as Hatha Yoga Pradipika and Light on Yoga, as well as modern scientific literature in the following search engines-Google Scholar, PubMed, and PsychInfo, using the keywords yoga, pranayama, hatha yoga, relaxation. meditation, substance use, addiction, impulsivity, craving, sleep quality, and fatigue. Using the information obtained, the team developed a yoga program and designed a pilot study that used the program. SETTING: The study took place in the Department of Integrative Medicine at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, India. PARTICIPANTS: Participants in the pilot study were 8 inpatients, 6 males and 2 females, who were on opioid agonist treatment (buprenorphine) for OUD. INTERVENTION: The intervention was the yoga program previously validated by the research team. In the pilot study, participants were taught a one-hour, yoga-based intervention, with sessions occurring once per day, for 10 sessions. OUTCOME MEASURES: For validation, 13 experts scored the yoga program that the research team had developed and gave suggestions for each yogic practice for use during the acute phase of withdrawal and the maintenance phase respectively. A content validity ratio (CVR) was calculated from their scoring, and the research team made changes to the program base on the scoring and suggestions. For the pilot study, assessments occurred at baseline and postintervention. The participants' yoga performance was rated by the yoga trainer on a yoga performance assessment scale (YPA). Other measurements included: (1) the Clinical Opiate Withdrawal Scale (COWS), (2) the Hamilton's anxiety rating scale (HAM-A), (3) the Hamilton's depression rating scale (HAM-D), (4) buprenorphine dosage, (5) the Clinical Global Impression Severity (CGI-S) scale, (6) a visual analog scale (VAS) for pain, (7) sleep quality (latency and duration), and (8) the module's safety. RESULTS: Four practices were removed from the program due to CVR scores below the cutoff, and one practice was found not to be feasible (Kapalabhati). Two categories of yoga modules emerged: (1) for the acute symptomatic phase (40 minutes) and (2) for the maintenance phase (one hour). Practices were added or excluded based on the phase. CONCLUSIONS: The yoga module that was developed for reducing withdrawal symptoms and cravings in OUD patients was found to be safe, feasible, and potentially useful as an adjunct therapy to conventional treatment.

Yoga for psychiatric disorders: from fad to evidence-based intervention?

There is growing evidence for yoga's neurobiological effects in people with psychiatric disorders. Postulated mechanisms of action include: (a) modulation of the hypothalamic-pituitary-adrenal (HPA) axis; (b) enhancement of GABAergic neurotransmission; (c) autonomic modulation; and (d) neuroendocrinological effects. Yoga as a therapeutic intervention in psychiatric disorders appears promising and merits further attention in clinical practice and research.

Does Yoga Have a Role in Schizophrenia Management?

PURPOSE OF REVIEW: To review the efficacy of add-on yoga therapy in improving symptoms of schizophrenia and quality of life and examine the possible underlying biological mechanisms of yoga in schizophrenia. RECENT FINDINGS: Quality of life, cognitive symptoms, and negative symptoms have been found to improve with add-on yoga therapy in schizophrenia (pooled mean effect size 0.8, 0.6, and 0.4, respectively). Yoga also seems to have a small effect on improving positive symptoms. Less explored areas include adverse effects of yoga itself as well as its effects on antipsychotic-induced complications. Preliminary findings suggest that the effects of yoga may be mediated by neurohormonal mechanisms and functional changes in brain activity. Add-on yoga therapy is a potential treatment option for improving quality of life, cognitive symptoms, and negative symptoms in schizophrenia. Future studies should explore efficacy in multicentric trials as well as possible neurobiological changes underlying the effects.

Impact of antipsychotic medication on IL-6/STAT3 signaling axis in peripheral blood mononuclear cells of drug-naive schizophrenia patients.

AIM: Immunopathogenesis remains a widely appreciated etiopathological model of schizophrenia. Persistent efforts have aimed to identify schizophrenia biomarkers indexing immune system abnormalities and also immuno-dampening effects of antipsychotic medications. Although data arising from published reports are encouraging, such studies are limited to a few immune parameters and not focused on a specific pathway. Th17 cells-mediated immuno-inflammatory responses have emerged as a potential mechanism in various neuropsychiatric conditions, including schizophrenia. The Th17 pathway is distinctly regulated through a coordinated action of multiple cytokines and transcription factors. In this study, we explored whether antipsychotic medication has any effect on the cytokines and transcription factors of the Th17 pathway. METHODS: A total of 27 drug-naive schizophrenia patients were recruited and followed up for 3 months after initiation of antipsychotic medication. Lymphocyte gene expression levels of two transcription factors (STAT3 and RORC) and one of their upstream regulators, IL6, were quantified before and after treatment. Plasma levels of cytokines, such as interleukin (IL)-1ß, IL-6, IL-17A, IL-23, and IL-33, were also analyzed before and after treatment. RESULTS: Treatment with antipsychotic medication for 3 months resulted in significant downregulation of STAT3 gene expression as well as reduction in plasma levels of IL-1ß, IL-6, and IL-17A. Significant reduction in total scores for the Scale for Assessment of Positive Symptoms and the Scale for Assessment of Negative Symptoms was also observed in schizophrenia patients after 3 months of antipsychotic treatment. CONCLUSION: Our findings suggest possible immuno-modulatory effects of antipsychotic medication on the critical regulators, such as IL-6 and STAT3, of the Th17 pathway in schizophrenia patients. The IL-6/STAT3 signaling axis involved in the transcriptional regulation of Th17 cells might appear as an important target of antipsychotic treatment in schizophrenia patients. Alternatively, irrespective of the effect of antipsychotic drugs, the IL-6/STAT3 signaling axis might be crucially involved in ameliorating psychotic symptoms.

Retinal vascular abnormalities in schizophrenia and bipolar disorder: A window to the brain.

OBJECTIVES: The examination of retinal microvascular abnormalities through fundus photography is currently the best available non-invasive technique for assessment of cerebral vascular status. Several studies in the last decade have reported higher incidences of adverse cerebrovascular events in Schizophrenia (SCZ) and bipolar disorder (BD). However, retinal microvasculature abnormalities in SCZ and BD have remained under-explored, and no study has compared this aspect of SCZ and BD till date. METHODS: Retinal Images of 100 SCZ patients, BD patients, and healthy volunteers each were acquired by trained individuals using a non-mydriatic camera with a 40-degree field of view. The retinal images were quantified using a valid semi-automated method. The average of left and right eye diameters of the venules and arterioles passing through the extended zone between 0.5 and 2 disc diameters from the optic disc were calculated. RESULTS: The groups differed significantly with respect to average diameters of both retinal venules (P < 0.001) and retinal arterioles (P < 0.001), after controlling for age and sex. Both SCZ and BD patients had significantly narrower arterioles and wider venules compared to HV. There were also significant differences between SCZ and BD patients; patients with BD had narrower arterioles and wider venules. CONCLUSION: Considering the affordability and easy accessibility of the investigative procedure, retinal microvascular examination could serve as a potential screening tool to identify individuals at risk for adverse cerebrovascular events. The findings of the current study also provide a strong rationale for further systematic examination of retinal vascular abnormalities in SCZ and BD.

Examination of retinal vascular trajectory in schizophrenia and bipolar disorder.

AIM: Evidence suggests microvascular dysfunction (wider retinal venules and narrower arterioles) in schizophrenia (SCZ) and bipolar disorder (BD). The vascular development is synchronous with neuronal development in the retina and brain. The retinal vessel trajectory is related to retinal nerve fiber layer thinning and cerebrovascular abnormalities in SCZ and BD and has not yet been examined. Hence, in this study we examined the retinal vascular trajectory in SCZ and BD in comparison with healthy volunteers (HV). METHODS: Retinal images were acquired from 100 HV, SCZ patients, and BD patients, respectively, with a non-mydriatic fundus camera. Images were quantified to obtain the retinal arterial and venous trajectories using a validated, semiautomated algorithm. Analysis of covariance and regression analyses were conducted to examine group differences. A supervised machine-learning ensemble of bagged-trees method was used for automated classification of trajectory values. RESULTS: There was a significant difference among groups in both the retinal venous trajectory (HV: 0.17 ± 0.08; SCZ: 0.25 ± 0.17; BD: 0.27 ± 0.20; P < 0.001) and the arterial trajectory (HV: 0.34 ± 0.15; SCZ: 0.29 ± 0.10; BD: 0.29 ± 0.11; P = 0.003) even after adjusting for age and sex (P < 0.001). On post-hoc analysis, the SCZ and BD groups differed from the HV on retinal venous and arterial trajectories, but there was no difference between SCZ and BD patients. The machine learning showed an accuracy of 86% and 73% for classifying HV versus SCZ and BD, respectively. CONCLUSION: Smaller trajectories of retinal arteries indicate wider and flatter curves in SCZ and BD. Considering the relation between retinal/cerebral vasculatures and retinal nerve fiber layer thinness, the retinal vascular trajectory is a potential marker for SCZ and BD. As a relatively affordable investigation, retinal fundus photography should be further explored in SCZ and BD as a potential screening measure.

Role of IL-6/RORC/IL-22 axis in driving Th17 pathway mediated immunopathogenesis of schizophrenia.

The immuno-inflammatory origin of schizophrenia in a subset of patients is viewed as a key element of an overarching etiological construct. Despite substantial research, the immune components exerting major effect are yet to be fully clarified. Disrupted T cell networks have consistently been linked to the pathogenesis of schizophrenia. Amongst the Th cell subsets, the Th17 cells have emerged as a paradigmatic lineage with significant functional implications in a vast number of immune mediated diseases including brain disorders such as schizophrenia. The present study was aimed at examining the functional role of the Th17 pathway in schizophrenia. To address this, genotyping of IL17A (rs2275913; G197A) Single Nucleotide Polymorphism was carried out by the PCR-RFLP method in 221 schizophrenia patients and 223 healthy control subjects. Gene expression of two transcription factors STAT3 and RORC was quantified in a subset of drug naïve schizophrenia patients (n = 56) and healthy controls (n = 52) by TaqMan assay. The plasma levels of fifteen cytokines belonging to Th17 pathway were estimated in a subset of drug naïve schizophrenia patients (n = 61) and healthy controls (n = 50) by using Bio-Plex Pro Human Th17 cytokine assays. The AA genotype was associated with higher total score of bizarre behaviour and apathy in female schizophrenia patients. A high gene expression level of RORC was observed in drug naïve schizophrenia patients. In addition, significantly elevated plasma levels of IL-6 and IL-22, and reduced levels of IL-1ß and IL-17F were noted in schizophrenia patients. Taken together, these findings indicate a dysregulated Th17 pathway in schizophrenia patients.

Current status of yoga in mental health services.

Yoga (derived from 'yuj' which means to yoke together or unite) has been used for millennia as a tool for self-improvement, with the ultimate goal of uniting the individual consciousness with the universal. The physical elements of yoga, although seen as necessary in the path to achieve the goal, they were not considered as the endpoint for a practitioner. Sage Patanjali, who codified the practices into an eight-limbed model (Ashtanga yoga) in the Patanjali Yoga Sutras, makes it clear that the target of yoga is primarily the mind. However, in the modern world, yoga practices have become immensely popular as aids to improve health. Yoga-based practices are being extensively used as therapeutic ingredients, alone or as adjuncts to other therapies in a variety of disorders, both physical and mental. There is now strong evidence to suggest that yoga-based interventions are beneficial in several lifestyle disorders. Recent research has also shown significant benefits in mental disorders such as depression, anxiety, and psychosis. This paper discusses the place of yoga as one of the therapeutic strategies in the holistic approach to mental disorders, and the challenges inherent to research in this area.

Yoga-based intervention in patients with somatoform disorders: an open label trial.

Somatoform disorders are common mental disorders associated with impaired functioning and increased utilization of health resources. Yoga-based interventions have been used successfully for anxiety, depression, and chronic pain conditions. However, literature on the use of yoga in treatment of somatoform disorders is minimal. The current study assessed the effect of a specific yoga-based intervention in patients with somatoform disorders. Consenting patients meeting ICD-10 criteria for somatoform disorders were offered a specific yoga module (1 h per day) as a treatment. Assessments including Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), and others were carried out at baseline and after 2, 6, and 12 weeks. Sixty-four subjects were included in the study and 34 completed 12 weeks follow-up. Significant improvement was noted in pain severity from baseline to 12 weeks after regular yoga sessions. The mean VAS score dropped from 7.24 to 2.88. Worst and average pain score in the last 24 h on BPI dropped from 7.71 to 3.26 and from 6.12 to 2.0,7 respectively. Results of the study suggest that yoga-based intervention can be one of the non-pharmacological treatment options in somatoform disorders. These preliminary findings need replication in larger controlled studies.

Designing and validation of a yoga-based intervention for schizophrenia.

CONTEXT: Schizophrenia is a chronic mental illness which causes significant distress and dysfunction. Yoga has been found to be effective as an add-on therapy in schizophrenia. Modules of yoga used in previous studies were based on individual researcher's experience. AIM: This study aimed to develop and validate a specific generic yoga-based intervention module for patients with schizophrenia. The study was conducted at NIMHANS Integrated Centre for Yoga (NICY). MATERIALS AND METHODS: A yoga module was designed based on traditional and contemporary yoga literature as well as published studies. The yoga module along with three case vignettes of adult patients with schizophrenia was sent to 10 yoga experts for their validation. RESULTS: Experts (n = 10) gave their opinion on the usefulness of a yoga module for patients with schizophrenia with some modifications. In total, 87% (13 of 15 items) of the items in the initial module were retained, with modification in the remainder as suggested by the experts. CONCLUSION: A specific yoga-based module for schizophrenia was designed and validated by experts. Further studies are needed to confirm efficacy and clinical utility of the module. Additional clinical validation is suggested.

Yoga and physical exercise - a review and comparison.

Yoga is a multifaceted spiritual tool with enhanced health and well-being as one of its positive effects. The components of yoga which are very commonly applied for health benefits are asanas (physical postures), pranayama (regulated breathing) and meditation. In the context of asanas, yoga resembles more of a physical exercise, which may lead to the perception that yoga is another kind of physical exercise. This article aims at exploring the commonalities and differences between yoga and physical exercise in terms of concepts, possible mechanisms and effectiveness for health benefits. A narrative review is undertaken based on traditional and contemporary literature for yoga, along with scientific articles available on yoga and exercise including head-to-head comparative trials with healthy volunteers and patients with various disease conditions. Physical exercises and the physical components of yoga practices have several similarities, but also important differences. Evidence suggests that yoga interventions appear to be equal and/or superior to exercise in most outcome measures. Emphasis on breath regulation, mindfulness during practice, and importance given to maintenance of postures are some of the elements which differentiate yoga practices from physical exercises.

Designing and validation of a yoga-based intervention for obsessive compulsive disorder.

Some yoga-based practices have been found to be useful for patients with obsessive compulsive disorder (OCD). The authors could not find a validated yoga therapy module available for OCD. This study attempted to formulate a generic yoga-based intervention module for OCD. A yoga module was designed based on traditional and contemporary yoga literature. The module was sent to 10 yoga experts for content validation. The experts rated the usefulness of the practices on a scale of 1-5 (5 = extremely useful). The final version of the module was pilot-tested on patients with OCD (n = 17) for both feasibility and effect on symptoms. Eighty-eight per cent (22 out of 25) of the items in the initial module were retained, with modifications in the module as suggested by the experts along with patients' inputs and authors' experience. The module was found to be feasible and showed an improvement in symptoms of OCD on total Yale-Brown Obsessive-Compulsive Scale (YBOCS) score (p = 0.001). A generic yoga therapy module for OCD was validated by experts in the field and found feasible to practice in patients. A decrease in the symptom scores was also found following yoga practice of 2 weeks. Further clinical validation is warranted to confirm efficacy.

Serum cortisol and BDNF in patients with major depression-effect of yoga.

Depression is associated with low serum Brain Derived Neurotrophic Factor (BDNF) and elevated levels of serum cortisol. Yoga practices have been associated with antidepressant effects, increase in serum BDNF, and reduction in serum cortisol. This study examined the association between serum BDNF and cortisol levels in drug-naïve patients with depression treated with antidepressants, yoga therapy, and both. Fifty-four drug-naïve consenting adult outpatients with Major Depression (32 males) received antidepressants only (n = 16), yoga therapy only (n = 19), or yoga with antidepressants (n = 19). Serum BDNF andcortisol levels were obtained before and after 3 months using a sandwich ELISA method. One-way ANOVA, Chi-square test, and Pearson's correlation tests were used for analysis. The groups were comparable at baseline on most parameters. Significant improvement in depression scores and serum BDNF levels, and reduction in serum cortisol in the yoga groups, have been described in previous reports. A significant negative correlation was observed between change in BDNF (pre-post) and cortisol (pre-post) levels in the yoga-only group (r = -0.59, p = 0.008). In conclusion, yoga may facilitate neuroplasticity through stress reduction in depressed patients. Further studies are needed to confirm the findings and delineate the pathways for these effects.

Acute effects of 3G mobile phone radiations on frontal haemodynamics during a cognitive task in teenagers and possible protective value of Om chanting.

Mobile phone induced electromagnetic field (MPEMF) as well as chanting of Vedic mantra 'OM' has been shown to affect cognition and brain haemodynamics, but findings are still inconclusive. Twenty right-handed healthy teenagers (eight males and 12 females) in the age range of 18.25 ± 0.44 years were randomly divided into four groups: (1) MPONOM (mobile phone 'ON' followed by 'OM' chanting); (2) MPOFOM (mobile phone 'OFF' followed by 'OM' chanting); (3) MPONSS (mobile phone 'ON' followed by 'SS' chanting); and (4) MPOFSS (mobile phone 'OFF' followed by 'SS' chanting). Brain haemodynamics during Stroop task were recorded using a 64-channel fNIRS device at three points of time: (1) baseline, (2) after 30 min of MPON/OF exposure, and (3) after 5 min of OM/SS chanting. RM-ANOVA was applied to perform within- and between-group comparisons, respectively. Between-group analysis revealed that total scores on incongruent Stroop task were significantly better after OM as compared to SS chanting (MPOFOM vs MPOFSS), pre-frontal activation was significantly lesser after OM as compared to SS chanting in channel 13. There was no significant difference between MPON and MPOF conditions for Stroop performance, as well as brain haemodynamics. These findings need confirmation through a larger trial in future.

Hyperprolactinemia with aripiprazole: understanding the paradox.

Aripiprazole, due to its partial agonist activity at the D2 receptors, is often recommended as the drug of choice in patients who develop antipsychotic-induced hyperprolactinemia. We report a case of a female patient who developed hyperprolactinemia while on treatment with aripiprazole. This partial D2 agonistic activity of aripiprazole could be dose related, and hence, at higher doses, aripiprazole by itself can have dopamine antagonistic properties and hence cause prolactin system abnormalities.

Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review.

BACKGROUND: Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness. OBJECTIVES: To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness. SEARCH METHODS: Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022. STUDY SELECTION: Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria. DATA EXTRACTION AND ANALYSIS: Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention. RESULTS: The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness. CONCLUSION: Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.