Homelessness And Schizophrenia: Socio-Demographic Characteristics, Antipsychotic Adherence, And Relapse

Research Aims

What Are The Socio-Demographic Characteristics Of The Homeless Schizophrenic Patients?

What Is The Level Of Adherence To Antipsychotic Drugs Among The Homeless Schizophrenic Patients Placed In Different Models Of Hosing First Models?

Does Homelessness Contribute To Schizophrenic Relapse Leading To Readmission Of The Patients?

Treatment and management of homeless individuals with mental disorder such as schizophrenia is a complex worldwide challenge (Rezansoff et al., 2016a). Therefore, persons who are homeless and both suffering from psychiatric disorder are a major public health policy focus internationally (Gaebel et al., 2015; Mechanic et al., 2012). It is estimated that more than 400,000 individuals in Europe are considered to be homeless at any given night, and the situation has been made worse by the refuges crisis in Europe (Fazel et al., 2014; Solari et al., 2012). According to Rezansoff et al. (2016), 11% of homeless individuals are schizophrenic. A study conducted in Sydney Australia, revealed that 36% of homeless persons were positively diagnosed as schizophrenic (Teesson et al., 2004).

 Different Studies have reported reduced antipsychotic drugs adherence among the homeless person’s resulting to recorded high number of antipsychotic non-adherence cases, increased period of hospitalization as suggested by (Rezansoff et al., 2016b; Coe et al., 2015; Novick et al., 2010). According Folsom et al. (2002), there is a strong relationship between homelessness and suboptimal adherence to prescribed regimes against schizophrenia. Moreover, available antipsychotic interventions provides limited guidance on how to take care of persons who are synchronously homeless and schizophrenic.

In countries such as Australia, homelessness and schizophrenia has been prioritized as a public health policy (Wilkins, 2017; Peterson, 2015a). For example, In Australia, research has revealed that by the year 2056, for every one elderly individuals there will be only three persons who are in the working age bracket, this is contrary to the research findings in the year 2007 that placed elderly citizen to 5 persons within the working age bracket according to (Beer, 2012). Therefore, homelessness among the elderly as an associated risk factor to the development of Schizophrenic conditions has been identified as weighty economic matter by the Australian Treasury (Peterson, 2015a; Yates and Bradbury, 2010). In Australia, different studies have associated homelessness among the low income and elderly citizens to the fact that about 95% of the housing in the market is controlled by the private sector that has appetite for profit rather than the social benefit of the entire society (Petersen et al., 2014; Yates and Bradbury, 2010; Minnery and Greenhalgh, 2007). Subsequently, the house prices and rents paid by the tenants is at the mercy of trends that are dictated by the marketing equilibriums.

Justification

Different western countries have developed different approaches to mitigate the effects of homelessness as a risk factor to mental illness such as schizophrenia. For example, Housing first, which is a public health housing based-intervention approach that has been adopted across the USA, Europe countries, and Canada. The intervention policy involves prioritizing rapid re-housing for individuals who are constantly homeless and who are suffering serious psychiatric illness such as schizophrenia (Somers et al., 2016; Tsemberis et al., 2000). 

There is limited information on the demographic characteristics of persons who are homeless in Sydney, Australia (Nielssen et al., 2018). Moreover, for the studies that have attempted to research on this area touching on the homelessness and its association to schizophrenia they have not dwelt so much on homelessness as a risk factor for schizophrenic relapse leading to the readmission of the patients (Rezansoff et al., 2016; Canavan et al., 2012; Fazel et al., 2008). Furthermore, the available research findings have not attempted to evaluate the impact of the First housing intervention to access the rate of the readmission of patients suffering from schizophrenia by comparing the significant differences in the three treatment groups. Moreover, there is limited information on the number of the homeless Australian citizens according to different demographics. The challenges and barriers to accessing affordable housing has not been well studied in the Australian context, this can be attributed to the fact that most studies have focused on the gender without factoring ethnicity.

Therefore, in this study I propose to determine the level of adherence to antipsychotic drugs by schizophrenic patients and assess the effect of homelessness to the readmission of schizophrenic patients randomly placed in three different treatment groups including congregate housing first (CHF), Scattered-site housing First (SHF), and Treatment as Usual (TAU). I propose a null hypothesis that, there is no association between the format of housing first and the number of readmission and adherence to antipsychotic drugs by schizophrenic patients.

The main aim of this research will be to apprehend and elucidate the demographic characteristics of the homeless, and understand the effect of homelessness as a risk factor for the relapse of schizophrenia among the residence of Sydney, Australia aged between 25-80 years old. Furthermore, this study is intended to evaluate the impact of either congregate Housing First (CHF) or Scattered-site Housing First (SHF) models compared to Treatment as usual (TAU) on the adherence to antipsychotic among the homeless who are diagnosed by schizophrenia.

General Objective

The outcomes generated out of this research will go a long way to seek answers for the gaps that exists on the current studies including information on the demographic characteristics of the affected homeless persons with confirmed cases of schizophrenia. At the same time, study results will identify challenges and barriers experienced by the homeless individuals in accessing a fordable houses. The findings from the intervention policies regarding housing first will help the government to come up with better mitigation methods of schizophrenia treatment and management. The conclusion and recommendations from this research will enable the public health policy makers in Australia come up with mitigation measures on how to reduce number of cases among the homeless individuals.

To assess whether homelessness contributes to non-adherence to antipsychotic drugs and a risk factor for schizophrenic relapse, leading to readmission of schizophrenic patients.

1. To determine socio-demographic characteristics of the homeless schizophrenic patients
2. To determine the level of adherence to antipsychotic drugs by homeless schizophrenic patients placed in different housing first intervention models
3. To assess homelessness as a risk factors that contribute to schizophrenic relapse leading to readmission of the patients.

According to Fazel et al. (2015), homelessness has been defined differently globally. Different countries have attempted to adopt a uniform definition of homelessness in an attempt to define eligibility criteria for services and tacking of progress in reduction of number of persons without proper home. For example, in the USA, Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) act of 2012, have based their definition mainly the McKinney-Vento Act.2. However, people at looming risk of getting into situation of being homelessness have been included by providing a formalized definition of chronic homelessness (Busch et al., 2010; Culhane and Metraux, 2008; Echenberg and Jensen, 2008).

In Europe a consensus has not been reached on a shared definition of homelessness (Canavan et al., 2012). Even though, there is an agreement that persons who are unsheltered, persons living with family members, and individuals accommodated in transitional shelters are recognized as homeless (Busch et al., 2010; Minnery et al., 2007). In Australia, homeless persons are individuals without regular accommodation, persons living in shelters, temporarily living with family or friend (Grenier et al., 2013; Greenberg et al., 2010). According to Grenier (2016), individuals can be termed as being in the risk of becoming homeless when their housing condition doesn’t meet the criteria for public health safety standards. Mott et al. (2012), characterizes homeless individuals as ones living in the government provided shelters and streets.

Studies have revealed an increase in the number of non-communicable diseases that are attributed to the ageing among the homeless populations including schizophrenia and cognitive impairment (Marek, 2017; Brown et al., 2012; Mott, 2012; Morrison, 2009; Ploeg et al., 2008; Garibaldi et al., 2005). Persons who are above the age of 50 years and are homeless have a risk of developing age related chronic diseases as compared to the general population according the findings by (Canavan et al., 2012; Ploeg et al., 2008; Shinn et al., 2007). A cohort study conducted in Boston, USA, where the average age of the study participants had mean age of 56 years revealed that 30 percent of the respondents reported at least one age related condition leading to functional impairment, whereas about 24 percent of the study participants reported cognitive impairment (Brown et al., 2012). Therefore, from different studies it has been concluded that homeless individuals tend to suffer from age related chronic conditions early in life as compared to the general population (Gonyea, 2010; McDonald et al., 2009; Cloke and May, 2005). The explanation given by different researchers include but no limited to increased rate of alcohol consumptions, increased tobacco usage, among other factors.

Specific objectives

There is shared need among the elderly and younger homeless persons globally, such needs include the basic human needs such as good shelter, Food, access to health care services, and economical self-reliance through proper income (Grenier, 2016). However, older homeless persons have exceptional need that is connected to access to social services and healthcare services offered by their governments (Morris et al., 2012). This is due to the fact that elderly homeless individuals have high risk of suffering from psychiatric related conditions (Marek, 2017), hence, they need specialized healthcare services that is not readily available in the shelters according to (Minnery and Greenhalgh, 2007). Some of the challenges and barriers experienced by the elderly in their quest to access health care services include stigmatization and discrimination emerging from the service providers within the health facilities, hence there is an urgent need for sensitization and awareness among the medical staff (Morris et al., 2012; Lipmann, 2009).For example, in Canada, lack of relevance psychiatric services within the government shelters have been cited as a major barrier to homeless persons with schizophrenia accessing the services (Latimer et al., 2017; McDonald et al., 2009)

Research have established that individuals without homes suffers worst mental illnesses such as schizophrenia as compared to the general population (Fazel et al., 2014). Multifactorial reasons including risk factors that increases individuals risks of homelessness have been associated with poor health outcomes such mental illness. At the same time, substance abuse, poor nutrition, and exposure to communicable diseases are other identified factors (Baggett et al., 2011; Sprake et al., 2014). The major factors that contribute to homelessness include lack of low-cost housing, lack of employment opportunities for workers with low-skills (Burt et al., 2001).

According to Carter and Little (2007), methodology is the chronology of events and processes involved during the research period. The objectives and research question should be coherent with the research design.

In this study both qualitative and quantitative research design will adopted. A semi structured questionnaire will be used to get information from the respondents. At the same time, Home care owners will be interviewed. The Study participants will be Australian citizens who permanently reside in Sydney, but are schizophrenic and homeless. 3 arm Housing First including ACT vs CHF plus support vs TAU models will be used in a randomized control trial that will involve homeless individuals with diagnosed cases of schizophrenia. The randomization will be carried out using centralized computer generated procedure. Based on the baseline interviews, eligible study participants will be randomly placed to CHF, SHF, and TAU. Thereafter, they will be directed to appropriate service representative. Independent variable in the study will be Homelessness while dependents variable will be readmission of schizophrenic patients and adherence to antipsychotic drugs by the schizophrenic patients will be out come measurement.

Homelessness

Some of the sample characteristics will be achieved through respondents self-rating or through observations of mental health indicators including ever admitted to hospital for schizophrenic conditions (1/0). Schizophrenic patient’s clinical history and medication will be obtained from the data that will be provided by the health facilities purposively selected during the study. Guidelines from the experts will define our acceptable level of adherence to the antipsychotic drugs, medication possession ratio (MPR) will be calculated using a number of days the drugs were prescribed within the follow up period as the numerator, and the denominator will be the total number of drugs prescribed after randomization the protocol will be adopted from (Rezansoff et al., 2016). The study participants will be observed for adherence to antipsychotic drugs and episodes of relapse will be recorded. The observation period will consist of length of time between the patient’s randomization and the study end date or date which patient has died. The follow uptime will vary among the patients.

In this study the two housing first interventions (SHF and CHF) will be compared to TAU. The SHF will give the patients opportunity to occupy market based apartments all over the Sydney, and the services will be provided by multidisciplinary psychiatrist team. The CHF conditions will be conducted in a shelter which was previously a hotel, all the patients will be given their own rooms. CHF condition will provide recreational activities, communal meal. The patients will have an all-round support from multidisciplinary team, and a medical facility will be situated on site. The patients randomly placed to the TAU conditions will not receive any housing support and services during the study period, but they will be followed in the same manner as other study participants in the two other intervention conditions.

The study participants will be purposively selected. Community agencies and health facilities providing services to the homeless schizophrenic individuals will be involved during this process of recruitment. Eligibility of the study participants include homeless schizophrenic Australian citizens who permanently reside in Sydney. Moreover, the persons eligible for recruitment in the study should be eligible for government financial benefits, free healthcare and prescription intervention programs from the government.

1. Persons between the ages of 25 to 80 years
2. Australian citizen permanently residing in Sydney.
3. The person should meet the criteria of homellesness and positively diagnosed with schizophrenia
4. The study participants or their legal representatives agreeing to sign consent.

The study is designed to detect differences between the intervention groups on the primary outcome variable. For example, previously conducted similar studies using MPR as a measure of adherence to antipsychotic drugs and readmission rates in comparable different interventions have reported SD of 0.29 (Rezansoff et al., 2016; Valenstein et al., 2013). However, for this study it is anticipated that there will be moderate effect with Cohen’s d = 0.6 (17% difference) and alpha level of 0.05, this will be clinically have real world meaning.

Therefore, I propose to recruit 45 eligible study participants in each of the 3 treatment arm, this would be sufficient to yield about 80% statistical power to reject the null hypothesis.

I propose to use structured questionnaire, interview notes, and tape recording to obtain the necessary data from the study participants.

For the statistical Analysis of the variables about the demographics such as age of the study participants (Continuous Variables), I propose to use descriptive statistics such as mean with standard deviation (SD). Counts and proportions (%) will be used to present Categorical variables including Age and ethnic status of the study participants. The independent sample t tests will be used to test for statistical significance difference between the continuous variable, whereas Pearson chi-square test will be used to compare categorical variables between groups. A single factor ANOVA will be used to test for statistical significant difference in number of readmission and drugs adherence between the schizophrenic patients who will be randomly placed in three different housing condition (SHF, CHF, and TAU). The data obtained will be entered into IBM SPSS Statistics software version 22.047, cleaned and all analyses will be conducted.

The eligible recruited study participants will be required to sign a consent form before being allowed to answer questions from study enumerators. The information given by the respondents during the course of this study will be treated with outmost confidentiality and respondents will be informed of that. The recordings from the conducted interviews during this study will be transcribed and de-identified late after getting answers from the study participants. Ethical clearance certificate will be sought from the Australian ethical review board, and in case of any change in the study methodology the ethical review board will be informed.

References

Baggett, T. P., Singer, D. E., Rao, S. R., O’Connell, J. J., Bharel, M., & Rigotti, N. A. (2011). Food insufficiency and health services utilization in a national sample of homeless adults. Journal of General Internal Medicine, 26(6), 627-634.

Beer, A. (2012). Australia’s Housing Stock: Undersupply or Oversupply? What can the Census tell us?. Australian Community Indicators Network.

Brown, R. T., Kiely, D. K., Bharel, M., & Mitchell, S. L. (2012). Geriatric syndromes in older homeless adults. Journal of general internal medicine, 27(1), 16-22.

Burt, M. R. (2001). Helping America’s homeless: management shelter or affordable housing?. The Urban Insitute.

Busch-Geertsema, V., Edgar, W., O’Sullivan, E., & Pleace, N. (2010, December). Homelessness and homeless policies in Europe: Lessons from research. In Conference on homelessness (Vol. 9, p. 10).

Canavan, R., Barry, M. M., Matanov, A., Barros, H., Gabor, E., Greacen, T., … & Díaz-Olalla, J. M. (2012). Service provision and barriers to care for homeless people with mental health problems across 14 European capital cities. BMC health services research, 12(1), 222.

Carter, S. M., & Little, M. (2007). Justifying knowledge, justifying method, taking action: Epistemologies, methodologies, and methods in qualitative research. Qualitative health research, 17(10), 1316-1328.

Cloke, P., May, J., & Johnsen, S. (2005). Re?phasing neoliberalism: New Labour and Britain’s crisis of street homelessness. Antipode, 37(4), 703-730.

Coe, A. B., Moczygemba, L. R., Gatewood, S. B., Osborn, R. D., Matzke, G. R., & Goode, J. V. R. (2015). Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic. Research in Social and Administrative Pharmacy, 11(3), e110-e120.

Culhane, D. P., & Metraux, S. (2008). Rearranging the deck chairs or reallocating the lifeboats? Homelessness assistance and its alternatives. Journal of the American Planning Association, 74(1), 111-121.

Echenberg, H., & Jensen, H. (2008). Defining and enumerating homelessness in Canada. Parliamentary Information and Research Service.

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), 1529-1540.

Folsom, D., & Jeste, D. V. (2002). Schizophrenia in homeless persons: a systematic review of the literature. Acta Psychiatrica Scandinavica, 105(6), 404-413.

Gaebel, W., & Zielasek, J. (2015). Homeless and mentally ill–a mental healthcare challenge for Europe. Acta Psychiatrica Scandinavica, 131(4), 236-238.

Garibaldi, B., Conde?Martel, A., & O’toole, T. P. (2005). Self?Reported Comorbidities, Perceived Needs, and Sources for Usual Care for Older and Younger Homeless Adults. Journal of general internal medicine, 20(8), 726-730.

Gonyea, J. G., Mills-Dick, K., & Bachman, S. S. (2010). The complexities of elder homelessness, a shifting political landscape and emerging community responses. Journal of Gerontological Social Work, 53(7), 575-590.

Greenberg, G. A., & Rosenheck, R. A. (2010). Mental health correlates of past homelessness in the National Comorbidity Study Replication. Journal of HealthCare for the Poor and Underserved, 21(4), 1234-1249.

Grenier, A., Barken, R., Sussman, T., Rothwell, D., & Lavoie, J. P. (2013). Literature review: Aging and homelessness. Aging.

Grenier, A., Barken, R., Sussman, T., Rothwell, D., Bourgeois-Guérin, V., & Lavoie, J. P. (2016). A literature review of homelessness and aging: Suggestions for a policy and practice-relevant research agenda. Canadian Journal on Aging/La Revue canadienne du vieillissement, 35(1), 28-41.

Hoe, J., Hancock, G., Livingston, G., Woods, B., Challis, D., & Orrell, M. (2009). Changes in the quality of life of people with dementia living in care homes. Alzheimer Disease and Associated Disorders, 23(3), 285.

Latimer, E. A., Rabouin, D., Cao, Z., Ly, A., Powell, G., Aubry, T., … & Veldhuizen, S. (2017). Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study. CMAJ open, 5(3), E576.

Lipmann, B. (2009). Elderly homeless men and women: Aged care’s forgotten people. Australian Social Work, 62(2), 272-286.

Marek, L. N. (2017). Does Homelessness Increase the Risk of Readmission in Acute Care Patients Diagnosed with Schizophrenia.

Mcdonald, L. Y. N. N., Donahue, P. E. T. E. R., Janes, J. U. L. I. A., & Cleghorn, L. A. U. R. A. (2009). Understanding the health, housing, and social inclusion of formerly homeless older adults. Finding home: Policy options for addressing homelessness in Canada.

Mechanic, D. (2012). Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs, 31(2), 376-382.

Minnery, J., & Greenhalgh, E. (2007). Approaches to homelessness policy in Europe, the United States, and Australia. Journal of Social Issues, 63(3), 641-655.

Morris, A., Jamieson, M., & Patulny, R. (2012). Is social mixing of tenures a solution for public housing estates. Evidence Base, 1(1), 1-20.

Morrison, D. S. (2009). Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology, 38(3), 877-883.

Mott, S., Moore, M., & Rothwell, D. (2012). Addressing homelessness in Canada: Implications for intervention strategies and program design. Montreal, QC: Centre for Research on Children and Families, McGill University.

Novick, D., Haro, J. M., Suarez, D., Perez, V., Dittmann, R. W., & Haddad, P. M. (2010). Predictors and clinical consequences of non-adherence with antipsychotic medication in the outpatient treatment of schizophrenia. Psychiatry research, 176(2), 109-113.

Petersen, M., Parsell, C., Phillips, R., & White, G. (2014). Preventing first time homelessness amongst older Australians. AHURI Final Report, Australian Housing and Urban Research Institute, Melbourne.

Peterson, M. (2015). Introduction: Homelessness is an ageing policy issue. Parity, 28(6), 9.

Ploeg, J., Hayward, L., Woodward, C., & Johnston, R. (2008). A case study of a Canadian homelessness intervention programme for elderly people. Health & social care in the community, 16(6), 593-605.

Rezansoff, S. N., Moniruzzaman, A., Fazel, S., McCandless, L., Procyshyn, R., & Somers, J. M. (2016). Housing first improves adherence to antipsychotic medication among formerly homeless adults with schizophrenia: results of a randomized controlled trial. Schizophrenia bulletin, 43(4), 852-861.

Rezansoff, S. N., Moniruzzaman, A., Fazel, S., Procyshyn, R., & Somers, J. M. (2016). Adherence to antipsychotic medication among homeless adults in Vancouver, Canada: a 15-year retrospective cohort study. Social psychiatry and psychiatric epidemiology, 51(12), 1623-1632.

Solari, C., Cortes, A., Brown, S., Khadduri, J., & Culhane, D. P. (2013). The 2012 Annual Homelessness Assessment Report (AHAR) to Congress: Volume 2, Estimates of Homelessness in the United States. Washington, DC: US Department of Housing and Urban Development.

Somers, J. M., Moniruzzaman, A., Currie, L., Rezansoff, S. N., Russolillo, A., & Parpouchi, M. (2016). Accuracy of reported service use in a cohort of people who are chronically homeless and seriously mentally ill. BMC psychiatry, 16(1), 41.

Sprake, E. F., Russell, J. M., & Barker, M. E. (2014). Food choice and nutrient intake amongst homeless people. Journal of human nutrition and dietetics, 27(3), 242-250.

Tsemberis, S., & Eisenberg, R. F. (2000). Pathways to housing: Supported housing for street-dwelling homeless individuals with psychiatric disabilities. Psychiatric services, 51(4), 487-493.

Valenstein, M., McCarthy, J. F., Ganoczy, D., Bowersox, N. W., Dixon, L. B., Miller, R., … & Slade, E. P. (2013). Assertive community treatment in veterans affairs settings: impact on adherence to antipsychotic medication. Psychiatric Services, 64(5), 445-451.

Wilkins, P. (2017). Monitoring and Evaluation of a Multi-Agency Response to Homelessness: An Australian Case Study. In Evaluating the complex (pp. 157-180). Routledge.

Yates, J., & Bradbury, B. (2010). Home ownership as a (crumbling) fourth pillar of social insurance in Australia. Journal of Housing and the Built Environment, 25(2), 193-211.

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