Health and Social Adjustment of Homeless Older Adults With a Mental Illness

Data were obtained from the ACCESS program public database. Data collection took place between 1994 and 1998. All ACCESS clients received intensive case management services. Of the 18 data collection sites across the country, nine were given extra resources to increase system integration. The results indicated that although the nine experimental sites showed increased service system integration, there were no differences in client improvement at the experimental and the control sites (19).

Participants were eligible if they had spent at least seven of the previous 14 nights at an emergency shelter, outdoors, or in a public building; had been identified as having a serious mental illness by a 30-item screening algorithm developed for a previous homelessness outreach study (20); and were not engaged in more than minimal mental health treatment. Serious mental illness was defined as having symptoms of depression, mania, or psychosis, on the basis of self-report, or having been observed by an interviewer to have symptoms of psychosis unrelated to substance use. All sites had specialized community outreach teams to recruit homeless people with an untreated mental illness.

Written informed consent was obtained from all participants. Structured interviews were conducted at baseline and at three- and 12-month follow-ups.

Psychometric information and methods for confirming treatment fidelity were reported in a previous publication (19). Demographic information about gender, race, years of education, marital status, employment, and money earned during the previous month was collected. Homelessness was assessed on the basis of sleeping location during the previous 60 nights. Literal homelessness was defined as sleeping outdoors, in an abandoned or public building or automobile, or at an emergency shelter. Being housed was defined as living in a hotel, boarding home, halfway house, residential program, institution, jail, or one's own or another's residence. Data about the individual's age during the first episode of homelessness, number of episodes of homelessness, and lifetime years of homelessness were also collected.

Psychiatric symptoms, alcohol use, drug use, and history of a suicide attempt were assessed with the relevant subscales of the Addiction Severity Index (ASI), a measure found to be valid with older adults (21,22). Scores range between 0 and 1, with higher scores indicating more severe symptoms. The ASI psychiatric score is calculated by equally weighing 11 questions about symptoms of sadness or anxiety, hallucinations, suicidal ideation, suicide attempt, whether one is currently prescribed psychiatric medication, and how much one is bothered by psychiatric symptoms. The ASI alcohol score is calculated by equally weighing six items about the number of days in the past 30 days one drank alcohol and felt drunk and the amount of money spent on alcohol, how much one is bothered by alcohol problems, and how important one feels it is to get treatment for these problems. The ASI drug score is calculated by equally weighing 11 items assessing over the past 30 days the number of days of use, the amount of money spent, and withdrawal symptoms related to several illegal drugs and how much one is bothered by drug problems and how important one feels it is to get treatment for these problems.

Selected items of the Diagnostic Interview Schedule (23) and the Psychiatric Epidemiology Research Interview (24) were used to create three composite scores: a depression score, a psychosis score, and an interviewer observation of overtly psychotic behavior. The depression score summed the number of depression symptoms reported by an individual from among a list of five symptoms that included depressed mood or decreased interest or pleasure, trouble concentrating, feelings of worthlessness or guilt, thoughts about death, and psychomotor agitation. The psychosis score assessed the frequency of ten psychosis symptoms; each symptom had a maximum value of 4 points, for a maximum total of 40 points. The interviewer-observation score represented the number of behaviors suggestive of psychosis, such as responses to internal stimuli, out of a possible 13, that were observed during the interview. Each behavior is rated on a scale of 0, not at all, to 4, a large extent, for a maximum score of 52.

Physical health was assessed by the total number of medical disorders endorsed from among a list of 17. Subjective health status was assessed with the question, “Compared to other people your age, would you say your health is excellent, very good, good, fair, or poor?”

Social support network size was calculated as the total number of people available from a list of nine roles, such as parent or friend, to help with three types of problems (short-term loan of $100, ride to an appointment, and someone to talk with if feeling suicidal), for a maximum total of 27 points (25). Social support satisfaction was calculated as the average response to nine questions derived from the Lehman Quality of Life Interview, each rated from 1, terrible, to 7, delighted (25). Quality of life was measured with a single item from the Lehman Quality of Life Interview (26), “Tell me how you feel about your life overall right now,” scored on the same scale. A composite satisfaction with safety score was calculated by averaging a client's ratings in five categories of safety, from 1, terrible, to 7, delighted.

Early-life instability was assessed with the Family of Origin Instability Scale (27), a 12-item scale that includes questions about family history before the client's 18th birthday, including history of abuse and financial difficulties. History of antisocial behavior was assessed with the Helzer Conduct Disorder Scale (28), which includes nine yes-or-no questions that are based on the DSM-III criteria for conduct disorder. Past legal involvement was assessed with questions from the ASI (21).

Kruskal-Wallis and chi square analyses were used to compare baseline data among young (age 18 to 34), middle-aged (age 35 to 54), and older (age 55 and older) participants because of nonnormal distributions and nonequivalent distributions between groups. Significant Kruskal-Wallis results were analyzed for post hoc between-group differences with the Mann-Whitney U test. Effect size was calculated by using Cohen's d.

The homelessness research literature supports the use of a relatively young age to demarcate “older adult,” because homeless adults resemble nonhomeless adults who are ten to 20 years older (6,29). Multinomial logistic regression was used to identify characteristics that independently differentiated older homeless adults from the younger groups.

Next, baseline characteristics of the subgroups with and without follow-up data were compared to identify potential biases in the follow-up sample. Finally, after adjustment for potentially confounding baseline differences identified by multinomial logistic regression, a mixed-model analysis was used to compare outcomes between age cohorts at three-month and 12-month follow-ups.

Table 1 provides a summary of demographic and homelessness characteristics at baseline. Primarily the older adults were male (61%), Caucasian (60%), and unmarried (94%).

Table 2 summarizes mental health, substance use, and physical health variables at baseline. Compared with members of the other age groups, the older adults reported significantly fewer symptoms of depression and psychosis and significantly fewer general psychiatric symptoms (ASI psychiatric score). The effect sizes were largest for general psychiatric symptoms. History of a suicide attempt was prominent among all three age groups—young (59%), middle-aged (50%), and older (26%). The ASI score for alcohol use was lowest among the older group; the ASI score for drug use was highest among the young group and lowest among the older group. The number of medical conditions endorsed by the older adults was equivalent to the number endorsed by the middle-aged adults but more than the number endorsed by the young adults.

Table 3 summarizes social support variables at baseline. Compared with participants in the younger age groups, the older adults had the fewest social supports but expressed greater satisfaction with them. The older adults reported higher quality of life and higher satisfaction with safety. They had the most childhood stability and the fewest conduct disorder symptoms.

Multinomial logistic regression was used to identify independent significant differences between age groups (the older adults were the reference group). The variables found to be significantly different were data collection site, work status, marital status, gender, depression score, years of education, money received through public support, years homeless, psychosis score, history of suicide attempt, number of medical problems, Family of Origin Instability Scale score, Helzer Conduct Disorder Scale score, and social support network size.