Home is where hearth is

The economic downturn worldwide has made the differences between the haves and have-nots even starker. Millions of individuals on zero-hour contracts and uncertainty in the job market has meant that rates of actual homelessness and those with precarious housing have gone up. Homelessness and homeless individuals are present across the globe - more visible in some settings than in others. Living on the streets in all kinds of inclement weather brings a different set of issues and problems compared with other varieties. Homelessness in this commentary will be defined as a lack of customary regular access to a conventional dwelling unit 1. In the paper by Stergiopoulos et al. 2 in this issue, among 1500 homeless people, nearly half were either depressed or had substance use disorders and half had traumatic brain injury. This reflects one of two things: firstly, whether drift hypothesis postulated by Faris and Dunham over 70 years ago 3 where those with schizophrenia migrate to inner cities still holds true or not but, more importantly, this study reflects the failure of the society and the profession in looking after those who are vulnerable due to a number of reasons. Craig et al. 4 had observed that between one-third and half of the users of night shelters showed a prevalence of functional psychoses, and these could be attributed to poor access to psychiatric services and barriers to effective care. These authors noted that a major emphasis of modern psychiatric practice has been the shift to and the provision of intensive short-term inpatient care which lasts for the acute phase of a mental illness. In the UK, at least in line with many other countries, services are geographically delineated, making it more difficult for ‘out of area’ individuals to get help. A significant observation by these authors was also that there appeared to be a failure to recognise high care needs of homeless individuals. In identifying and managing the mental health needs of individuals who are homeless, clinicians, researchers and policy makers have a major challenge they need to consider. First and foremost clear agreed definitions. Clinicians need to stand up and advocate for our vulnerable patients, and psychiatric care needs to be provided in a joined-up manner. Early interventions and home treatments are suitable but can be effective only if individuals and their carers have reasonably secure addresses where they are housed and can be approached and treated. Secondly, policies have to take into account huge variations in society and the role unemployment and poverty will play in increasing homelessness. Whether psychiatric disorders lead to homelessness and whether homelessness leads to mental illness is a circular argument and this vicious downwards spiral needs to be broken. As a matter of routine, research funding should include funding to enable to be set up and developed and evaluated. Policies are undoubtedly important in achieving this, but these have to be accompanied with adequate resources. There is an urgent need to explore and measure social determinants of both mental and physical health. Mental and physical health need to be integrated in a sensible pragmatic manner with adequate funding. If physicians are generally not very good at dealing with mental illness, psychiatrists are not often very competent in dealing with physical health, so services must be complete. For example, services should include de-addiction programmes, physical and mental health assessments, social care, education, employment activities. The geographical barriers and emotional barriers which prevent individuals or their caregivers accessing professional help are related to stigma by the society but also by the staff towards homeless individuals, which in turn puts homeless individuals off from seeking help. This needs to be broken using educational packages for staff. Early diagnosis and intervention using a number of strategies where services go to people in need rather than people coming to services is another step forward. In countries like the UK where housing stock is becoming unaffordable, the group most at risk are the young, who are vulnerable to psychiatric disorders as well as substance abuse. Additional complications as a result of mental illness and homelessness are an increase in criminal activities and convictions. Services therefore must work collaboratively with the justice system to ensure that those who need treatment the most do not end up where there is no treatment available. Working with schools, education departments and voluntary agencies in a constructive manner will help the most vulnerable individuals. It is inevitable that there will be barriers and disenchantment, but clinicians must stand up and advocate for the most vulnerable individuals, who often do not have a voice. It is our moral responsibility and professional duty.