Mental Health Services for Homeless in Cork City, Ireland: Psychiatric Diagnosis; Suicide and Violence Risk Factors. Dr. Elaine Dunne a , Dr. Maura Duggan b , Dr. Julie O’Mahony c - PowerPoint PPT Presentation
Mental Health Services for Homeless in Mental Health Services for Homeless in Cork City, Ireland: Cork City, Ireland: Psychiatric Diagnosis; Suicide and Psychiatric Diagnosis; Suicide and Violence Risk Factors Violence Risk Factors Dr. Elaine Dunne Dr. Elaine Dunne a , Dr. Maura , Dr. Maura Duggan Duggan b , Dr. Julie O’Mahony , Dr. Julie O’Mahony c c a Senior Registrar, South Lee Mental Health Senior Registrar, South Lee Mental Health Service, Cork University Hospital, Cork, Service, Cork University Hospital, Cork, Ireland; Ireland; b Consultant in Psychiatry, Consultant in Psychiatry, Adult Adult Homeless Integrated Services, Cork, Ireland; Homeless Integrated Services, Cork, Ireland; c Skibbereen Medical Centre, Co. Cork, Ireland Skibbereen Medical Centre, Co. Cork, Ireland
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Mental Health Services for Mental Health Services for Homeless in Cork City, Ireland: Homeless in Cork City, Ireland: Psychiatric Diagnosis; Suicide Psychiatric Diagnosis; Suicide
and Violence Risk Factorsand Violence Risk Factors
Dr. Elaine DunneDr. Elaine Dunneaa, Dr. Maura , Dr. Maura DugganDugganbb, Dr. Julie O’Mahony, Dr. Julie O’Mahonyc c
aaSenior Registrar, South Lee Mental Health Service, Senior Registrar, South Lee Mental Health Service, Cork University Hospital, Cork, Ireland; Cork University Hospital, Cork, Ireland; bbConsultant in Consultant in Psychiatry, Psychiatry, Adult Homeless Integrated Services, Cork, Adult Homeless Integrated Services, Cork, Ireland; Ireland; ccSkibbereen Medical Centre, Co. Cork, IrelandSkibbereen Medical Centre, Co. Cork, Ireland
BackgroundBackground
Homeless are those for whom no Homeless are those for whom no accommodation exists, which they accommodation exists, which they could be reasonably expected to use, could be reasonably expected to use, or those who could not be expected to or those who could not be expected to remain in existing accommodation and remain in existing accommodation and are incapable of providing suitable are incapable of providing suitable accommodation for themselvesaccommodation for themselvesGovernment of Ireland (1988) Housing Act. Irish Statute Book.Government of Ireland (1988) Housing Act. Irish Statute Book.
The charitable organisation, Simon, The charitable organisation, Simon, estimates that nationally there are estimates that nationally there are currently at least 4,176 adults and currently at least 4,176 adults and 1,405 children experiencing 1,405 children experiencing homelessness in Irelandhomelessness in Ireland
Despite this, little is formally known Despite this, little is formally known about the extent of the problem and about the extent of the problem and certainly about its relationship to certainly about its relationship to mental illnessmental illness
Estimates of the prevalence of severe mental Estimates of the prevalence of severe mental disorder among the homeless in other countries disorder among the homeless in other countries range from 25%-50%range from 25%-50%
Recent guidelines recommend that a detailed Recent guidelines recommend that a detailed understanding of the mental health needs and understanding of the mental health needs and priorities of the population of homeless people priorities of the population of homeless people should be gained to provide a guide as to how to should be gained to provide a guide as to how to allocate available resources in order to provide allocate available resources in order to provide care which is relevant to the requirements of care which is relevant to the requirements of individual patients and their familiesindividual patients and their familiesA Vision for Change. Department of Health and Children (2006) available at A Vision for Change. Department of Health and Children (2006) available at www.dohc.ie/publications/vision_for_change.html www.dohc.ie/publications/vision_for_change.html
Suicide and violenceSuicide and violencePrevalence rates of suicide in the homeless Prevalence rates of suicide in the homeless population range from 1-3% and, those who population range from 1-3% and, those who commit suicide have high rates of co-commit suicide have high rates of co-morbidity, substance misuse, and violencemorbidity, substance misuse, and violence
In the UK, around one third of those In the UK, around one third of those convicted of homicide had a diagnosis of convicted of homicide had a diagnosis of mental disorder based on life history. 3% of mental disorder based on life history. 3% of homicide perpetrators with mental illness homicide perpetrators with mental illness were homelesswere homeless
Appleby L. Department of Health, UK. Safety First: Report of the National Appleby L. Department of Health, UK. Safety First: Report of the National ConfidentiaInquiry into Suicide and Homicide by People with Mental Illness ConfidentiaInquiry into Suicide and Homicide by People with Mental Illness 2001 available at www.dh.gov.uk/en/Publicationsandstatistics 2001 available at www.dh.gov.uk/en/Publicationsandstatistics
Objectives of this studyObjectives of this study
To establish a detailed profile of service To establish a detailed profile of service users of the mental health service for users of the mental health service for homeless in Cork City, with a particular homeless in Cork City, with a particular focus on risk factors for suicide and focus on risk factors for suicide and violenceviolence
To compare this group with those To compare this group with those attending a local General Adult Mental attending a local General Adult Mental Health ServiceHealth Service
MethodsMethods
With the approval of the With the approval of the Ethics Committee of the Ethics Committee of the Cork Teaching Hospitals, Cork Teaching Hospitals, information was information was collected and recorded from a review of case collected and recorded from a review of case notes of all service users of the Mental Health notes of all service users of the Mental Health Service for Homeless People in Cork CityService for Homeless People in Cork City
Similar data was gathered from the case notes of Similar data was gathered from the case notes of service users attending a Cork General Adult service users attending a Cork General Adult Mental Health ServiceMental Health Service
Statistical analysis was carried out using Statistical analysis was carried out using Graphpad Prism version 5 for windowsGraphpad Prism version 5 for windowsGraph Pad Prism version 5.0, Graph Pad Software, San Diego, CA, USAGraph Pad Prism version 5.0, Graph Pad Software, San Diego, CA, USA
ResultsResults
Approximately 472 individuals Approximately 472 individuals availed of the homeless services in availed of the homeless services in Cork City at the time of the survey Cork City at the time of the survey Homelessness: An Integrated Strategy 2009-2011; www.corkcity.ieHomelessness: An Integrated Strategy 2009-2011; www.corkcity.ie
Homeless Homeless General Adult General Adult Service n (%)Service n (%) ServiceService n (%) n (%)
Number of current patients Number of current patients 54 (100)54 (100) 219 (100)219 (100) Gender * Gender *
Male Male 48 (89) 48 (89) 100 (46) Female 100 (46) Female 6 (11)6 (11) 119 (54)119 (54)
*statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001
Table 1. Patient Profile of Homeless Table 1. Patient Profile of Homeless and General adult servicesand General adult services
Figure 1. Age ProfileFigure 1. Age Profile
Homeless service
16-24
25-34
35-44
45-54
55-64
>65*
General Adult service
16-24
25-34
35-44
45-54
55-64
>65*
*statistically significant difference between groups; Fisher’s exact test: p=0.03
Diagnosis (Figure 2)Diagnosis (Figure 2)
There was a significantly higher There was a significantly higher prevalence of schizophreniform disorder; prevalence of schizophreniform disorder; personality disorder; alcohol and drug personality disorder; alcohol and drug dependence; and a lower prevalence of dependence; and a lower prevalence of affective disorders in the homeless service affective disorders in the homeless service users, though no difference between users, though no difference between groups in relation to either depression or groups in relation to either depression or bipolar affective disorder alonebipolar affective disorder alone
Homeless patients were significantly more Homeless patients were significantly more likely to have a history of alcohol (74% v likely to have a history of alcohol (74% v 27%; p<0.0001) or drug (61% v 11%; 27%; p<0.0001) or drug (61% v 11%; p<0.0001) misusep<0.0001) misuse
Risk Factors (Figure 3)Risk Factors (Figure 3) Factors known to be associated with Factors known to be associated with
increased risk and those which were common increased risk and those which were common in people who committed suicide and in people who committed suicide and homicide in the UK are listed in Fig. 3 along homicide in the UK are listed in Fig. 3 along with their prevalence in the groups studied with their prevalence in the groups studied herehere
Homeless patients were more likely than Homeless patients were more likely than those attending the general adult mental those attending the general adult mental health services to have a history of health services to have a history of deliberate self harm (54% v 21%; p<0.0001) deliberate self harm (54% v 21%; p<0.0001) and physical violence (48% v 10%; and physical violence (48% v 10%; p<0.0001)p<0.0001)
Figure 3. Factors associated with Figure 3. Factors associated with of suicide and violence of suicide and violence
0 20 40 60 80 100
%
Unmarried*
Unemployed*
Long term physical illness
Dual diagnosis*
History of DSH*
History of violence*
Duration of symptoms <1year
Post discharge
Recent adverse life events
Family history of suicide
>5 admissions*
Missed last contact*
Symptoms at last contact*
Recent noncompliance*
Homeless service
General adult service
*statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001
Service Contact (Figure 3)Service Contact (Figure 3)
There were higher levels of non There were higher levels of non compliance and active symptoms in compliance and active symptoms in the homeless group but they also the homeless group but they also had significantly more input from had significantly more input from multidisciplinary team members multidisciplinary team members (74% v 37%, p<0.0001) and were (74% v 37%, p<0.0001) and were seen more frequently by the seen more frequently by the consultant psychiatrist (mean of 3.3 consultant psychiatrist (mean of 3.3 weekly v 10.4 weekly; p<0.0001)weekly v 10.4 weekly; p<0.0001)
ConclusionsConclusions
The homeless group were significantly The homeless group were significantly more likely to be male, unemployed, more likely to be male, unemployed, unmarried and under 65 compared to their unmarried and under 65 compared to their general adult counterparts or compared to general adult counterparts or compared to adults in the general population of Corkadults in the general population of Cork
Such social isolation and lack of Such social isolation and lack of occupation may exacerbate or maintain occupation may exacerbate or maintain symptoms and add to risk of relapse and symptoms and add to risk of relapse and suicidesuicide
Severe mental illness has a high Severe mental illness has a high prevalence in the homeless population, prevalence in the homeless population, with particularly high levels of psychotic with particularly high levels of psychotic illness and substance dependence even in illness and substance dependence even in comparison to general adult mental health comparison to general adult mental health servicesservices
The group of homeless patients also had a The group of homeless patients also had a high prevalence of risk factors for suicide high prevalence of risk factors for suicide and violence and violence
Poor compliance and severity of illness Poor compliance and severity of illness lead to a requirement for significant input lead to a requirement for significant input from multidisciplinary mental health teams from multidisciplinary mental health teams membersmembers
LimitationsLimitations
Data collected for the study was Data collected for the study was based solely on case note records. It based solely on case note records. It is possible that some details may not is possible that some details may not have been available leading to an have been available leading to an underestimation in results such as underestimation in results such as presence of risk factorspresence of risk factors
ImplicationsImplications The profile emerging from this study draws The profile emerging from this study draws
attention to the complexity of this minority group of attention to the complexity of this minority group of mental health service usermental health service user
From the findings it is clear that, in addition to the From the findings it is clear that, in addition to the physical and social needs of any homeless person physical and social needs of any homeless person with issues such as isolation and lack of occupation, with issues such as isolation and lack of occupation, this group have the additional burden of severe and this group have the additional burden of severe and complex mental illness, addiction and are at risk of complex mental illness, addiction and are at risk of suicide and possibly violencesuicide and possibly violence
It is essential that those most at risk are recognised It is essential that those most at risk are recognised and receive appropriate input form well resourced and receive appropriate input form well resourced multidisciplinary teams to ensure there is intensive multidisciplinary teams to ensure there is intensive treatment of any underlying mental illness as well treatment of any underlying mental illness as well as dealing with addiction and social issues in order as dealing with addiction and social issues in order to reduce morbidity and riskto reduce morbidity and risk
