The causes of homelessness are complex, and mental illness and related mood disorders add additional layers of difficulties. Approximately 25% of the homeless population suffers from some serious mental illness (Kusmer, 2002). Many homeless suffer from common mental illnesses such as depression, psychotic disorders, substance abuse, and personality disorders. In addition, the population of homeless is very diverse including all ethnic groups, usually ranging in age between 30 to 50 years of age, unmarried, unemployed, with the largest segment of the population being women (Martens, 2002).
Two growing trends are increasingly responsible for the rise in homelessness over the past 20 years: the growing shortage of affordable rental housing and a simultaneous increase in poverty (National Coalition for Homeless, 2005). In 1998, the U.S. Conference of Mayor’s survey of homelessness in 30 cities found that children under the age of 18 years accounted for 25% of the urban homeless population. This same study found that unaccompanied minors comprised 3% of the urban homeless. Most studies of the homeless show that single adults are more likely to be male and comprise 45%, while 14% are single women (U.S. Conference of Mayors, 1998). Families with children are among the fastest-growing segments of the homeless population representing approximately 40% of people who become homeless (Shinn & Weitzman, 1996).
The homeless population varies demographically according to location. The U.S. Conference of Mayors (1998) found that 49% are African Americans, 32% Caucasian American, 12% Hispanic, 4% Native American, and 3%Asian American. Approximately 22% of the homeless population left their last place of residence because of domestic violence (Homes for the Homeless, 1998). The homeless population commonly identified the usual signs of mood disorders such as: ongoing sadness, anxiety, lack of energy, loss of interest in ordinary activities, sleep problems, excessive weight loss or gain, physical aches and pains, difficulty concentrating, hopelessness, and thoughts of suicide and death (McMurray-Avila, 1997). One of the identified mood disorders, depression, is the most treatable of all mental illnesses. About60%–80% of depressed people can be successfully treated outside the hospital with psychotherapy alone or with specific drugs.
Unfortunately, most drug therapies, if needed, take at least 6 to 19 weeks before there are real signs of improvement. There is a reluctance to receive drug treatment due to side effects of the drugs (McMurray-Avila)and the continuing stigma of mental illness in our society. Advocacy is critical to ending homelessness. Advocacy means working with the homeless to bring about positive changes in policies and programs on the local, state, and federal levels.
Breaking the cycle of homelessness and related mood disorders also re-quires eliminating some of the obstacles to receiving medical care that the homeless face. Obstacles for the homeless include: a lack of awareness of services available, lack of financial resources and health insurance, language or cultural barriers, poor attitudes of some providers of services, lack of transportation, difficulty scheduling and keeping appointments, fear and distrust of institutions, and fragmented community services (Kus-mer, 2002).
On the bright side, organizations which offer information and assistance with depression and treatment include: The National Institute of Mental Health Depression Awareness, Recognition, and Treatment Program(2003); the National Depressive and Manic Depressive Association (2003); the National Alliance for the Mentally Ill (2003) and its branch organizations available in each state; and the National Mental Health Association (2003) which publishes information on a variety of mental health issues. In addition, the President’s New Freedom Commission on Mental Health (2003) clearly identified goals needed to transform mental health care in the United States, which in turn should decrease the number of homeless with mental illness when implemented.
There is a paucity of nursing research linking the role that professional nurses play as advocates in improving the care for homeless with mental illness and related mood disorders. Because primary health care for the homeless population is often provided by nurses, there is an excellent nursing opportunity to initiate helpful research in this area as well as assist those with mental illness to get care so that they may function at a higher level in our society. Interventions are those successful actions taken to attempt to break the cycle of homelessness.
Project Achieve (www.homelessness.net, 2003) attacked the cycle of homelessness for families and individuals with information resources described on their website. This web site lists access to social services and emergency shelters to meet basic needs, services to prepare individuals for successful independent living, and case-management services sites to provide counseling, assistance with employment, and housing placement. This kind of web site assistance could be provided regionally throughout the country, educating health professionals and others who lack the knowledge of available resources. Another valuable resource is a listing of available grant money on this web site that can be used to develop additional programs to better meet the needs of the homeless.
The strengthening of the family unit of individuals with chronic mental illness is an important need revealed by community based case management programs. This was a longitudinal study of family support among homeless mentally ill in community-based housing programs (Wood, P., Harbert, Hough, & Hotstetter, 1998). This study was one of the first to look at the strength of homeless family relationships over time. As contact with family members increased, so did their mental health as did greater satisfaction in their relationships and housing.
The most useful strategies for professionals working with homeless mentally ill individuals and families include: setting a tone of respect using observational, listening, and interviewing skills that quickly identify problems; locating existing resources; making timely and appropriate referrals; and functioning as an advocate when needed (Williams, 1994). There has been a slow increase in research targeting the problems and needs of the homeless over the past decade.
However, in the field of nursing there continues to be a paucity of research related to the important roles that professional nurses can play and the interventions they could use to provide care for the homeless chronically mentally ill. Research is needed on the nature of the relationship between homelessness and related mental disorders such as depression and related mood disorders.
The etiology of homelessness needs studies which include demographics comparing national, cultural, psychosocial, genetic, and neurobiological determinants of specific homeless populations. Other studies might explore the impact of urban versus rural environments on person vulnerable to homelessness. Both qualitative and quantitative nursing research co joined with the research done by other disciplines is essential to clearly document the important role and interventions already used in practice by the professional nurse in providing care to the mentally ill individuals and their families.