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Dr. Elaine Dunne a , Dr. Maura Duggan b , Dr. Julie O’Mahony c

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

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Dr. Elaine Dunne a , Dr. Maura Duggan b , Dr. Julie O’Mahony c

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  1. Mental Health Services for Homeless in Cork City, Ireland: Psychiatric Diagnosis; Suicide and Violence Risk Factors Dr. Elaine Dunnea, Dr. Maura Dugganb, Dr. Julie O’Mahonyc aSenior Registrar, South Lee Mental Health Service, Cork University Hospital, Cork, Ireland; bConsultant in Psychiatry, Adult Homeless Integrated Services, Cork, Ireland; cSkibbereen Medical Centre, Co. Cork, Ireland

  2. Background Homeless are those for whom no accommodation exists, which they could be reasonably expected to use, or those who could not be expected to remain in existing accommodation and are incapable of providing suitable accommodation for themselves Government of Ireland (1988) Housing Act. Irish Statute Book.

  3. The charitable organisation, Simon, estimates that nationally there are currently at least 4,176 adults and 1,405 children experiencing homelessness in Ireland Despite this, little is formally known about the extent of the problem and certainly about its relationship to mental illness

  4. Mental illness & homelessness Estimates of the prevalence of severe mental disorder among the homeless in other countries range from 25%-50% Recent guidelines recommend that a detailed understanding of the mental health needs and priorities of the population of homeless people should be gained to provide a guide as to how to allocate available resources in order to provide care which is relevant to the requirements of individual patients and their families A Vision for Change. Department of Health and Children (2006) available at www.dohc.ie/publications/vision_for_change.html

  5. Suicide and violence Prevalence rates of suicide in the homeless population range from 1-3% and, those who commit suicide have high rates of co-morbidity, substance misuse, and violence In the UK, around one third of those convicted of homicide had a diagnosis of mental disorder based on life history. 3% of homicide perpetrators with mental illness were homeless Appleby L. Department of Health, UK. Safety First: Report of the National ConfidentiaInquiry into Suicide and Homicide by People with Mental Illness 2001 available at www.dh.gov.uk/en/Publicationsandstatistics

  6. Objectives of this study • To establish a detailed profile of service users of the mental health service for homeless in Cork City, with a particular focus on risk factors for suicide and violence • To compare this group with those attending a local General Adult Mental Health Service

  7. Methods With the approval of the Ethics Committee of the Cork Teaching Hospitals, information was collected and recorded from a review of case notes of all service users of the Mental Health Service for Homeless People in Cork City Similar data was gathered from the case notes of service users attending a Cork General Adult Mental Health Service Statistical analysis was carried out using Graphpad Prism version 5 for windows Graph Pad Prism version 5.0, Graph Pad Software, San Diego, CA, USA

  8. Results Approximately 472 individuals availed of the homeless services in Cork City at the time of the survey Homelessness: An Integrated Strategy 2009-2011; www.corkcity.ie

  9. Table 1. Patient Profile of Homeless and General adult services Homeless General Adult Service n (%) Service n (%) • Number of current patients 54 (100) 219 (100) • Gender * Male 48 (89) 100 (46) Female 6 (11) 119 (54) • Marital status* Married 1 (2) 55 (25) Unmarried 53 (98) 164 (75) • Employment status Unemployed* 52 (96) 149 (68) Student 2 (4) 14 (6) Employed* 0 (0) 56 (26) • Ethnic minority 4 (7) 7 (3) *statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001

  10. Figure 1. Age Profile *statistically significant difference between groups; Fisher’s exact test: p=0.03

  11. Diagnosis (Figure 2) • There was a significantly higher prevalence of schizophreniform disorder; personality disorder; alcohol and drug dependence; and a lower prevalence of affective disorders in the homeless service users, though no difference between groups in relation to either depression or bipolar affective disorder alone • Homeless patients were significantly more likely to have a history of alcohol (74% v 27%; p<0.0001) or drug (61% v 11%; p<0.0001) misuse

  12. Figure 2. Diagnosis *statistically significant difference; Χ2: p=0.03(schizophreiform disorder); p<0.0001 (personality disorder, alcohol dependence, drug dependence)

  13. Risk Factors (Figure 3) • Factors known to be associated with increased risk and those which were common in people who committed suicide and homicide in the UK are listed in Fig. 3 along with their prevalence in the groups studied here • Homeless patients were more likely than those attending the general adult mental health services to have a history of deliberate self harm (54% v 21%; p<0.0001) and physical violence (48% v 10%; p<0.0001)

  14. Figure 3. Factors associated with of suicide and violence *statistically significant difference; Χ2 or Fisher’s exact test: p<0.0001

  15. Service Contact (Figure 3) There were higher levels of non compliance and active symptoms in the homeless group but they also had significantly more input from multidisciplinary team members (74% v 37%, p<0.0001) and were seen more frequently by the consultant psychiatrist (mean of 3.3 weekly v 10.4 weekly; p<0.0001)

  16. Conclusions • The homeless group were significantly more likely to be male, unemployed, unmarried and under 65 compared to their general adult counterparts or compared to adults in the general population of Cork • Such social isolation and lack of occupation may exacerbate or maintain symptoms and add to risk of relapse and suicide

  17. Severe mental illness has a high prevalence in the homeless population, with particularly high levels of psychotic illness and substance dependence even in comparison to general adult mental health services • The group of homeless patients also had a high prevalence of risk factors for suicide and violence • Poor compliance and severity of illness lead to a requirement for significant input from multidisciplinary mental health teams members

  18. Limitations Data collected for the study was based solely on case note records. It is possible that some details may not have been available leading to an underestimation in results such as presence of risk factors

  19. Implications • The profile emerging from this study draws attention to the complexity of this minority group of mental health service user • From the findings it is clear that, in addition to the physical and social needs of any homeless person with issues such as isolation and lack of occupation, this group have the additional burden of severe and complex mental illness, addiction and are at risk of suicide and possibly violence • It is essential that those most at risk are recognised and receive appropriate input form well resourced multidisciplinary teams to ensure there is intensive treatment of any underlying mental illness as well as dealing with addiction and social issues in order to reduce morbidity and risk

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