SAMENTA Psychiatric disorders among homeless people: evidences for improving psychiatric services and housing policies.
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1 SAMENTA Psychiatric disorders among homeless people: evidences for improving psychiatric services and housing policies. Preliminary results Chan-Chee C 1, Douay C 2, Detrez M-A 2, Le Masson V 3, Le Strat Y 1, Chauvin P 4, Laporte A 2 and the SAMENTA research group 1 Institut de Veille Sanitaire, Saint-Maurice 2 Observatoire du Samusocial de Paris 3 Hôpital Sainte-Anne, Paris 4 Inserm - UPMC UMRS 707, Paris
2 Context Increasing national interest in the issue of homelessness and mental health Reports of difficulties in access to health care services Need for data for the policymakers
3 Aims Estimate the prevalence of psychiatric disorders and addiction among the homeless in the Ile-de-France region (Paris and suburbs) Propose recommendations for improving access to mental health services and guidelines for housing policies
4 Methods (I) Definition of the homeless population Person without personal housing sleeping in rough places or hosted by organisations offering shelter for free or with little financial participation. At least once during the last 5 days. Only French-speaking adults (18 years +) were interviewed. 3 types of services Emergency (day centres, emergency shelters, hot meal distribution) Long term rehabilitation centres Hostels (social hostels or hotels prepaid by organisations) Random three-degree sampling method Selection of services stratified by type and size Randomisation of days of interviews in each selected service Selection of the person among those present in the service on the day of interview Generalised Weight Share Method (Lavallée, 1995) for unbiased estimates with minimum variance
5 Methods (II) 910 services 169 services selected 125 services accepted to participate 859 interviews (Feb. April 2009) 840 questionnaires Participation rate : 71 %
6 Questionnaire Methods (III) Demographics, professional experience, financial resources, housing and homelessness Reported somatic health, treatment and care MINI plus 6.0 (Mini International Neuropsychiatric Interview) Access to mental health services Alcohol (AUDIT), drugs use. Diagnosis procedure Fieldwork : 30 pairs of interviewers lay interviewer + clinician psychologist Post-interview : 4 psychiatrists + clinician psychologists
7 Method Diagnosis procedure (test ) 45 homeless with a medical record : 24 with psychiatric diagnoses and 21 without psychiatric diagnoses 3 pairs of interviewers and clinician psychologists blinded to diagnosis 2 psychiatrists blinded to diagnosis Analysis Kappa coefficients to assess agreement (i) between diagnosis in medical records and diagnosis by psychiatrists, (ii) between two psychiatrists and (iii) between psychiatrist and MINI Results on agreement between diagnosis in medical records and diagnosis by psychiatrists : GOOD between psychiatrists : VERY GOOD between psychiatrist and MINI : MODERATE for psychotic disorders Conclusion Framework adequate for diagnosis procedure MINI + clinicians (psychologists and psychiatrists)
8 Results Estimated population = [IC 95%: ; ] Women (%) Mean age (years) Born in France (%) Living alone (%) Living with child (%) 34.9 (n = 7 399) (n = 8 469) 70.2 (n = ) 23.9 (n = 5 067) Mean duration homelessness = 7.0 years [IC 95%: 6.1 ; 8.0] Pathways into homelessness : 35% economic reasons 29% domestic conflict 28% lost/left accommodation 13% migration / moving house 4% health / addiction problems
9 Results Estimated population = [IC 95%: ; ] Women (%) Mean age (years) Born in France (%) Living alone (%) Living with child (%) SERVICES 34.9 (n = 7 399) (n = 8 469) 70.2 (n = ) 23.9 (n = 5 067) Emergency services (n = ) Rehabilitation (n = 7 747) Hostels (n = 2 842)
10 Prevalence of psychiatric disorders Psychotic disorder 13.2 Anxiety disorder** Mood disorder (severe) Mood disorder (mild/moderate) 15.8 Personality disorder** 21.1 Suicide risk (moderate/high) % TOTAL FEMALES MALES **p<.01
11 Prevalence of psychiatric disorders by type of services (I) % 26.5% 35.2% 24.8* * * Emergency Rehabilitation Hostels Psychotic disorders Anxiety disorders Severe mood disorders * p<.05
12 Prevalence of psychiatric disorders by type of services (II) * * * Emergency Rehabilitation Hostels Personality disorders Mood disorders mild and moderate Suicide risk moderate/high (MINI) * p<.05
13 Comorbid disorders % Suicide risk Mood Anxiety Personality Psychotic Mood * Anxiety * Personality 20.6* * Psychotic * 0* 0* 1 Of the individuals with mood disorders, 13.9% presented a moderate or high suicide risk
14 1 addiction : 28.5 % Dependence to alcohol : 21.0 % Regular cannabis use : 16.1 % Addiction Regular cocaine use : 2.4 % Regular use of other drugs (heroine, crack, methadone ) : <1% * p<0,05 Prevalence of addiction (alcohol, drugs) by type of services * * 18.9* Emergency Rehabilitation Hostels 1 addiction Alcohol Cannabis * 13.8* * * 2.6*
15 Comorbidity between psychiatric disorders and addiction Psychotic disorder Personality disorder * * Mood disorder * 18.2* Anxiety disorder 6.5* * Regular use cannabis Alcohol dependence 1 addiction * p<0,05
16 Access to mental health services Life time access to mental health services (health professional / hospitalisation / treatment) = 68.2 % Current access to mental health services = 18.2 % Psychotic disorder Mood disorder (severe) Mood disorder (mild/moderate) 13.2 Anxiety disorder
17 Lost contact with mental health services Lost contact with mental health services = 71.8% Psychotic disorder 41.8 Mood disorder (severe) 81.1 Mood disorder (mild/moderate) 78.8 Anxiety disorder
18 Limits Discussion (I) Homeless persons who never use services Psychotic disorders, 13.2% Homeless 12.7% [95%CI ] (Fazel, PLoS Med. 2008), Paris 1996: 16% (Kovess, Soc Psychiat Epidemiol 1999) Mood disorders, 20.3% Homeless 11.4% [95%CI ] (Fazel), Paris 1996: 23.7% Severe (4.5%) ~ 3.2% general population Fr (Health Barometer) Mild/moderate (15.8%) > 4.6% general population Fr (HB) Personality disorders, 21.1% Homeless 23.1% [95%CI ] (Fazel) Anxiety disorders, 12.3% Prevalence x 3 in females vs. males (21.0% vs. 7.5%) 9.8% general population Fr (ESEMeD)
19 Alcohol dependence, 21% Discussion (II) Prevalence x 3 in males vs. females (27.2% vs. 9.3%) Homeless 37.9% [95%CI ] (Fazel), Paris 1996: 23.7% % general population Fr (ESEMeD, HB) 17.6% no alcohol lifetime > 8.4% general population Fr ( HB) Drug regular use, 17.5% Homeless drug dependence 24.4% [95%CI ] (Fazel), Paris 1996 dependence/abuse : 10.3% Cannabis 16% > 7.5% general population Fr (HB) Other drugs ~ 1% homeless and general population Fr (HB) Low levels of comorbidity Mental health care, 68.2% lifetime, 71.8% lost contact Homeless Paris 1996 : 59.3% lifetime
![5% Homeless drug dependence 24.4% [95%CI 13.2 35.6] (Fazel), Paris 1996 dependence/abuse : 10.3% Cannabis 16% > 7.](/docs-images/47/20284649/images/page_19.jpg "5% general population Fr (HB) Other drugs ~ 1% homeless and general population Fr (HB) Low levels of comorbidity Mental health care, 68.")
20 Conclusion Prevalence of psychiatric disorders and addiction Higher than in general population Different according to services Psychotic and personality disorders in emergency services Anxiety disorders in hostels Implications for health services for the homeless Low access to health services High rates of loss to follow up Integrating treatment for psychiatric disorders and social/housing interventions should be considered
21 Recommendations Prevent social exclusion of individuals with severe mental illness Better detection of psychiatric disorders and mental distress in homeless individuals Reinforce the coordination between psychiatric care and other professionals providing outreach care to homeless people Inform and train the welfare/social professionals to refer to the mobile mental health services for the precarious Maintain contact with the health care system Collaboration between the psychiatric system and social professionals Advocacy against the double stigma of mental illness and homelessness
22 Acknowledgements All the homeless people who participated in this study Field interviewers and psychologists Settings where the study took place Voluntary drivers of the camper-vans where interviews were carried Samusocial services which took part in the pilot Samusocial services which ensured the management of the study Epiconcept for the construction of the database Prefecture of Paris to have facilitated the parking of the camper vans in Paris Members of the steering committee Donators
23 SAMENTA research group François Beck, INPES Christine Chan-Chee, InVS Pierre Chauvin, UMRS 707, Inserm UPMC Marc-Antoine Détrez, Observatoire du Samusocial de Paris Caroline Douay, Observatoire du Samusocial de Paris Jean-Marie Firdion, CMH ENS Ulm Marie-Jeanne Guedj, Hôpital Sainte-Anne Marie Jauffret-Roustide, InVS / Cesames Anne Laporte, Observatoire du Samusocial de Paris Stéphane Legleye, Ined Valérie Le Masson, Hôpital Sainte-Anne Erwan Le Méner, ISP- ENS cachan Yann Le Strat, InVS Alain Mercuel, Hôpital Sainte-Anne Sylvie Quesemand-Zucca, Hôpital Sainte-Anne
24 Thank you for your attention
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