Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

Abstract

Background:

Homelessness creates a significant social and economic burden in the society. Homelessness and mental illness are two interconnected social issues that poses challenges to individuals and communities across the globe. This systematic review aims to synthesize the existing literature on interventions for the homeless persons with mental illness.

Objectives:

To systematically review the existing literature on psychosocial interventions for homeless persons with mental illness.

Search methods:

Five databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar were searched using homelessness, psychosocial interventions, mental ill, residential mental health facility, and case management for experimental studies published from January 2000 to December 2022.

Study selection:

Abstract review was conducted for the screened studies, and full-text review was done for studies which met inclusion exclusion criteria.

Data extraction and analysis:

Among the 6,387 studies screened 20 studies were selected which fulfilled inclusion criteria. The full text review yielded data of 12,174 homeless persons with mental illness who undergone intervention.

Results:

The major psychosocial interventions found including critical time intervention, case management, housing support intervention, assertive community treatment, and life skills training. These interventions were helpful in sustaining housing stability, preventing relapse, reducing hospitalizations, and improving quality of life of the homeless persons with mental illness.

Conclusion:

Targeted and integrated interventions addressing homelessness and mental illness are required to tackle the social problems of homelessness and mental illness. Further research is required to explore the most effective strategies that address homelessness and mental illness.

Keywords

Homelessness mental illness psychosocial interventions systematic review

Introduction

Homelessness is a condition that has significant social and economic impacts on society. The prevalence of mental health issues is higher among the homeless population than the general population (Fazel et al., 2014, 2008; Lebrun-Harris et al., 2013; Schanzer et al., 2007; Tripathi et al., 2013). The common mental health conditions among the homeless population include schizophrenia, mood disorders, and substance use disorders (Fazel et al., 2008; Montgomery et al., 2013; Onapa et al., 2021; Timms, 2021; Tripathi et al., 2013). The literature shows that the social and environmental factors contributing to homelessness also aggravate mental health conditions (Cross et al., 2010; Moyo et al., 2015; Sullivan et al., 2000). Social issues like poverty, unemployment, and unstable housing largely contribute to homelessness and create a massive mental health burden on society (Mago et al., 2013; Shelton et al., 2009; Sullivan et al., 2000). Homelessness and mental illness have a two-way relationship, wherein homelessness can cause or exacerbate mental illness, and mental illness can lead to homelessness (Moorkath et al., 2018; Padgett, 2020; Tarr, 2018). The population’s mental health is at risk due to various factors like familial rejection, lack of basic needs including food and clothing, and evictions (Alegría et al., 2018; Shelton et al., 2009; Van Laere et al., 2009). The mental health problems of the homeless population are mostly neglected due to the absence of policies and programs, and the organizations involved in helping this population are primarily focused on are primarily involved in providing them shelter and basic needs (Padgett, 2020; Tripathi et al., 2013; Ulhassan et al., 2019). The availability and accessibility of mental health services are low in most countries and most of the time the organizations who care for the homeless cannot afford the treatment cost of the mentally ill population (Canavan et al., 2012; Rosenheck, 2000).

Psychosocial interventions for the homeless mentally ill include social interventions like providing the homeless persons with housing and basic needs, crisis intervention for the homeless mentally ill, provision of employment and income, providing healthcare facilities, and providing social support along with protection from discrimination and stigma (Pottie et al., 2020; Rogers, 2018). The broad spectrum of psychosocial interventions for homeless persons with mental illness include behavioral interventions to improve functioning, social interventions to improve social inclusion, psychological and pharmacological interventions to improve symptoms, and better reintegration into the community (Rogers, 2018; Timms, 2021). Systematic reviews comprehensively addressing psychosocial interventions for homeless persons with mental illness are limited. However, studies focusing on the interventions like housing support, critical time intervention, case management, peer support, and social skill training are available (Baumgartner & Herman, 2012; Corrigan et al., 2017; Helfrich & Fogg, 2007; Herman et al., 2011; Hwang et al., 2012; Jones et al., 2003; Lachaud et al., 2021; Reid et al., 2021; Stergiopoulos et al., 2018; Tinland et al., 2020; Whisler et al., 2021). In this context the current study aimed to review experimental studies that used psychological and social interventions for homeless persons with mental illness alone or in combination with pharmacological treatment after discharge from a hospital or institution.

Methods, measures, and procedures

The current review has been reported based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA; Moher, 2009) guidelines. The first author searched for articles in five different databases based on the search terms framed by all the authors. The search was conducted in standard databases including PubMed, ProQuest, Cochrane Library, OVID, and Google Scholar. An advanced search was conducted among all five databases by using the search terms for the articles published between January 2000 and December 2022. The search terms were related to psychosocial interventions for the homeless persons with mental illness. It included homelessness, psychosocial interventions, mentally ill, residential mental health facilities, and case management with a combination of AND and OR. The primary outcome measures considered were housing sustainability and change in symptoms. The secondary outcomes considered were reduction in relapse of homelessness and social inclusion of the homeless persons with mental illness. The current review included only the studies published in English language.

Study selection

We included all experimental studies including randomized controlled trials and quasi-experimental studies published between January 2000 and December 2022. The study designs, methods, and data collection tools have been explained in Supplemental Table S3.

Study settings and population

All the included studies were required to have homeless patients with mental illness diagnosed using DSM – 5 (American Psychiatric Association, 2013) or ICD 10 (World Health Organization, 1993) criteria including Schizophrenia spectrum disorders, mood disorders, neurotic, stress-related disorders, and mental and behavioral disorders because of psychoactive substances. The study setting could be rehabilitation institutions, community mental health facilities, psychiatric hospitals, or homeless shelters. Studies that include homeless persons with mental illness who have been receiving pharmacological treatment and psychosocial care in either under psychiatric hospitals, community mental health facilities, or homeless shelters were considered.

Exclusion criteria

The review excluded qualitative literature such as reviews, case reports, and other qualitative studies as well as studies with sample size less than 30. Further, studies which have not reported specific psychiatric diagnoses for subjects or have reported interventions for medical conditions alone have been excluded.

Summary of included studies

Studies that describe the psychological or social interventions for homeless persons with mental illness diagnosed with Schizophrenia spectrum disorders, mood disorders, neurotic, stress-related disorders, and mental and behavioral disorders because of psychoactive substance use in psychiatric hospitals, homeless shelters, or community mental health facilities were included in the review. Interventions including case management, critical time intervention, housing first, peer support, and life skills training have been considered for the current review. The contents of the interventions have been explained in Supplemental Table S3.

Data extraction, risk of bias, and analysis

Data were extracted by using a data extraction form developed for the current study. The data sheet included Subject of study, Study design and duration, Intervention group, Control group, Outcome measure, and Results. The screening of the titles and abstracts were done by first author and selected articles that met the inclusion criteria. The first author carried out screening and data extraction independently and the second author independently reviewed the selected articles based on the inclusion criteria. The authors discussed study selection and arrived at a consensus. The sources of biases were analyzed to ensure the quality of the selected studies. The first and second authors independently analyzed the risk of bias according to the Risk of Bias 2 for intervention studies (RoB2; Sterne et al., 2019; Supplemental Table S2). Then the studies were categorized independently by authors including studies with low risk, with high risk, and studies with unclear risk of bias. Selection bias, reporting bias, performance bias, detection bias, and attrition bias were considered. The current study employed the PICOS framework (population/problem, intervention, comparison, outcomes, and study design).

Results

Search process

The advanced database search retrieved 6,387 articles published during the selected period. Figure 1 shows the PRISMA flow chart of the study selection. After removing duplicates, 6,353 were included in the screening. Zotero software was used for the retrieval of data and citations. The number of studies was further reduced to 20 after removing the articles for reasons listed in the figure. The 20 articles selected for the study are mentioned in the data extraction table (Supplemental Table S1).

Figure 1.

PRISMA 2020 flow diagram for new systematic reviews.

Study characteristics

A total of 12,174 homeless individuals with a psychiatric diagnosis were included for the study. The sample size of the studies included ranged from 32 to 7,229. Seven studies were conducted in Canada (Aubry et al., 2016; Currie et al., 2014; Hwang et al., 2012; Lachaud et al., 2021; Reid et al., 2021; Stergiopoulos et al., 2018; Whisler et al., 2021), twelve studies were conducted in the United States (Baumgartner & Herman, 2012; Cheng & Kelly, 2008; Corrigan et al., 2017; Essock et al., 2006; Helfrich & Fogg, 2007; Herman et al., 2011; Jones et al., 2003; Rosenheck et al., 2003; Seidman et al., 2003; Shern et al., 2000; Tsemberis et al., 2004; Weissman et al., 2005), and one in France (Tinland et al., 2020). All studies were conducted in high-income countries and no studies from middle- and low-income countries were retrieved.

Types of interventions

The intervention group were given different interventions, including Critical Time Intervention, Life Skills Training, Housing Support Intervention, Intensive Case Management, Assertive Community Treatment, Peer support interventions, Psychiatric rehabilitation, and a combination of these interventions and pharmacological interventions. The duration of interventions lasted from 3 months to a follow-up period of up to 5.5 years. In most studies, the control group underwent usual care or treatment as usual (TAU). Most of the studies focused on primary outcomes, and only three analyzed the secondary outcome measure and cost-benefit. Most of the studies mentioned follow-up rates among the homeless persons with mental illness.

Among the studies retrieved for review five studies provided Critical Time Intervention (Baumgartner & Herman, 2012; Herman et al., 2011; Jones et al., 2003; Reid et al., 2021; Stergiopoulos et al., 2018), ten studies provided housing support intervention (Aubry et al., 2016; Cheng & Kelly, 2008; Currie et al., 2014; Hwang et al., 2012; Lachaud et al., 2021; Rosenheck et al., 2003; Seidman et al., 2003; Tinland et al., 2020; Tsemberis et al., 2004; Whisler et al., 2021), one study provided life skills training (Helfrich & Fogg, 2007), two studies provided peer support interventions (Corrigan et al., 2017; Weissman et al., 2005), four studies provided case management with housing support (Aubry et al., 2016; Cheng & Kelly, 2008; Currie et al., 2014; Rosenheck et al., 2003), one study provided integrated psychiatric rehabilitation (Shern et al., 2000), one study provided Assertive community training alone (Essock et al., 2006), and one study provided Assertive Community Treatment with housing support (Whisler et al., 2021).

Critical time intervention (CTI)

Critical time intervention for homeless individuals is an evidence-based practice that helps to navigate effectively during critical periods such as transition from homelessness to housing or while leaving a shelter care program. It provides intensive and time limited services such as housing support, healthcare services, and employment support with the aim of housing stability for homeless people and preventing from returning to homelessness (Herman et al., 2011). Critical Time Intervention (CTI) has been consistently associated with increased housing stability and social integration among mentally ill homeless individuals, reducing the likelihood of returning to homelessness (Baumgartner & Herman, 2012; Herman et al., 2011; Jones et al., 2003; Stergiopoulos et al., 2018). CTI has decreased inpatient hospital stays, emergency department visits, and psychiatrist visits (Jones et al., 2003; Reid et al., 2021; Stergiopoulos et al., 2018). Intervention participants have shown improved quality of life and reduced episodes of homelessness. (Herman et al., 2011; Stergiopoulos et al., 2018). After receiving the Critical Time Intervention, a reduction in mental health issues, substance use problems, and an improvement in overall psychological well-being were reported by intervention participants (Baumgartner & Herman, 2012; Reid et al., 2021; Stergiopoulos et al., 2018). A lesser cost for acute and outpatient care of homeless persons with mental illness was observed compared to the standard care group after the CTI intervention (Jones et al., 2003). The critical time intervention suggests potential long-term benefits since the positive effects observed persist beyond the intervention period.

Case management (CM)

The case management interventions proved to improve housing stability among homeless persons with mental illness (Aubry et al., 2016; Cheng & Kelly, 2008; Currie et al., 2014). Findings from two studies reported reductions in mood disorders, PTSD, and psychotic disorders as a result of case management interventions (Currie et al., 2014; Hwang et al., 2012). The CM interventions also facilitated reducing substance use, improved community functioning and quality of life, and improved overall health and well-being (Aubry et al., 2016; Tinland et al., 2020). Women with access to case management interventions showed improved healthcare utilization, social support, and victimization (Cheng & Kelly, 2008). Case management showed the potential to reduce the cost of treatment in the intervention group.

Housing support

The interventions that provide stable housing support homeless individuals with mental illness for retention in primary care and contribute to overall well-being. The selected studies adopted the housing first model of intervention for providing housing support intervention. The housing first approach is an evidence-based intervention originated in the New York city in the late 1980s. The approach offers immediate access to stable housing for the homeless people, and a range of support services are being offered to them once they are placed into the housing such as physical and mental health care, services to manage substance use problems, employment services, and community reintegration (Whisler et al., 2021). The housing support programs consistently increased the stability of housing among homeless individuals with mental illness (Aubry et al., 2016; Lachaud et al., 2021; Tinland et al., 2020; Tsemberis et al., 2004). The risk of returning to homelessness reduces, and homeless mentally ill individuals focus more on their mental health and well-being with safe and stable housing (Aubry et al., 2016; Lachaud et al., 2021; Rosenheck et al., 2003; Shern et al., 2000). Most of the studies that provided housing support interventions noted improvement in mental health symptoms among homeless persons with mental illness (Cheng & Kelly, 2008; Currie et al., 2014; Tinland et al., 2020). Stable housing contributed to sustainability in primary care and mental health treatment that created a positive impact on mental health recovery (Aubry et al., 2016; Lachaud et al., 2021; Tinland et al., 2020; Whisler et al., 2021). Housing support interventions were associated with decreased substance use among homeless mentally ill individuals, contributing to improved overall health outcomes (Aubry et al., 2016; Cheng & Kelly, 2008; Essock et al., 2006; Tinland et al., 2020; Tsemberis et al., 2004). Further, housing support interventions were linked to the improved overall quality of life for homeless mentally ill individuals, enhancing social integration and community involvement (Aubry et al., 2016; Essock et al., 2006; Helfrich & Fogg, 2007).

Intervention using Assertive Community Treatment showed reduction in substance use, number of institutionalizations, and life satisfaction of homeless mentally ill (Helfrich & Fogg, 2007). A study which used the collaborative approach of Assertive Community Treatment with Housing First showed improvements in housing sustainability, community functioning, improved quality of life, and reduced emergency department visits (Aubry et al., 2016). Another RCT which provided Case management with Housing First found improvement in mental health symptoms in the long run among the homeless mentally ill population and an improvement in health service use (Currie et al., 2014). Another RCT found reduction in substance use problems improved quality of life and a reduction in the comparative cost of treatment by using a combination of Housing First with Case management approach (Baumgartner & Herman, 2012). The provision of community housing improved housing stability, reducing relapse of homelessness, neuropsychological functioning, and reducing alcohol use (Fazel et al., 2008; Seidman et al., 2003). Another study that provided life skills training found that self-care management, functioning, and community participation improved with life skills training (Helfrich & Fogg, 2007). The peer support programs have been found to help maintain employment stability, housing stability, physical and mental health, and improving the quality of life of the mentally ill homeless population (Corrigan et al., 2017; Weissman et al., 2005). The charges for hospitalization shown reduction in two studies (Jones et al., 2003; Tinland et al., 2020).

The studies included in the review found significant improvement in mental health symptoms, housing stability, hospitalization rates, and quality of life of homeless mentally ill population in the follow-up period. Critical Time Intervention, Case Management, Housing support, life skills training, peer-enhanced housing support, and assertive community treatment in combination with housing support have shown improvements in primary and secondary outcome measures.

Discussion

The review explored the impact of various psychosocial interventions for homeless persons with mental illness. The results suggest that housing support, case management, critical time intervention, and assertive community treatment and combinations of these approaches are effective measures to address the issues of the homeless mentally ill population.

Most of the studies focused on housing support and critical time intervention because homelessness was considered the prime focus over mental illness. Fifteen out of 20 studies focused on housing support and critical time intervention, and 3 studies provided case management intervention alone or in combination with assertive community treatment or housing support intervention. The most common primary outcome was housing stability followed by mental health symptoms and substance use problems (Essock et al., 2006; Herman et al., 2000; Hwang et al., 2012; Lachaud et al., 2021; Rosenheck et al., 2003; Shern et al., 2000; Tinland et al., 2020; Whisler et al., 2021). The prevalence of homelessness is high among the mentally ill population and there is a direct relationship between homelessness and mental illness which demands addressing the issue of homelessness (Greenberg & Rosenheck, 2009; Johnson & Fendrich, 2007; Martens, 2001; McQuistion & Gillig, 2006; Moorkath et al., 2018). The review found a paucity of research on behavioral interventions for homeless persons with mental illness (Dauriac-Le Masson et al., 2020; Maguire, 2005; Wang et al, 2019).

Most of the studies were part of large public-funded projects, suggesting that replicating the interventions in small settings may be challenging in terms of cost. All the studies were conducted in high-income countries, which may reflect the lack of resources for public housing and interventions for homelessness in low and middle-income countries. The studies from high income countries shows the effectiveness of community based psychosocial interventions for mentally ill population, but in low and middle-income countries the major treatment strategy adopted is pharmacological management (Bird et al., 2022). The Critical Time Intervention, Case Management, Housing support programs are proven to be helpful in reducing mental health issues, substance use problems, stable housing, and overall quality of life of homeless individuals with mental illness in high income countries and it can benefit the homeless population in low- and middle-income countries also. These interventions can help in community-based management of overly populated countries like India which has a larger number of homeless persons. Only two studies evaluated cost reductions in hospitalization of the homeless mentally ill after intervention (Jones et al., 2003; Tinland et al., 2020). An increase in public spending can positively impact the usage of collateral sources like psychiatric hospitals, homeless shelters, and private hospitals (Culhane et al., 2002; Onapa et al., 2021; Richardson et al., 2012; Rogers, 2018; Sleet & Francescutti, 2021). There is a need for public investment in homelessness and mental health in terms of addressing these mutually contributing factors.

We found only one study focused on the impact of the intervention on homeless mentally ill women who belong to a particularly vulnerable population (Cheng & Kelly, 2008). The homeless mentally ill women have higher rates of victimization, drug use, and low social support (Chambers et al., 2013). The experiences of homeless mentally ill women are unique and require attention from treatment and policy levels (Kalyanasundaram et al., 2022; Moorkath et al., 2021; Moorkath et al., 2018). This review highlights the requirement for tailor-made interventions for homeless mentally ill women to address the specific issues of this population.

Life skills training found to be effective in improving the functionality, safe community participation, and self-care management among the mentally ill homeless adults (Helfrich & Fogg, 2007). The transition out of homelessness and quality of life of the mentally ill homeless population can be improved with life skill training (Aviles & Helfrich., 2004; Crane et al., 2013). The impact of life skill training on the other outcome measures including housing stability, mental health symptoms, and quality of life can also be considered for research.

An improvement in housing stability in the intervention group was noted in most of the studies which considered it as an outcome measure (Aubry et al., 2016; Lachaud et al., 2021; Tinland et al., 2020). Retention in health care which was found to be similar in intervention and control groups in one study (Weissman et al., 2005) may be because of lesser sample size, inadequate follow-up period, and the type of intervention provided. Most of the studies focused on housing stability and mental health improvement, but other outcome measures including cost savings, community integration, functionality, and feasibility of the interventions were not mentioned in most of the studies. Since most of the studies are part of large public funded projects from high-income countries, evidence on cost and feasibility are essential, especially to replicate such programs in low- and middle-income countries.

There are several challenges that persist even though the interventions offer promise. The limited resources and funding hinder the implementation of comprehensive interventions or programs targeting people experiencing homelessness and mental illness. Increasing investment in affordable housing, mental health services, and outreach programs is needed to effectively address homelessness and mental illness. The stigma becomes a significant barrier for homeless individuals to seek help and allocate resources for homeless individuals. Furthermore, the effectiveness of these interventions can vary based on local contexts and the availability of supportive services. To optimize the outcomes, interventions should be tailor made which can address the unique needs of the communities. Hence, targeted and time-limited interventions must be developed to match the local requirements.

Limitations

The application of meta-analytic methods was infeasible due to the substantial differences in study designs, subjects under study, interventions, and outcome measures. The outcome measures under the study primarily comprised housing stability and mental health symptoms, and other outcome measures have not given adequate significance. The evidence on the cost and feasibility of the interventions were not explored or mentioned in most of the studies, hence, the cost-effectiveness of replicating the interventions is not apparent in the review.

Conclusion

A range of psychosocial interventions have been shown to be effective in helping homeless people with serious mental health problems. These include Critical Time Intervention, supportive housing, case management, and integrated treatment. These interventions address the complex needs of homeless mentally ill individuals like stable housing, mental health symptoms and can help to improve their quality of life. Further research might focus on the barriers that prevent these established interventions from being more generally introduced.

Supplemental Material

sj-docx-1-isp-10.1177_00207640231217173 – Supplemental material for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

Supplemental material, sj-docx-1-isp-10.1177_00207640231217173 for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review by Roniyamol Roy, K Janaki Raman, E Aravind Raj and Shivarama Varambally in International Journal of Social Psychiatry

Supplemental Material

sj-docx-2-isp-10.1177_00207640231217173 – Supplemental material for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

Supplemental material, sj-docx-2-isp-10.1177_00207640231217173 for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review by Roniyamol Roy, K Janaki Raman, E Aravind Raj and Shivarama Varambally in International Journal of Social Psychiatry

Supplemental Material

sj-docx-3-isp-10.1177_00207640231217173 – Supplemental material for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

Supplemental material, sj-docx-3-isp-10.1177_00207640231217173 for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review by Roniyamol Roy, K Janaki Raman, E Aravind Raj and Shivarama Varambally in International Journal of Social Psychiatry

Supplemental Material

sj-docx-4-isp-10.1177_00207640231217173 – Supplemental material for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review

Supplemental material, sj-docx-4-isp-10.1177_00207640231217173 for Outcomes of psychosocial interventions for homeless individuals with mental illness: A systematic review by Roniyamol Roy, K Janaki Raman, E Aravind Raj and Shivarama Varambally in International Journal of Social Psychiatry

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Prior publication

Nil.

ORCID iDs

Roniyamol Roy

E Aravind Raj

Supplemental material

Supplemental material for this article is available online.

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