While no one is certain how many homeless veterans suffer from schizophrenia, experts agree that their numbers are significant—and because of the nature of their illness and living conditions, they often present with a variety of health care challenges.
VA estimates that 107,000 veterans are homeless on any given night and that, over the course of a year, approximately twice that many experience homelessness, according to the National Coalition for Homeless Veterans.
How many of them have schizophrenia? That’s even more difficult to pin down, although it is believed that 76% of the homeless veterans experience alcohol, drug or mental-health problems, according to a national Housing and Urban Development report, “The Forgotten Americans-Homelessness: Programs and the People They Serve” – the National Survey of Homeless Assistance Providers and Clients (NSHAPC, 1999.) In the overall homeless population (estimated at 600,000), people with untreated psychiatric illnesses comprise one-third, or 200,000 people, according to the Coalition for the Homeless Mentally Ill.
“There are a substantial number of studies that have estimated that somewhere between 20% and one-third of homeless individuals have some kind of serious mental disorder, and schizophrenia is probably the most common,” noted Stephen R. Marder, MD, Director of the VISN 22 Mental Illness Research Education and Clinical Center in the VA Greater Los Angeles Healthcare System, and professor and director of the Section on Psychosis at the Semel Institute at UCLA. Marder also served as the medical consultant for the acclaimed movie “The Soloist,” which told the story of a homeless former classical music prodigy who was playing his cello on the streets of Los Angeles.
“There are a number of challenges for individuals with schizophrenia,” said Marder, who added that the term “schizophrenic” should be avoided, as patients and others in the field consider it pejorative. “They are often disabled; some studies suggest that only about 19% of them are employed, and many of those are not employed at a level which would allow them to support adequate housing,” he observes.
Another challenge, according to a recent study in the journal Health Communications, is that these individuals are often dissatisfied with the quality of communication they have with their providers, which, in turn, was often linked to a lack of trust.1
The researchers studied two groups of individuals: patients who had been diagnosed with a serious mental illness, or SMI (i.e., schizophrenia or bipolar disorder) or substance abuse disorder (SUD), and a random sample of non-SMI patients. They were asked to rate provider communications as either “very good,” “good” or “poor.”
The researchers found that poor trust for the provider decreased the likelihood of the patients rating that provider as either “very good” or “good,” and that this decrease was significantly greater for VA patients who either had an SMI or SUD diagnosis.
Lack of Insight Makes Situation Worse
One of the manifestations of schizophrenia, Marder added, can be lack of insight. “They don’t perceive themselves as having an illness, and therefore don’t seek treatment,” he observed. “If you look at homeless people on the street, a number of them respond to hallucinations and are isolative; one can tell these people have some kind of disturbance.”
Each state has its own legal system which tries to address those individuals, “But if they are not captured by that system, they can certainly remain homeless – and very ill,” noted Marder.
What’s more, he continues, oftentimes the medications and treatments that are used to treat schizophrenia are not completely effective. “So patients are either left with symptoms like hallucinations or other side effects,” Marder said. “They could be feeling sick or restless; there could be substantial weight gain. Some medications are sedating, some affect sexual performance, and all these can lead to some patients refusing to take these medications.”
Finding the best medications for an individual can be challenging, but the VA offers programs to help patients learn to live with some of the residual symptoms, he said, including cognitive behavior therapy for psychosis. “Individuals with untreated symptoms can still be very good candidates for rehabilitation,” he asserted.
Housing Key to Treatment
While housing may not be perceived as a medical issue, mental health issues can, nevertheless, be exacerbated by the lack of adequate housing, noted Marder. “There are systems that provide housing—some veterans will not get VA benefits but will get SSI, for example—but they are rather complicated, and those with impaired cognition in particular find them hard to navigate.” Accordingly, he says, “VA is trying to come up with some very innovative approaches to addressing the mental health issues in an individual who is either homeless or does not have adequate housing.”
One approach involves a program called “Housing First,” through which VA offers housing vouchers to homeless veterans. (In 2009, the VA’s specialized homeless programs served more than 92,000 veterans.) In a statement announcing the initiation of the L.A. program in early 2011, it was noted that this was a departure from general practice; VA formerly had required the homeless veterans to be sober and in treatment before being given a housing voucher. In this program, they are housed first and then offered services.
Programs such as Housing First, Marder said, help address one of the major challenges attendant to homeless veterans with schizophrenia: the difficulty of ensuring that they maintain their medication schedule.
“There are a number of other ways to do this,” he explained. “For example, some patients can receive long-acting medications given as an injection, which last for two to four weeks. For some who are unreliable pill takers, this approach helps them out. But homelessness had to be addressed upfront as a problem in order to provide them with other kinds of treatment, and I do think that VA has a very good understanding of that.”
Intensive case management
Marder noted that VA also has specialized clinical programs such as intensive case management for individuals who are high utilizers of VA services and require wrap-around services; that way, a single program can help them address all their needs, from housing to benefits to case management.
“Some veterans have co-morbidities, with problems like substance abuse,” he observed. “In order to provide adequate treatment you need to address both the psychiatric illness and substance abuse in a coordinated manner in some sort of specialized program.”
One example is Homeless Veteran Coordinators who help homeless veterans and their families, and other veterans who may be at risk of becoming homeless, with access to the most appropriate programs. They also offer guidance for VAMCs, federal, state and local partners, community agencies, service providers and others in the community.
Another program available, according to Marder, is VA Mental Health Intensive Case Management. Veterans are treated by teams of professionals, which include psychiatrists, psychologists, case managers and support staff. In addition to close ongoing contact with the case manager and mental health professionals (for behavioral assessment, therapy and consultation, and behavior change), veterans can attend group sessions covering issues such as spirituality and medication management, and, in addition, receive skills training. Participants also get together for leisure activities with the staff, which helps them learn social skills, and they are given assistance in finding housing.
Assistance also is available, Marder said, for a particular group of homeless veterans which unfortunately is growing. “Over the past decade, more and more individuals with serious mental illness – particularly veterans – end up in the justice system, being taken off the streets for some kind of violation,” added Marder. “VA has an adjustment program to help veterans who’ve been incarcerated return to the community with some type of coordinated care.”
VA, in fact, has two programs addressing legal concerns of veterans. The Healthcare for Reentry program is designed to address the community re-entry needs of incarcerated veterans—and more specifically, to prevent homelessness, reduce the impact of medical, psychiatric and substance-abuse problems upon community readjustment, and decrease the likelihood of reincarceration, according to its website description. Veteran Justice Outreach seeks to avoid the unnecessary criminalization of mental illness and extended incarceration among veterans by intervening with VHA mental health and substance abuse services when clinically indicated.
1. Bohnert AS, Zivin K, Welsh DE, Kilbourne AM. Ratings of Patient-Provider Communication Among Veterans: Serious Mental Illnesses, Substance Use Disorders, and the Moderating Role of Trust. Health Commun, 2011 Mar 1:1-8.