Year : 2020 | Volume
: 2 | Issue : 3 | Page : 196--200
Homelessness and Mental Illness: Views from Early Career Psychiatrists from Asian Countries
Agaah Ashrafi1, Dulangi Dahanayake2, Abhishek Ghosh3, Mi Jang4, Bikram Kafle5, Suvarna Jyothi Kantipudi6, Vivian Kapil7, Rawan Masri8, Rossalina Lili9, Swapnajeet Sahoo3, Siddharth Sarkar10, Norman Sartorius11,
1 Department of Psychiatry, Tehran, University of Medical Sciences, Tehran, Iran
2 Faculty of Medicine, University of Colombo, Sri Lanka
3 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Mental Health Services, National Center for Mental Health, Seoul, Korea
5 Department of Psychiatry, Devdaha Medical College, Kathmandu University, Kathmandu, Rupandehi, Nepal
6 Department of Psychiatry, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
7 Department of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, United Kingdom
8 Division of Psychiatry, School of Medicine, Yarmouk University, Irbid, Jordan
9 Community Psychiatry Section, Indonesian Psychiatrist Association, Indonesia
10 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
11 Association for the Improvement of Mental Health Programmes (AMH), Geneva, Switzerland
Dr. Siddharth Sarkar
Department of Psychiatry and NDDTC, AIIMS, New Delhi - 110 029
Homelessness is an important social determinant of health. The information has been sparse on the relationship between homelessness and mental illnesses in Asian countries. In this perspective paper, we present the synthesis of viewpoints of early career psychiatrists from several Asian countries on the relationship of homelessness and mental illnesses. An online questionnaire was used to gather responses. The definition of homelessness was kept broad and included both temporary and lasting homelessness. The responses were synthesized into paragraphs to describe the perspective for the country. Although difficulties were experienced in the estimation of homelessness, the numbers of homeless individuals varied from practically negligible in Jordan to about 1.77 million in India. Mental health issues were present in the homeless population and included affective disorders, psychotic disorders, and substance use disorders. The psychiatrists generally had a considerate viewpoint toward treating the mentally ill homeless people. There is a need for more literature on the interface of homelessness and mental illness from Asian countries, especially where the homeless populations are substantial.
|How to cite this article:|
Ashrafi A, Dahanayake D, Ghosh A, Jang M, Kafle B, Kantipudi SJ, Kapil V, Masri R, Lili R, Sahoo S, Sarkar S, Sartorius N. Homelessness and Mental Illness: Views from Early Career Psychiatrists from Asian Countries.World Soc Psychiatry 2020;2:196-200
|How to cite this URL:|
Ashrafi A, Dahanayake D, Ghosh A, Jang M, Kafle B, Kantipudi SJ, Kapil V, Masri R, Lili R, Sahoo S, Sarkar S, Sartorius N. Homelessness and Mental Illness: Views from Early Career Psychiatrists from Asian Countries. World Soc Psychiatry [serial online] 2020 [cited 2021 Apr 18 ];2:196-200
Available from: https://www.worldsocpsychiatry.org/text.asp?2020/2/3/196/304808
Homelessness, as a social determinant of health, has received attention from public health professionals as well as clinicians., Homelessness is associated with the poor physical and mental health of the individual. The prevalence of psychiatric disorders in the homeless population may be higher than the general population., It has been seen that addictive disorders and serious mental illnesses such as schizophrenia and bipolar disorders might be issues that need attention in the homeless population., However, access barriers like insurance and prioritization of treatment make care provision patchy for patients who are homeless, whose main concern may relate to finding a home and paying for basic necessities.
Data about psychiatric illnesses among the homeless population has largely emanated from Western Europe and North American countries. In the data from the non-Asian Organisation for Economic Co-operation and Development countries, the rates of homelessness ranged from 0.03% (Croatia) to 0.94% (New Zealand). Systematic reviews showed that the most common psychiatric co-morbidities were alcohol and drug dependence, followed by psychosis and major depressive episodes. There was evidence to suggest an increase in the prevalence of alcohol dependence in recent decades., The wide variation in the prevalence of psychiatric illness in the homeless is probably attributable to the definition of homelessness and the sampling techniques. Information about rates of psychiatric illnesses in the homeless population has been sparse from the low- and middle-income countries. Low- and middle-income countries house a substantial part of the world population, and more than half of the world population resides in Asia. Thus, information about homeless individuals, their mental health needs, and care provisions are of consequence from the social psychiatry perspective.
In the absence of reliable systematic information on homelessness and mental health needs from Asia, impressions from psychiatrists would be another way to find out whether homelessness was a concern in the clinical setting. The Early Career Fellowship of the World Congress of Social Psychiatry, 2019, held in Bucharest brought together psychiatrists from different countries with an intent to foster a spirit of working together. As a follow-up activity, it was planned to address the issue of homelessness and mental illnesses in various countries, where the participants could provide both published literature and their clinical impressions in their context. The countries were chosen based on the willingness of the early career psychiatrists to participate, and eleven psychiatrists contributed (five from India and one each from Indonesia, Iran, Jordan, South Korea, and Sri Lanka). Thus, this synthesis of perspectives gathered responses on whether homelessness existed in their country (with prevalence estimates if available), key publications on this topic if available, how was homelessness defined and where did such individuals stay, mental health (including addiction) care needs, and accessibility of services. We have considered a broad definition of homelessness-from persons living directly on the streets only to other definitions that included those living in shelters for the homeless. Both temporary (e.g., homelessness due to disaster) and lasting homelessness (e.g., homelessness, not precipitated by an acute event) were included in the definition. The responses were gathered using a semi-structured online questionnaire [Box 1]. The respondents were requested to provide country-specific information, using any published sources that they considered reliable. The responses could be considered as impressions of early career psychiatrists working with patients with psychiatric disorders.[INLINE:1]
Country Specific Responses
Indonesia has been prone to natural disasters such as tsunami, volcanic eruptions, and recently, there had been 853,000 individuals displaced as a consequence of that. The country is already home to approximately 25 million people who do not have access to proper housing and continue to live along railway tracks, riverbanks, and streets., Homeless people with mental illness do have difficulties in finding their way back home and are also disowned by the families, which eventually lands them in government or private shelters. Despite the presence of rehabilitation centers for homeless people with mental illness, factors such as limited resources in the form of an inadequate number of staff, increased workload, and inadequate facilities coupled with lack of knowledge and training about mental illness are the prime contributing factors for inadequate care to homeless people with mental illness. Although homeless people are more in need of access to medications, mental health care services, and rehabilitation services, there is a general feeling of discomfort in treating homeless people with mental illness according to the author's perspective, the feeling being more negative toward homeless people with substance use disorders.
India has close to 1.77 million homeless people, and homeless persons with mental illness can be up to 1% of the mentally ill as per the National Mental Health Survey conducted by NIMHANS. There have been researches about homeless in India which have discussed the role of various interconnected factors contributing to homelessness in the mentally ill, homelessness in women, in particular, provisions of the Mental Health Care Act 2017, and pathways to care for them.,,,, The homeless people tend to live on the streets, in the bus and railway stations, temples, open spaces without basic amenities like toilets, and get exposed to harsh weather conditions. Homeless people do tend to suffer from a range of mental health issues ranging from psychotic disorders to affective disorders., Substance use disorders tend to be an area of concern in homeless people, and they would benefit from biopsychosocial interventions and rehabilitation services. Mental health-care services such as rescue from streets, providing self-care, and medication for mental illness are offered, but it is not common for these homeless people to have easier access to these services despite their needs. The general perception is that psychiatrists feel more comfortable in treating a homeless person with mental illness than one with a substance use disorder.
Though homelessness exists in Iran, formal, documented, and validated, data are not available. It has been estimated that up to 15,000–20,000 people in Tehran city may be homeless., The definition of homelessness has been a point of contention. The definition varies between different studies and it is one of the main reasons that the prevalence of homelessness is not clear yet. In Tehran city, during recent years, some places called “Garmkhaneh” have been provided by the government, which means sort of a warm house! These places are like large warehouses or domiciles, full of beds and heaters for these people to spend the night there, just preventing them from freezing in cold winter nights. Some of these places may also provide some food, but their quality and quantity might be modest. Many homeless individuals have mental health care needs, especially given the fact that many homeless individuals suffer from psychotic disorders.,,, They have needs related to treatment and rehabilitation, with a focus on concomitant issues like high-risk behaviors, HIV, and the use of drugs and alcohol. There are no specific services designated for these people. Social emergency service has been developed during past years, but this service is neither sufficient nor practical, and mostly ends up with preventing, reporting, and managing crime issues.
The concept of homelessness might be less relevant and applicable as Jordanian culture is collectivist, and cultural and religious components generate a network of organizations and government programs that adequately house the homeless. All the residents of the country have access to free psychiatric services at the National Health System Clinics and Hospitals. Despite this, psychiatrists in the region feel the need for assessment of psychotic disorders and substance misuse. Even though there may not be a rich experience of treating homeless people by psychiatrists in this region, the psychiatrists would be more comfortable in treating homeless persons with mental illness rather than individuals with comorbid substance use disorder.
Even though there are not many researches to estimate the exact prevalence of homelessness in Nepal, there are few studies that have looked on homeless children, especially in Kathmandu Valley. A minority of children were becoming homeless, owing to being orphaned and abandoned. Some orphaned children do visit their extended families, and being homeless may not necessarily mean being without families in this part of the world. The presence of a “step-parent” was associated with a less likelihood of visit to the family, while the presence of biological parents was associated with a greater likelihood of contacting the family again. The presence of 'step-parent' probably acted as a 'push' to leave home compared to “pull” factors like economic mobility for leaving home and living in the city streets. The caste system, which still persists in this region, also seems to play a role with regard to being homeless, wherein a majority of homeless belonged to higher caste for whom there are limited economic opportunities back home in societal fabric. One interesting difference from other cultures is the presence of gender differences in the homeless. This is a consequence of the cultural and social status of girls, as there are also restrictions on their freedom, and they are less likely to be sent away from the families to work. Prevalence estimates of emotional and behavioral problems among sheltered homeless children were 28.57%. Boys predominantly had ADHD and conduct disorder, where girls had depression and anxiety. These homeless children are sheltered by quite many nongovernmental organizations, and the mental health care needs are much more than other groups of children. Some of these shelters do have psychological services in the form of counselors who tend to visit them once a week. Psychiatrists feel comfortable in treating homeless persons with substance use disorder as they feel about treating homeless persons with mental illness.
In South Korea, there were about 11,340 persons nationwide who were homeless, as reported by a study done a few years ago. Among them, the majority were males. One of the significant causes of homeless was personal maladjustment, which includes divorce, bereavement, domestic violence, mental health disorders, alcohol use disorders, gambling followed by financial reasons including unemployment, bankruptcy, rent arrears, shortage of social service or support system. The presence of metabolic disorders followed by dental diseases and then mental disorders were common findings among homeless people. Their needs ranged from financial support, housing support, medical support, employment support to psychological support. In 2013, there was a manual about programs for welfare institutions for the homeless, which also covered mental health services. These homeless people stay at facilities, streets, and atypical housing. The majority of homeless people also suffered from depression. Among the homeless who consumed alcohol, a very significant proportion had problematic drinking patterns. Mental health services such as community mental health center, community alcohol management center, and support center for homeless people are available for homeless individuals. There is no difference in the comfort level of psychiatrists in treating homeless persons with substance use disorder and treating homeless persons with mental illness.
Despite the presence of homeless persons in Sri Lanka, there has not been much research to provide exact estimates for the same. Homeless people tend to stay in the streets and also in children's homes and elder charity homes run by the government and nongovernment organizations. Furthermore, there are people living in temporary rented rooms and atypical housing, especially in the densely populated urban areas such as Colombo and its suburbs. There is a proportion of chronic mentally ill who tend to default after discharge from inpatient care, and might end up being homeless. Despite the mental health care needs of the homeless, the community mental health services are scarce. Some chronically ill patients are not discharged from in-patient long-stay units due to a lack of permanent accommodation in the community. Natural disasters such as the 2004 tsunami, floods, and landslides have also led to the displacement of people from their homes, leading to homelessness. Psychiatrists in Sri Lanka are comfortable treating homeless persons with mental illnesses and substance use disorders. However, the follow-up of these patients is sometimes difficult due to the lack of a social support system, which makes it challenging to locate them in the community.
This synthesis of perspectives provides some insights into whether homelessness was a problem in the country, and whether some services are available to cater to the mental health needs of these homeless individuals. In addition, attention has been paid towards the social issues faced by individuals who were homeless. One of the inferences that could be drawn is that there is wide variability in the manner in which homelessness was seen as a construct. This determines the extent of the people who were considered homeless. This has been remarked in previous literature as well, and thus inferences in prevalence rates require caution. Nevertheless, almost negligible rates of homelessness in countries like Jordan suggest that social cohesion and sense of social responsibility may be important factors for the reduction/prevention for homelessness. On the other hand, resource constraints in developing Asian countries may prolong the expected transient homelessness in situations of natural calamities. Some of the factors such as poverty, substance use, mental health issues, and family problems seem to be common determinants for high-income and low-income countries.
Mental health (including substance use) concerns were raised as important considerations in homeless individuals in these representative Asian countries. Previous literature also has suggested a high burden of mental illnesses in the homeless population., Differences exist in the current and projected health-care spending between high-income and low-income countries. This would imply that differences would exist in the resources available for helping the homeless mentally ill, highlighting the potential unmet gaps in low-income countries. Thus, solutions that are less resource-intensive and have favorable cost-effective parameters are likely to have a greater uptake in the provision of care in this population.
Two questions were asked about whether the respondent psychiatrist was more (or less) comfortable in treating a homeless individual with psychiatric disorder or substance use disorder vis-à-vis the general population. While four of eight respondents were less comfortable in treating a homeless individual with mental illness, only one was more comfortable in treating such patients. Three of eight respondents were less comfortable in treating a homeless individual with an addictive disorder, while two were more comfortable in treating such patients.
A few caveats should be mentioned about this synthesis of perspectives while drawing interpretations. First, this is not a systematic review of the literature. There may be other relevant literature available for each country, though we aimed to collate a few published relevant and representative literature. Second, the perspective from individual psychiatrists does not necessarily reflect that of most or all psychiatrists or mental health professionals in the country. Third, heterogeneity of conceptualizations of constructs, including that of homelessness, might have remained across participants, as we did not define them a priori. And finally, there was some variability in the extent of information provided for each of the countries. Nonetheless, the paper provides a synthesis of some views of homelessness and mental illnesses across several countries in Asia in a single platform, including from those countries where literature on the topic has been scant.
To conclude, the literature on homeless individuals was sparse in certain Asian countries and contexts. Even in larger countries, reliable estimates of the extent of homelessness have been limited. Yet, cognizance of the plight of homeless individuals has been taken, and their mental health issues and predictors of mental health problems have been studied. One could consider greater research consideration on this issue, including exploration of the qualitative aspects of the mental illness experience in the homeless individual, understanding the types of mental illnesses that occur, knowing the care pathways, cost-benefit analysis of interventions, exploring the best ways to handle homelessness, and delving into access barriers and facilitators. Furthermore, the relationship of mental illness and homelessness can be assessed for causality and directionality of causation, if applicable, can be explored in these contexts.
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|1||Martens WH. A review of physical and mental health in homeless persons. Public Health Rev 2001;29:13-33.|
|2||Wiecha JL, Dwyer JT, Dunn-Strohecker M. Nutrition and health services needs among the homeless. Public Health Rep 1991;106:364-74.|
|3||Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Med 2008;5:e225.|
|4||Schreiter S, Bermpohl F, Krausz M, Leucht S, Rössler W, Schouler-Ocak M, et al. The prevalence of mental illness in homeless people in Germany: A systematic review and meta-analysis. Dtsch Ärztebl Int 2017;114:665.|
|5||Foster A, Gable J, Buckley J. Homelessness in schizophrenia. Psychiatr Clin North Am 2012;35:717-34.|
|6||Alessandrini G, Ciccarelli R, Battagliese G, Cereatti F, Gencarelli S, Messina MP, et al. Treatment of alcohol dependence. Alcohol and homelessness: Social point of view. Riv Psichiatr 2018;53:107-12.|
|7||Kim MM, Swanson JW, Swartz MS, Bradford DW, Mustillo SA, Elbogen EB. Healthcare barriers among severely mentally ill homeless adults: Evidence from the five-site health and risk study. Adm Policy Ment Health 2007;34:363-75.|
|8||Available form: https://www.oecd.org/els/family/HC3-1-Homeless-population.pdf. [Last accessed on 2020 Apr 02].|
|9||Abdul Hamid W, Wykes T, Stansfeld S. The homeless mentally ill: Myths and realities. Int J Soc Psychiatry 1993;39:237-54.|
|10||Smartt C, Prince M, Frissa S, Eaton J, Fekadu A, Hanlon C. Homelessness and severe mental illness in low- and middle-income countries: Scoping review. BJPsych Open 2019;5:e57.|
|11||Kallivayalil RA. 23rd Congress of the world Association of Social Psychiatry: “Social determinants of mental health and access to care”. World Soc Psychiatry 2019;1:89.|
|12||Available from: http://www.internal-displacement.org/countries/indonesia. [Last accessed on 2020 Feb 16].|
|13||Available from: https://www.habitat.org/where-we-build/indonesia. [Last accessed on 2020 Feb 16].|
|14||Rossalina R. Mental Health Training Needs Assessment of Foundation Staff and Primary Health Care Staff in the Area Surrounding Galuh Foundation Bekasi. West Java: Thesis. University of Indonesia; 2009.|
|15||Swaminath G, Enara A, Rao R, Kumar KVK, Kumar CN. Mental Healthcare Act, 2017 and homeless persons with mental illness in India. Indian J Psychiatry 2019;61:S768-S772.|
|16||Kumar P. Homelessness and mental health: Challenging issue in an Indian context. Am Int J Res Humanit Arts Soc Sci 2014;7:160-3.|
|17||Moorkath F, Vranda MN, Naveenkumar C. Lives without Roots: Institutionalized Homeless Women with Chronic Mental Illness. Indian J Psychol Med 2018;40:476-81.|
|18||Chaudhry S, Joseph A, Singh IP. The reality of homeless women in India. Violence Violations 2014;8:18-22.|
|19||Narasimhan L, Gopikumar V, Jayakumar V, Bunders J, Regeer B. Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India. Int J Ment Health Syst 2019;13:54.|
|20||Aliverdinia A, Pridemore WA. Individual-level factors contributing to homelessness among adult males in Iran. Sociol Spectr 2012;32:209-25.|
|21||Sajjadi S, Kamal SH, Darzi HA. The socioeconomic status of street homeless in Tehran. Adv Environ Biol 2014;10:1297-304.|
|22||Zadeh AO, SeyedAlinaghi S, Hassanzad FF, Hajizadeh M, Mohamadi S, Emamzadeh-Fard S, et al. Prevalence of HIV infection and the correlates among homeless in Tehran, Iran. Asian Pac J Trop Biomed 2014;4:65-8.|
|23||Fateh A. The foregrounding of homelessness in Iran by a progressive media. Iran Stud 2013;46:149-64.|
|24||Ahearn J. “Homefulness: The Cultural Safety Net in the Hashemite Kingdom of Jordan”. Independent Study Project (ISP) Collection. 2528; 2017. Available from: https://digitalcollections.sit.edu/isp_collection/2528. [Last acessed on 2020 Feb 16].|
|25||Baker R, Panter-Brick C, Todd A. Homeless street boys in Nepal: Their demography and lifestyle. J Compar Family Stud 1997;28:129-46.|
|26||Worthman CM, Panter-Brick C. Homeless street children in Nepal: Use of allostatic load to assess the burden of childhood adversity. Dev Psychopathol 2008;20:233-55.|
|27||Ojha SP, Ma J, Chapagain M, Tulachan P. Emotional and behavioural problems among sheltered homeless children. JNMA J Nepal Med Assoc 2013;52:457-61.|
|28||Available from: http://www.mohw.go.kr/react/al/sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&CONT_SEQ=342148&page=1. [Last accessed on 2020 Feb 16].|
|29||Nam K. A study on social service for the chronic homeless in Korea. J Crit Soc Policy 2013;39:7-43.|
|30||Kim S. An exploratory study on the risk factors of homelessness throughout the life cycle: Focusing on the unhappy experiences of growth. Soc Welfare Res 2017;48;143-71.|
|31||Ariyadasa E, McLaren H, McIntyre-Mills J. Children's Homelessness in Sri Lanka. In Faces of Homelessness in the Asia Pacific. New York: Routledge; 2017. p. 64-77.|
|32||Dieleman JL, Sadat N, Chang AY, Fullman N, Abbafati C, Acharya P, et al. Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016–40. Lancet 2018;391:1783-98.|