Homelessness persists in the US, and across the world, despite decades of recognition and longstanding efforts to end the condition. There have been major successes in our understanding of what policies and programs work to prevent and end homelessness. However, the work must and will find new ways to adapt and improve if we are to see further progress.
Meanwhile, COVID-19 is still poised to create an explosion in evictions, foreclosures and introduce a huge swath of the US population to the stresses of housing instability and homelessness. Those experiencing homelessness are aging. Mental health and substance use disorder rates continue to climb. The ongoing epidemic of opiate overuse and the obesity crisis ravage the country. Only a couple of decades ago, “dual diagnosis” programs began to address issues of comorbid mental health and substance use. Today, it is becoming more widely accepted that even this synthesis oversimplifies the problem. In reality, there are parallel, complex relationships involved between multiple, interacting physical, mental health, and substance use issues.
This work has always been an uphill climb; one that began long before the explosion of homelessness seen in the 1980s and 90s. It requires empathy, innovation, and a thoughtful approach to understanding the myriad forces that create and prolong this condition for those forced to endure it. Recently, recognition of this unique complexity of this problem has grown as programs, researchers, and policy-makers have broadened the scope of what it means to be living in homelessness.
A Very Special Issue of Medical Care
This post is, in part, a celebration of the recent gathering and publication of a special issue by our sponsoring journal Medical Care, titled Multimorbidity Among Homeless Populations. The special issue was organized by the American Public Health Association’s Caucus on Homelessness. Special thanks to the US Veteran’s Administration (VA) which contributed a large number of studies. This issue highlights the remarkable contribution to the field made by the VA’s National Center on Homelessness Among Veterans (NCHAV) in recent years. The Center also sponsored open access to the special issue. This means that the full text of every article is available at no charge.
This issue comes as the research community increasingly recognizes the importance of homelessness as a significant public health issue. Another special issue on ‘Homelessness and Public Health’ was recently produced by the International Journal of Environmental Research and Public Health (IJERPH). The AMA’s Journal of Ethics will soon be publishing a special issue on homelessness as well; their first since 2009.
Cutting-Edge Research
Without further editorializing, here’s a brief tour through the issue and some of the remarkable findings within.
The special issue begins with recognition of the progress made and a pair of remarkable commentaries. Then, the issue reports on a study showing real maturation in understanding of the impact of housing on healthcare utilization. In a 4-year prospective cohort study in Ontario, healthcare costs climbed with increased housing stability for the first year, but then trended down from there. Wiens et al. also showed that pharmacy costs increase with housing stability and trips to the emergency department go down. (I feel the need to point out increasing medication use is actually a good thing in this context). This was bolstered in a study by DeLia et al. showing supportive housing reduced emergency department visits, inpatient admissions, increasing medication costs, with primary care visits holding steady.
More studies by Quinn, Schutt, and their respective colleagues shared insights into the personal and interpersonal circumstances in maintaining this critical housing support and the impact of that housing on other services too. In particular, Quinn et al. showed improved HIV treatment with supportive housing entry regardless of the level of case management available, though depression and persistent racial disparities still take their toll.
Multimorbidity
Multimorbidity was highlighted by studies showing: 1) increasing rates of trimorbidity (through worsening rates of physical health conditions, substance use, but most especially mental illness); 2) alcohol use disorder and multiple health conditions were top predictors of nursing home admission following first-entry into an emergency shelter; 3) increased clinical complexity and multimorbidity even in adolescents experiencing homelessness.
In another study that highlights the hardship faced by those struggling with mental health concerns, Elbogen et al. shared their work predicting future experience of homelessness as a by-product of both economic distress and severe mental health burden. Using data from a national survey they showed that both severe mental illness and financial strain predict entry into homelessness. (No real surprise, unfortunately). More importantly, they showed that financial hardship was a big part of the pathway from mental illness into homelessness.
Finally, a pair of sleep studies in formerly homeless adults and youth in and out of shelters provided a remarkable new view into the trauma, pain, and mental health experienced by people with this kind of experience.
Just the beginning
All this is just a slice of the amazing research that the journal was able to publish as a result of this special issue. I encourage you to take a deeper look for yourself! I personally want to thank the journal, the VA, all our reviewers, and my co-editors for their assistance and support. It was a remarkable, if challenging, experience pulling this article together in the middle of an era-defining public health crisis.
Ben King