1. What is the prevalence of mental health issues for people who experience homelessness?

Homelessness is a traumatic experience that can have deeply negative implications for a person’s mental health. At the same time, a person who is struggling to manage a mental illness may be at greater risk of losing their housing because of challenges associated with their condition. For instance, earning the income needed to pay rent may not be possible for someone who has clinical depression and is unable to go to work, someone who has schizophrenia and is unable to maintain organized thought, or someone who has post-traumatic stress disorder and whose body is in a constant state of alert. It is indisputable that homelessness and mental health are related, but it is not a straightforward relationship.

 

Before you begin this section, we encourage you to take a moment and consider the question of prevalence. What percentage of people who experience homelessness do you think are impacted by mental illness? What mental illnesses do you think are most common amongst people who experience homelessness? Is everyone’s experience of mental illness and homelessness the same? Thinking about these questions helps us to better understand the complex nature of the relationship between homelessness and mental health. We will explore this relationship throughout this section and chapter, but we invite you to use the space below to record your thoughts before moving forward.

 

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This book was written in the fall and winter of 2021, as the COVID-19 pandemic was in its second year and the Omicron variant was emerging. Two years of lockdowns, distancing, and social isolation were weighing heavily on people’s minds. You may be reading this as the pandemic continues, or in a time past as it has come under control. Either way, we ask you to pause for a moment here and reflect on your own mental well-being as well as that of your family and friends. How have you coped with the pressures of living through a global health crisis? What measures have you and your loved ones taken to improve your mental health? What support did you find from your community?

 

The experience of living through a pandemic and living through homelessness have some commonalities. They are both highly stressful and isolating events, and while people may draw upon their own personal strength and coping skills, their lives are heavily impacted by the decisions government officials make. The pandemic is not a perfectly parallel comparison to homelessness, but it helps to highlight how stress, isolation, and loss of personal agency can lead to poor mental health.

 

As you reflect on your experience with the COVID-19 pandemic, we encourage you to think about how it has impacted your higher education studies. Even prior to the pandemic, student mental health concerns had been identified as an emergent crisis issue. We begin this section with a look at student mental health, beginning with a video entitled, “Combating the Mental Health Crisis on Canadian Campuses” created by CBC News: The National in October 2017. We then present a video entitled, “Jennifer’s Story: Hope, Courage and Recovery From Mental Illness” about a young woman whose untreated mental illness caused her to leave university in her fourth year of study and subsequently become homelessness.

 

We begin with the intersection of university students, mental health issues, and homelessness to highlight some important points. First, when we talk about mental health and homelessness, we are not talking about the one-dimensional stereotypes you may have seen in the media, but rather about real people’s lives. Second, while mental illness may be felt at a personal level, by the person who is affected and their loved ones, it is also shaped by broader social factors. This means that even within your own university, the policies that are in place will determine what kinds and how much support are available for students who are struggling with their mental wellness. We invite you now to watch these two videos, about mental health and homelessness, while considering it from a student perspective. Consider while you watch, what supports your university offers and how effective you think they are at buffering against the risk of housing loss.

 

We began with these two videos as a way of presenting a more complex image of mental illness and homelessness than is commonly shown in movies and on television. You likely have seen the images of someone who is experiencing severe psychosis, such as hearing voices, and is sleeping outside in public spaces. Certainly, this is some people’s experience. However, we want you to approach this chapter with a much broader perspective. In framing the question for this section, we asked about the prevalence of mental health issues, rather than mental illness. This was done intentionally, with the recognition that mental illnesses are diagnosed through clinical assessment, whereas mental health issues are more broadly defined. A person may not have a clinical diagnosis but may still not be mentally well. We wanted to capture the full spectrum in posing this question.

 

What we found was that there is no clear answer to this question. What is the prevalence of mental health issues for people experiencing homelessness? No one knows. What is clear, is there is no precise accounting of mental illness rates, but that it is higher than the general public. When we asked homelessness researchers who specialize in mental health about the prevalence, they explained that the rates differ depending on a range of factors, such as which conditions are included in the estimate. For instance, if we are talking about diagnosed severe mental illness, the rates are lower than if we expand the question to consider people who may not have a diagnosis but are nonetheless mentally unwell. In the next two videos, Dr. Tim Aubry and Dr. Nick Kerman explain how the estimates vary depending on the parameters used.


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Dr. Tim Aubry: What is the prevalence of mental health issues for people who experience homelessness? 

In this video, Dr. Tim Aubry discusses how severe and persistent mental illness is a health vulnerability for the 15% – 20% of the homeless population who experience chronic homelessness. He argues that there are also very high rates of depression and anxiety for people who experience homelessness in general, as a result of living in poverty, experiencing homelessness, and/or being victimized on the street. This video is 1:37 in length and has closed captions available in English. 

Key Takeaways – Dr. Tim Aubry: What is the prevalence of mental health issues for people who experience homelessness? 

  1. It is estimated that within the homeless population, 15% – 20% experience chronic homelessness. This group also tends to have severe and persistent mental illness, which is considered a health vulnerability that contributes to the risk of homelessness.
  2. In addition, there are very high rates of depression and anxiety amongst people experiencing homelessness in general. Living in poverty, experiencing homelessness, and/or being victimized on the street leads to decreased mental wellness.

 

 

Dr. Nick Kerman: What is the prevalence of mental health issues for people who experience homelessness? 

In this video, Dr. Nick Kerman explains that it can be challenging to identify the prevalence rates of mental illness for people experiencing homelessness because the studies that have tried to collect this information vary widely in methodology. He notes that those who experience homelessness have higher rates of mental illness than the general population, with a conservative estimate being approximately 40% – 50%. Dr. Kerman further notes that the category of ‘mental health problems’ is broad and may include both severe mental illness but also more common mental health conditions, such as depression and anxiety. He concludes that considerations of mental health must also include a discussion of substance use, which may be used as a coping strategy by some individuals. As a solution, connecting people with safe and affordable housing may improve mental well-being and decrease substance use problems. This video is 2:54 in length and has closed captions available in English. 

Key Takeaways – Dr. Nick Kerman: What is the prevalence of mental health issues for people who experience homelessness? 

  1. The prevalence rates of mental illness for people who experience homelessness is difficult to determine, in part because studies that have tried to collect this information have varied widely in methodology.
  2. We can say with confidence that the prevalence of mental health problems amongst people experiencing homelessness is significantly higher than that of the general population. A reliable, and potentially low, estimate would be in the 40% – 50% range.
  3. The category of ‘mental health problems’ is broad. People living with severe mental illness are over-represented amongst people experiencing homelessness, but we also see more common mental health conditions like depression and anxiety as well that are quite prevalent.
  4. It is also important to consider substance use rates when discussing mental health problems.
    • An estimated 25% – 35% of people experiencing homelessness might be considered to have a substance use problem.
    • It is important to understand that people who have substance use problems while experiencing homelessness may not have had one before. For some, substance use becomes a way of coping with the reality and hardships of homelessness. If individuals exit homelessness and have safe and affordable housing they may not continue to have a substance use problem.

 

Substance use is common amongst people who have mental illness and are experiencing homelessness, often as a form of self-medicating and trying to cope with hardships. The research shows a complex relationship between mental illness, substance use, and homelessness. For instance, Gicas et al., (2021) questioned whether there is a connection between psychosis in adults experiencing homelessness and the age at which they first used cannabis. They conducted research in Vancouver’s Downtown Eastside using surveys and a battery of neurocognitive tests including the use of structural and diffusion tensor imaging MRI scans. They found that early cannabis exposure (prior to age 15) was associated with an increased risk of developing substance induced psychosis and that later first-usage increased the risk of developing schizophrenia or schizoaffective disorder. Further, the results also indicated that early cannabis exposure may result in changes in regional brain volume (Gicas et al., 2021).

 

Another study from Vancouver was conducted to examine whether patterns of substance use and risk behaviours were associated with specific psychiatric disorders amongst people who had experienced homeless (Vogel et al., 2019). The results showed a complex picture. They found that major depressive disorder was associated with the use of stimulants and benzodiazepines, post-traumatic stress disorder (PTSD) was associated with stimulant use, panic disorder was associated with alcohol and benzodiazepine use, opioid use was less common in participants with a psychotic disorder, injection drug use occurred more frequently among participants with major depressive disorder, PTSD, and mood disorder with psychotic features (Vogel et al., 2019). These findings are important because they show us that while substance use may commonly co-occur with mental illness amongst people experiencing homelessness, it is not a straightforward relationship.

 

In another study, a sample of 1,585 people experiencing homelessness were assessed for alcohol and/or substance dependence and bipolar disorder, unipolar depression, and psychotic disorder to better understand whether relationships existed between these conditions (Maremmani et al., 2018). The researchers found that alcohol and/or substance dependence was more common amongst those who were younger, of Indigenous ancestry, lower educated, and located in Western Canada. The odds of alcohol and/or substance dependence were higher among those affected by bipolar disorder, and unipolar depression to a lesser extent. This study shows that people experiencing homelessness who have a major mental illness are at high risk of concurrent alcohol and/or substance dependence but that there are factors such as diagnosis, ethnicity, and location that need to be considered (Maremmani et al., 2018). We invite you now to learn more about this study – and the relationship between substance use, mental illness, and homelessness – in this section’s featured reading below.


Featured Reading:

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Maremmani, A. G. I., Bacciardi, S., Somers, J. M., Nikoo, M., SchĂźtz, C., Jang, K. L., & Krausz, M. (2018). Substance dependence among bipolar, unipolar depression and psychotic homeless: A Canadian national study. Frontiers in Psychiatry, 9, 701–701.  

 


The prevalence of mental health issues among people experiencing homelessness is difficult to determine, in large part because substance use is a complicating factor. Concurrent mental health and substance use disorders are highly prevalent for people experiencing homelessness. In a study from British Columbia, researchers used a range of assessments with 500 individuals living in shelters or on the street and categorized participants into four groups: (1) those without any current mental disorder, (2) those with substance use disorders only, (3) those with substance use disorders only, and (4) those with concurrent substance use and mental disorders (SchĂźtz et al., 2019). Results showed that those with dual diagnoses report more severe physical and psychological symptoms, and these individuals were more likely to be younger, Indigenous, and to be unsheltered. Importantly, they also reported significantly more challenges receiving the health care services they need. This group, with both mental illness and substance use disorders, is highly vulnerable because they lack access to basic services, like health care and shelter, despite having some of the most complex needs (SchĂźtz et al., 2019).

 

This population’s inequitable access to mental health services is another key reason we lack definitive rates of mental health issues. If we were to only account for those with diagnosed mental illnesses, the rates would be considerably lower than if we consider poor mental health more generally. Although many people would qualify as meeting the criteria for mental illness, their lack of access to mental health professionals makes those diagnoses and treatments less likely. There are many complicated reasons why people who experience homelessness have inequitable access to health care, as we discuss further in the chapters on Primary Care & Nursing and Emergency Medicine, but a lack of communication, discrimination, and stigma are key drivers for these poor outcomes.

 

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All Canadians, whether housed or experiencing homelessness, are facing a shortage of mental health supports. To learn more, we invite you to watch this brief segment from Global News about how access to mental health services has become a national problem. As you watch this, we encourage you to think about how this lack of access may be even more detrimental for people experiencing homelessness. This video was also released in October 2019, prior to the COVID-19 pandemic. How do you think the demand for mental health services may have changed during this period of time? 

 


What do you think?

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There are not enough mental health services across the country to meet the needs of Canadians. What do you think could be done to increase both the number of mental health services and their accessibility? How can we ensure people who experience homelessness have access to the mental health supports they need to be well? 


The prevalence of mental health issues amongst people experiencing homelessness is not well known because many do not have access to mental health practitioners who could offer diagnoses and treatments. In the next two videos, Dr. John Ecker and Dr. Katrina Milaney explain the estimates of mental health issues vary widely for people experiencing homelessness, and that the lack of mental health services is a key reason why. 

 

Dr. John Ecker: What is the prevalence of mental health issues for people who experience homelessness? 

In this video, Dr. John Ecker argues it is difficult to identify an exact prevalence rate of mental illness for people experiencing homelessness because the research is varied, with estimates ranging from 10% – 60%, and because not every person living with a mental illness will have been diagnosed or received proper mental health care. However, Dr. Ecker concludes that we can, with some degree of certainty, say that people who experience homelessness as a group have a higher rate of mental health challenges compared to the general population. This video is 0:57 in length and has closed captions available in English.

Key Takeaways – Dr. John Ecker: What is the prevalence of mental health issues for people who experience homelessness? 

  1. It is hard to get an exact prevalence rate of mental illness for people who are experiencing homelessness. Studies have shown results as low as 10% and as high as 60% of the proportion of people who experience homelessness and have a diagnosed mental health challenge.
  2. Not every person will have a diagnosis because access to mental care is challenging. We need to consider people who may have undiagnosed mental health conditions in the prevalence rates as well.
  3. Despite not having an exact number, we can say that people who experience homelessness have a higher rate of mental health challenges compared to the general population.

 

 

Dr. Katrina Milaney: What is the prevalence of mental health issues for people who experience homelessness? 

In this video, Dr. Katrina Milaney discusses the wide range of mental illness prevenance estimates found in the literature. She notes that studies variously indicate 25% to 75% of individuals who experience homelessness have mental health concerns. Dr. Milaney argues that determining an exact figure is a complicated issue because many people who experience homelessness, and chronic homelessness, in particular, have been excluded from mainstream health care and may not have received a proper diagnosis nor adequate care. Further, she postulates that the experience of homelessness itself is a form of mental distress, and may serve to exacerbate existing mental health conditions. This video is 1:11 in length and has closed captions available in English. 

Key Takeaways – Dr. Katrina Milaney: What is the prevalence of mental health issues for people who experience homelessness? 

  1. Studies have shown the rate of mental illness amongst people experiencing homelessness ranges from 25% – 75%.
  2. Determining the exact figure is a complicated issue. People who experience homelessness, and in particular chronic homelessness, have often been excluded from mainstream health care and may not have been given a diagnosis nor received proper care.
  3. Increasingly the argument being put forth is that homelessness itself is a form of mental distress and a mental health concern that can exacerbate existing conditions.

 

The exact prevalence of mental health issues for people experiencing homelessness is unknown, in part because of different considerations about what is included and in part because these individuals often lack access to mental health services that could provide diagnoses and treatments. We have seen a range of different estimates throughout this section so far, with researchers identifying studies that show figures as low as 10% and as high as 75%.

 

When we set out to write this book our mission was to explore seemingly simple questions that had complex answers. The prevalence of mental health issues is no exception. Homelessness, poor mental health, and substance use are often connected, but not in straightforward nor singular ways. People may experience a mental illness that results in housing loss, or they may be experiencing homelessness and find that their mental well-being declines as a result. In the next video Dr. Sean Kidd, Chief of the Psychology Division at the Centre for Addiction and Mental Health in Toronto, explains that when we take a broad view, we see that nearly every person who experiences homelessness will have mental health challenges because of the associated stress, violence, and trauma.

 

Dr. Sean Kidd: What is the prevalence of mental health issues for people who experience homelessness?

In this video, Dr. Sean Kidd explains that there are different estimates of mental illness prevalence for people experiencing homelessness, based on what is included in the definition. When considering major mental health disorders, such as major depression, PTSD, schizophrenia, and the overlay of addictions, it is estimated that this impacts 50% of people experiencing homelessness. When extended to general mental well-being, nearly every person who has experienced homelessness for a period of time will have mental health challenges, large amounts of stress, and experiences of violence. Dr. Kidd argues that homelessness is traumatizing, not in a single event kind of way, but as an everyday, ongoing form of deprivation. This video is 1:56 in length and has closed captions available in English.

Key Takeaways – Dr. Sean Kidd: What is the prevalence of mental health issues for people who experience homelessness?

  1. There are different estimates of mental illness prevalence for people experiencing homelessness, depending on what is included as a mental health challenge.
    • Considering major mental health disorders, such as major depression, PTSD, schizophrenia, and the overlay of addictions it is an estimated 50% of the homeless population who experience mental illness.
    • Extending beyond major mental health disorders, to consider general mental health, nearly every person who experiences homelessness for a period of time will have mental health challenges, large amounts of stress, experiences of violence and trauma, and may be struggling with or trying to recover from addiction.
  2. Homelessness is traumatizing. It is not necessarily a single or specific event, like a car crash, but rather traumatizing in ongoing, everyday deprivations, insults, injuries, assaults, and degrading experiences that happen over a period of time.

 

In much the same way, Dr. Cheryl Forchuk argues that we need to broaden our perspectives and consider every person who experiences homelessness part of a disenfranchised mental health population. Dr. Forchuk explains that it is better to be over-inclusive and ensure everyone receives the mental health services they need than to be more restrictive and miss people who could benefit from the support. She explains further in the video that follows. 

 

Dr. Cheryl Forchuk: What is the prevalence of mental health issues for people who experience homelessness?

In this video, filmed at a hospital during the COVID-19 pandemic, Dr. Cheryl Forchuk makes the argument that the homeless population should be treated as a disenfranchised mental health population. In one study 187 youth experiencing homelessness were given proper assessments, and 100% were diagnosed with mental health and/or addictions issues. Dr. Forchuk argues that not every person is comfortable revealing their situation, and so it is better to provide everyone experiencing homelessness with mental health and addictions supports than to miss people who may benefit. This video is 1:23 in length and has closed captions available in English.

Key Takeaways – Dr. Cheryl Forchuk: What is the prevalence of mental health issues for people who experience homelessness?

  1. The homeless population is a disenfranchised mental health population. This might be slightly over-inclusive, but when looking at the issues people are experiencing, if they did not have a mental health problem and/or addiction problem prior they certainly have one after.
    • It is better to be over-inclusive and treat everyone with mental health and addictions supports than to see people without resources.
  2. Not every person feels comfortable revealing their mental health situation.
  3. In one study 187 youth experiencing homelessness were given proper assessments and 100% were diagnosed with mental health and/or addiction issues.

 

Throughout this section, we sought to identify the prevalence of mental health issues amongst people experiencing homelessness. What we found is that it is somewhere between 10% and 100%. That may not seem very helpful, but it is insightful. What it tells us, is that we are lacking knowledge in this area and that not enough people who are experiencing homelessness and poor mental health are coming into contact with the mental health care system. What we know definitively is that the rates of diagnosed mental illnesses and overall poor mental health are higher for people who experience homelessness than for those who are housed. Yet, despite being amongst the most in need of mental health services, many people who experience homelessness do not receive timely mental health care. 

 

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We began this section by asking you to consider your own experiences of stress, isolation, and loss of agency during the COVID-19 pandemic. While we noted that this is not a perfect comparison, it does demonstrate some of the daily conditions that people who experience homelessness have to live with. Mental health challenges often arise as a result of homelessness and people may turn to substance use as a means of coping. Homelessness may also be the result of an untreated mental illness that began while a person was housed. The relationship between homelessness, mental health, and substance use is a complex one that is at the root of why we see such varied estimates. There is an old saying that it is better to be safe than sorry. With this in mind, we argue that whether the prevalence rates are 10% or 100%, what matters most is that we address the causes of homelessness, reduce the amount of time people spend in it, and increase access to supports and services for everyone. 

 

Podcast: What is the prevalence of mental health issues for people who experience homelessness? (11:18)

Click the link below to listen to all of the researchers answer the question “What is the prevalence of mental health issues for people who experience homelessness?” in audio format on our podcast!

 


 

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Understanding Homelessness in Canada Copyright © 2022 by Kristy Buccieri, James Davy, Cyndi Gilmer, and Nicole Whitmore is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

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