A study of risk factors for homelessness among the severely mentally ill was extended to include women, and a case-control study of 100 indigent women with schizophrenia meeting criteria for literal homelessness and 100 such women with no history of homelessness was conducted. Subjects were recruited from shelters, clinics, and inpatient psychiatric programs in New York City. Clinical interviewers used standardized research instruments to probe three domains of risk factors: severity of mental illness, family background, and prior mental health service use. Findings adjusted for ethnicity revealed that homeless women had higher rates of a concurrent diagnosis of alcohol abuse, drug abuse, and antisocial personality disorder. Homeless women also had less adequate family support

Caton, Carol L. M.

Cournos, Francine

Dominguez, Boanerges

Eagle, Paula F.

Opler, Lewis A.

Shrout, Patrick

English

PubMed

Columbia University Academic Commons

Risk Factors for Homelessness amongWomen with SchizophreniaCarol L. M Caton, PhD, Patrick E. Shrout, PhD, Boanerges Dominguez, MS,Paula F. Eagle, MD, LewisA. Opler, MD, PhD, and Francine Coumos, MDInlodwtionIn previous eras, women have beenfound among hoboes, wanderers, andinmates of almshouses,1-4 and today theyconstitute about 20% of the contempo-rary adult homeless population.5 Home-less women without kin have been foundto be more psychiatrically disabled thanother subgroups of the homeless,5 particu-larly those in mid-adulthood and older.6Although mentally ill women who arehomeless are thought to require specialservices,7 little is known about how theydiffer from mentally ill women who neverexperience homelessness.Some studies that have explored thedifferences between the homeless and theresidentially stable either have focused onone sex or have had such small numbers ofwomen subjects that comparisons be-tween the sexes were not possible.10Studies that have included adequate num-bers of both sexes have found that thehomeless or residentially unstable havegreater alcohol11'12 and/or drug11'13 abuse;higher symptom levels11'12; greater non-compliance with prescribed treatments11,12;and a greater prevalence of foster care,group home placement, and runawayepisodes in childhood.14 While the litera-ture suggests that multiple factors distin-guish the homeless from the never-homeless, we know of no prior attempt tostudy multiple risk factors in a singleinvestigation ofwomen.We recently reported findings onmen with schizophrenia from our case-control study of homelessness designed totest hypotheses about three domains ofrisk: severity of illness, family background,and prior mental health services use.15 Wenow report findings on women withschizophrenia, based on a replication ofthe design and the method of the study ofmen.MethodsA case-control design was used with100 women in a sheltered homeless groupand 100 women in a never-homelessgroup. All 200 subjects had experienced atleast one psychiatric hospitalization, werebetween the ages of 18 and 64 years, andwere currently enrolled in a mental healthprogram targeted at the public patientwith severe mental illness. To be eligiblefor inclusion, the women were required tomeet DSM-III-R criteria for schizophre-nia or schizoaffective disorder, deter-mined through the Structured ClinicalInterview for DSM-III-R (SCID).16 Forboth groups, potential study subjects werereferred by clinical staff based on thesubject's chart diagnosis, treatment his-tory, and capacity to give voluntary in-formed consent. Such referrals were con-sidered consecutively by the researchstaff. Women with a recent episode ofliteral homelessness"7 were recruited froma shelter, a 24-hour drop-in center, andthree transitional housing programs(n = 93), as well as from three psychiatricinpatient units (n = 7). None were re-cruited from the streets. Women whowere never literally homeless were se-lected from four outpatient clinics (n = 80)and three inpatient units (n = 20). Allinpatients were ready for discharge. Al-though case subjects were matched withcontrol subjects on inclusion criteria, theywere drawn from different types of mentalhealth programs and thus may not besimilar on all dimensions.Of the 249 women who were asked toparticipate in the study, 19 (7.6%) refusedand 12 (4.8%) dropped out before com-pleting the interview battery. Refusalswere nearly three times greater in thenever-homeless group. Eighteen (7.2%)of homeless subjects with completedinterviews were eliminated from the studybecause of inconsistent or poor-qualitydata that could not be improved with areinterview. In such cases, the subject wasCarol L. M. Caton, Boanerges Dominguez,Paula F. Eagle, Lewis A. Opler, and FrancineCoumos are with the Department of Psychiatryand School of Public Health at ColumbiaUniversity's College of Physicians and Sur-geons, New York, NY. Patrick E. Shrout is withthe Department of Psychology, New YorkUniversity, New York, NY.Requests for reprints should be sent toCarol L. M. Caton, PhD, Department ofPsychiatry, Columbia University, 722 W 168thSt, Box 114, New York, NY 10032.This paper was accepted March 7, 1995.American Journal of Public Health 1153Public Health BriefsTABLE 1 -Background Characteristics of Never-Homeless and HomelessWomen with SchizophreniaNever Homeless(n = 100), %Place of birthAmerican bornForeign bornPlace of residence for the greatest % oftime from birth to 18 yNew York City areaOtherRace/ethnicityBlackHispanicWhiteReligionProtestantCatholicOtherNoneMarital statusSingleMarried/conjugalSeparated/divorcedWidowedVeteran statusYesNoEmployment statusEmployedUnemployedIncome from entitlementsYesNoEarned incomeYesNoIncome from familyYesNo74.026.060.040.039.026.035.032.046.013.09.043.017.034.06.02.098.021.079.085.015.019.081.039.061.0Homeless(n = 100), %81.019.055.045.052.010.038.040.041.015.04.049.87.036.28.03.097.026.074.088.012.019.081.08.092.0scale of adequacy2l based on the fre-quency of contact, quality of relationship,material support, emotional support, andcompanionship available from familymembers regardless of living arrangement(see footnote* for explanation of scale).Prior service use was also exploredwith items contained in the CommunityCare Schedule.21 Medication adherencewas rated on a 4-point scale based on thesubject's self-report. Long-term follow-upcare was defined in terms of the numberof months in outpatient treatment withthe same therapist. For practical reasons,interviewers had to conduct some inter-views in the sites where subjects wereenrolled. Therefore, they were not blindto the homeless/never-homeless status ofsome study subjects. However, they werenot aware of the study hypotheses.The case subjects (the homeless)were compared with the control subjects(the never-homeless) with respect tothree classes of study variables. In theillness domain, there were six variables:premorbid social attainment scale score,Positive and Negative Syndrome Scale(PANSS) positive symptom score, PANSSnegative symptom score, and binary indi-cators of alcohol abuse, drug abuse, andantisocial personality disorder. In thefamily domain, there were two variables:family disorganization index and ad-equacy of family support. In the serviceuse domain, there were two variables:medication adherence and existence of along-term therapist.Case and control subjects were ini-tially compared without taking into ac-count sampling characteristics of theCurrent age, yMeanMedianModeStandard deviationYears of educationMeanMedianModeCountStandard deviationeither too delusional or too disorganizedto function as a reliable informant. It ispossible that the more disturbed subjectswere not included in the final sample.Research instruments are describedin detail in our initial report.15 In sum-mary, preillness social functioning wasrated with the UCLA Social AttainmentScale.'8 Positive and negative dimensionsof schizophrenia were assessed with the43.0042.0045.0011.911.5512.0012.001002.9542.0042.0034.009.9311.5312.0012.001002.10Positive and Negative Syndrome Scale(PANSS).19 Current and lifetime alcoholand drug abuse/dependence were evalu-ated with the SCID.16 Antisocial person-ality disorder was evaluated with theSCID-II.20Family disorganization in childhoodwas evaluated with 4-point rating scales inthe Community Care Schedule.2' Currentfamily support was rated on a 4-point*The scale of adequacy of family support:family support was rated on a 4-point scalefrom 1 (adequate) to 4 (grossly inadequate).Ratings are based on the following informationpertaining to close relatives, usually parentsand siblings: frequency of contact, quality ofrelationship, material support, emotional sup-port, and companionship. The ratings aredefined as follows:* Adequate (1). Subject has frequent con-tact with family, who give food, clothing, andmoney when able. Subject can talk to at leastone family member about her problems. Sub-ject occasionally goes to movie or dinner withfamily member.* Fair (2). Subject has less frequent (threeto four times a year) contact with family, butfamily assists with material and emotionalsupport. Socialization takes place only rarely.* Poor (3). Subject has frequent contactwith family, but family gives little or no materialor emotional support.* Grossly inadequate (4). Subject has infre-quent contact with family, and family gives nomaterial or emotional support. There is es-trangement.August 1995, Vol. 85, No. 81154 American Journal of Public HealthPublic Health Briefsgroups. They were then compared withstatistical adjustments made using logisticregression, with the binary case/controlvariable treated as the outcome, and therisk variables and possible confounderstreated as explanatory variables. Possibleconfounders were chosen from thosedemographic variables in Table 1 thatwere at all related to the case/controlvariable (at the P < .15 level). The onlyvariable falling into this category is ethnic-ity. No adjustment was made for currentincome variables because they can beexpected to be related to homelessnessstructurally rather than incidentally.To facilitate the comparison of ad-justed and unadjusted associations be-tween the risk variables and the case/control distinction, both are presentedusing results from logistic regression analy-ses. The test statistic presented is thelikelihood ratio chi square (LRT) fromthe logistic analyses.22ResultsThe homeless case group and never-homeless control group had many traits incommon (see Table 1), including medianage (42 years), marital status (nearly twothirds had been involved in a conjugalrelationship at some time, but only 17% ofthe never-homeless and 7% of the home-less were currently married or living witha partner), median level of education (12years), and employment status (morethan three fourths were unemployed).Moreover, most (62% of homeless and65% of never-homeless) were members ofethnic minorities. However, there weregreater numbers of Blacks among thehomeless than among the never-homeless(52% vs 39%) and greater numbers ofHispanics among the never-homeless thanamong the homeless (26% vs 10%).Table 2 summarizes tests of studyhypotheses on the differences betweennever-homeless and homelesswomen withschizophrenia. Within the illness domain,there were no significant differences be-tween the homeless and the never-homeless on the UCLA Social Attain-ment Scale scores in either unadjusted oradjusted tests. In addition, there were nomajor differences in PANSS positive ornegative symptom levels. However, ahigher proportion of homeless subjectshad a concurrent alcohol abuse diagnosis(P < .05 for both unadjusted and ad-justed tests) and/or a concurrent drugabuse diagnosis (P < .05 for both tests).Similarly, a significantly greater numberof homeless subjects had a concurrentdiagnosis of antisocial personality disor-der (P < .05 for both unadjusted andadjusted tests), a finding that persistedwhen the criterion of lack of a fixedaddress for a month or more was deletedfrom the diagnostic algorithm. We plan todiscuss the assessment of antisocial per-sonality disorder among the severelymentally ill elsewhere (Caton CLM,Shrout P, Dominguez B, unpublishedmanuscript).23Within the family domain, therewere no differences on the index of familydisorganization. Family support was lessadequate for the homeless (P < .01 forboth tests).In terms of service use issues, therewere no differences between the homelessand the never-homeless with regard tomedication adherence or the duration oftime in treatment with the same therapist.When the data were adjusted for recruit-ment status (outpatient or discharge-ready inpatient), findings remained thesame.When the four variables that weresignificant in Table 2 were included as aset in a logistic regression model alongwith ethnicity, only one variable-ad-equacy of family support-remained sig-nificant (Wald = 14.2; df = 1; P < .01).The odds of homelessness among those atthe low end of family support wereestimated to be about three times largerthan those at the high end of the supportmeasure. To determine if adequacy offamily support is itself sufficient to ac-count for the effects of alcohol abuse,drug abuse, and antisocial history, wecarried out a stepwise regression analysis,with adequacy of family support andethnicity entered in the first step. In thesecond step, antisocial history was statisti-cally significant (Wald = 4.38; df = 1;P < .05) as well as practically significant:the odds of homelessness were estimatedto be nearly 10 times greater among thosewomen with a history of antisocial behav-ior. Alcohol abuse appeared not to haveunique effects when ethnicity, familyAmerican Journal of Public Health 1155August 1995, Vol. 85, No. 8TABLE 2-Test of Key Hypotheses on the Risk of Homelessness among UrbanWomen with SchizophreniaNever Homeless Homeless(n = 100) (n = 100) Unadjusteda AdjustedbMean SD Mean SD LRT P LRT PIllness domainUCLA Social Attain- 19.3 7.1 20.4 7.4 1.10 0.30 1.20 0.27ment Scale scorePANSS positive 15.4 6.5 16.5 7.7 1.22 0.27 1.07 0.30symptoms scorePANSS negative 17.6 7.3 18.9 6.5 1.66 0.20 1.32 0.25symptoms scoreAlcohol abuse 0.16 0.37 0.30 0.46 5.60 <0.05 5.61 <0.05(0 = no, 1 = yes)Drug abuse (0 = no, 0.15 0.36 0.29 0.46 5.79 <0.05 5.39 <0.051 = yes)Antisocial personality 0.01 0.10 0.08 0.27 6.45 <0.05 7.03 <0.05disorder (0 = no,1 = yes)Family domainIndex of family disor- 13.1 3.8 13.1 3.9 0.00 0.98 0.15 0.69ganizationAdequacy of family 1.8 1.1 2.6 1.3 18.06 < 0.01 12.96 < 0.01supportService use domainMedication adher- 1.64 0.95 1.57 0.95 0.29 0.59 0.53 0.46enceLong-term therapist 49.4 51.90 39.6 54.40 1.51 0.22 1.00 0.32Note. LRT = likelihood ratio test.aLikelihood ratio test and P value from logistic regression models with no other variables heldconstant.bLikelihood ratio test and P value from logistic regression models holding ethnicity constant.Public Health Briefssupport, and antisocial history were con-trolled, but drug abuse remained a trend.DiscussionThis study addressed risk factors forhomelessness only among persons withschizophrenia. It did not probe the impor-tance of schizophrenia itself or the rela-tive importance of schizophrenia andpoor family support as risk factors forhomelessness. Homeless women withschizophrenia differed from their never-homeless counterparts in two of the threedomains we studied: family backgroundand illness characteristics. Both the uni-variate (see Table 2) and the logisticregression analyses revealed that poorfamily support is a key risk factor forhomelessness. Because this was not alongitudinal study, we cannot ascertainthat poor family support preceded thefirst episode of homelessness. While poorfamily support is not a risk factor for theinitial onset of homelessness, we contendthat it is a risk factor for the persistence ofhomelessness. Family living settings arecommon among the severely mentally ill.The loss of an opportunity to live with kincreates the need to find housing in amarket with few available options.Like their male counterparts,15women who ended up in our homelessgroup were more likely to have concur-rent alcohol and/or drug abuse, antisocialpersonality disorder, and poor familysupport. In contrast to findings for men,15however, the logistic regression analysisrevealed that adequacy of family supportwas a more important risk factor forwomen than were any of the variables inthe illness domain. The results wereconsistent with a mediation explanation;the effect of substance abuse may be todecrease family support, which in turnleads to homelessness. Antisocial history,while partially mediated by family sup-port, appears to have an independenteffect on homelessness. Findings suggestthat illness behavior and family character-istics ofwomen with schizophrenia shouldbe closely monitored to prevent homeless-ness. OAcknowledgmentThe research on which this report is based wassupported by National Institute of MentalHealth grant MH44705.A more detailed presentation of the studyreported here is available from Dr Caton.References1. Garret GR, Bahr HM. Women on skidrow. Q J Stud Alcohol. 1973;34:1223-1243.2. Martin MA. Homelessness among chroni-cally mentally ill women. In: Bachrach LL,Nadelson CC, eds. Treating ChronicallyMentally iIl Women. Washington, DC:American Psychiatric Press; 1988:125-140.3. Martin MA. Homeless women: an histori-cal perspective. In: Beard R, ed. On BeingHomeless: HistoricalPerspectives. New York,NY: Museum of the City of New York;1988:12.4. Golden S. The Women Outside. Berkeley,Calif: University of California Press; 1992.5. Burt MR, Cohen BE. America's Homeless:Numbers, Characteristics, andPrograms ThatServe Them. Washington, DC: Urban Insti-tute Press; 1989:49-51. Report 89-3.6. Rossi PH, Fisher GA, Willis G. TheCondition of the Homeless of Chicago.Chicago, Ill: National Opinion ResearchCouncil; 1986:81-82.7. Bachrach LL. Homeless women: a contextfor health planning. Milbank Q. 1987;65:371-396.8. Fischer PJ, Shapiro S, Breakey WR,Anthony JC, Kramer M. Mental healthand social characteristics of the homeless: asurvey of mission users.Am JPublic Health.1986;76:519-524.9. Weitzman BC, Knickman JR, Shinn M.Predictors of shelter use among low-income families: psychiatric history, sub-stance abuse, and victimization. Am JPublic Health. 1992;82:1547-1550.10. Koegel P, Burnam A, Farr RK Theprevalence of specific psychiatric disordersamong homeless individuals in the innercity of Los Angeles. Arch Gen Psychiatry.1988;45:1085-1092.11. Drake RE, Wallach MA, Hoffman JS.Housing instability and homelessnessamong aftercare patients of an urban statehospital. Hosp Community Psychiatry. 1989;40:46-51.12. Drake RE, Wallach MA, Teague GB,Freeman DH, Paskus TS, Clark TA.Housing instability and homelessnessamong rural schizophrenic patients. Am JPsychiatry. 1991;148:330-336.13. Susser ES, Lin SP, Conover SA. Riskfactors for homelessness among patientsadmitted to a state mental hospital. Am JPsychiatry. 1991;148:1659-1664.14. Susser ES, Lin SP, Conover SA, StrueningEL. Childhood antecedents of homeless-ness in psychiatric patients. Am J Psychia-ty. 1991;148:1026-1030.15. Caton CLM, Shrout PE, Eagle PF, OplerLA, Felix A, Dominguez B. Risk factors forhomelessness among schizophrenic men: acase-control study. Am J Public Health.1994;84:265-270.16. Spitzer RL, Williams JBW, Gibbon M,First MB. The structured clinical interviewfor DSM-III-R (SCID): I. history, ratio-nale, and description. Arch Gen Psychiatry.1992;49:624-629.17. Rossi PH, Wright JD, Fisher GA, Willis G.The urban homeless: estimating composi-tion and size. Science. 1987;235:1336-1341.18. Goldstein MJ. Further data concerning therelation between premorbid adjustmentand paranoid symptomatology. SchizophrBull. 1978;4:236.19. Kay SR, Fiszbein A, Opler LA. ThePositive and Negative Syndrome Scale(PANSS) for schizophrenia. SchizophrBull1987;13:261-275.20. First MB, Spitzer RL, Gibbon M, WilliamsJBW. The structured clinical interview forDSM-III-R personality disorders: part I.description. JPers Disord. In press.21. Caton CLM. The Community Care Sched-ule. New York, NY: New York StatePsychiatric Institute; January 1989.22. Hosmer DW, Lemeshow S. Applied Logis-tic Regression. 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Risk factors for homelessness among women with schizophrenia

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Risk factors for homelessness among women with schizophrenia

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