Homeless missing out on vital psychiatric care - researcher

Homeless people with acute mental health disorders are missing out on vital psychiatric care when they are discharged from hospital straight back into the streets, a researcher says.

A 2019 study found approximately 21 percent of people experiencing homelessness battle psychotic disorders, and some are failing treatment due to the lack of access to stable housing.

Matthew Tennant, a senior lecturer in the University of Otago's Department of Psychological Medicine, said mental disorders and lacking shelter were directly connected.

"The relationship between major mental illness and homelessness is bidirectional.

"When someone has a major mental illness, they are much more likely to be homeless because they may struggle to have the essential skills required to maintain an income to maintain stable accommodation without support.

He said inconsistent accommodation was destabilising for those with psychotic disorders.

"When someone has a major mental illness and they don't have stable and secure accommodation, it's very, very hard for them to be recovering.

"[That is] because if someone's [mental health] is unstable, unpredictable, chaotic, and then you're putting them into an external environment which is also chaotic and unstable, unreliable, unpredictable, it [would be] a very hard place to recover from."

Tennant said homelessness could have long-lasting effects on the treatment of acute mental disorders.

"One of my patients had been suffering from untreated psychosis for a five-year period... and he wasn't always aware [about] the treatment that he needed.

"He was paranoid at the time and it was hard for the services who were trying to look after [him] to even find him, because they didn't have an address where he was gonna be.

"As soon as we got [the patient] started on the right treatment and had some support [around] him, he became much better."

Counselling intervention was not enough to address the issue, Tennant said.

"The brief counselling intervention that happens in most of the cases is, to be honest, an insult.

"What we need to be offering is foundational care to begin with, and once you've done that, then you can build adequate treatment in terms of medications, psychological interventions, vocational support and that's how you build towards recovery."

Inadequate access to a home for those with schizophrenia is a breach of the Code of Health and Disability Services Consumers' Rights and should be investigated, he said.

"[The code sets] the right for the people to receive services that are of an appropriate standard. It says that the care should comply with professional and ethical standards, that it should be providing for people in their need and and, that it should be optimising quality of life.

"So, it's arguable that if we're not able to provide that sort of foundation, then we're not complying with professional standards of care."

Tennant said the issue was complex.

"In our 2018 census, over 100,000 people were identified in the severely housing deprived groups, and that's over 2 percent of our population, this is not an insignificant group of people.

"On top of that, there's significant other psychiatric comorbidity, mood disorders, anxiety disorders and trauma related disorders, and also issues with addiction, so this is a really complex group of people who need actually quite a wrap around support. It's not a simple thing."

He said more should be done to address the issues involving homelessness and mental health.

"As a society, we should be prioritising and valuing our most vulnerable people, because when you start off with those values then you can start to make a new, more nuanced plan after that.

"At the moment in New Zealand, we are not valuing or prioritising people who have major mental illnesses or those who are homeless."

'Challenging situation'

A study from the Ministry of Social Development found 17 percent of people receiving mental health services from DHBs were experiencing housing instability, while 4 percent - almost 2000 people - were completely homeless.

It found loss of accommodation during acute illness or hospitalisation may have affected between 10 and 20 percent of those being treated.

"Housing difficulties can be a factor in the deterioration in mental health among people with existing mental health conditions.

"On the other hand, serious mental illness can result in unsatisfactory housing outcomes because of the compounding effect that flows from the experience of mental illness - poverty, discrimination, disrupted education, employment problems, high residential mobility, periodic hospitalisation, physical health problems, alcohol/substance abuse, homelessness and detachment from clinical services."

Deputy Health and Disability Commissioner Dr Vanessa Caldwell acknowledged the lack of appropriate housing had an impact on treatment of mental health disorders.

"A lack of community support options, including appropriate housing, impacting on the ability of providers to safely discharge people from inpatient psychiatric units is an issue we see in complaints to HDC.

"In most of these cases the lack of appropriate community options results in people staying in an inpatient unit when such an admission is no longer clinically indicated - rather than being discharged to no fixed abode.

Caldwell said inpatient psychiatric units were not an appropriate alternative accommodation option for people without housing.

"And using them as such can have a significant and detrimental effect on a person's health and well-being. These units are not designed for long-term admissions and are not an appropriate place for people to be when they are no longer acutely unwell.

"This is an incredibly challenging situation for providers to navigate, and highlights the importance of Te Whatu Ora working closely with community support providers, including supported accommodation and housing providers, to assist in ensuring the availability of culturally safe community options to allow people to be safely discharged from psychiatric units."

'Working closely with providers'

In a statement, the Ministry of Housing and Urban Development said it worked closely together with service providers to prevent and respond to homelessness.

"This includes a range of initiatives to support people with acute mental health disorders and other high and complex needs," such as the Rapua Te Āhuru Mōwai pilot project and Housing First.

"The Rapua Te Āhuru Mōwai pilots [provides] intensive wrap-around support and quality permanent housing for people leaving acute inpatient units with no suitable accommodation," a spokesperson said.

"Housing First provides housing and tailored support services for individuals, whānau and families who have been sleeping rough and have high or complex needs."

More information on the cross-government responses to homelessness including the Rapua Te Āhuru Mōwai pilots can be found online.