Mental Illness and Substance Abuse

The prevalence of serious mental illness and substance abuse is high among homeless persons. In a nationwide U.S. survey of homeless people, 39% had mental health problems, 50% had an alcohol and/or drug problem, and 23% had concurrent mental health and substance use problems (Burt, 2001). Common psychiatric diagnoses among homeless people include major depression, bipolar disorder, schizophrenia, and personality disorders. A systematic review of the prevalence of schizophrenia in homeless persons found rates ranging from 4 to 16% and a weighted average of 11% in the ten methodologically strongest studies (Folsom and Jeste, 2002). Characteristics associated with a higher prevalence of schizophrenia were younger age, female sex, and chronic homelessness. Marked cross-national variation is seen in the prevalence of schizophrenia, with prevalence rates of 23-46% reported among homeless people in Sydney, Australia (Teesson, et al., 2004).

The prevalence of substance abuse is extremely high among homeless single adults. In a study from St. Louis, Missouri, large increases were seen in the prevalence of drug use among homeless men and women between 1980 and 2000. In 2000, 84% of men and 58% of women had an alcohol or drug use disorder (North, et al., 2004). In another study, about three-quarters of homeless adults met criteria for substance abuse or dependence (O'Toole, et al., 2004). Homelessness increases the risk of adverse health outcomes among substance abusers: in five Canadian cities, the risk of a non-fatal overdose was twice as high among illicit opiate users who were homeless compared to those who were housed (Fischer, et al., 2004).

Homeless adolescents also have very high rates of mental health problems and substance abuse. In a study from Seattle, 83% of street youths had been physically and/or sexually victimized after leaving home, and 18% met criteria for posttraumatic stress disorder (Stewart, et al., 2004). Across the U.S., 55% of street youth and 34% of shelter youth had used illicit drugs other than marijuana since leaving home, in comparison to 13% of youth who had never been runaway or homeless (Greene, et al., 1997). Street youth use a wide range of drugs, including hallucinogens, amphetamines, sedative/tranquilizers, inhalants, cocaine, and opiates. Unfortunately, the initiation of injection drug use is quite common, with an incidence rate of 8.2 per 100 person-years among street youth in Montreal (Roy, et al., 2003).

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