Homelessness Is Not Just a Housing Problem

Editorial H omelessness is about more than rooflessness. A home is not just a physical space: it provides roots, identity, security, a sense of belonging and a place of emotional wellbeing. " So says the United Kingdom charity Crisis [1]. This Editorial's title comes from another charity, Shelter [2], which breaks down the causes of homelessness into individual factors such as drug and alcohol misuse; lack of social support; family background, including family breakdown and disputes; and an institutional background, including being in prison, or increasingly and perhaps especially shamefully today, the armed services. A systematic review published in this month's PLoS Medicine [3] looks at just one aspect of this complex issue—the prevalence of mental disorders in the homeless. The analysis shows that there is a substantial prevalence of mental disorders among homeless people in Western countries. Among prior studies meeting criteria for consideration, the prevalence of alcohol dependency ranged from 8.1%–58.5%, and drug dependence ranged from 4.5%–54.2%. For psychotic illnesses, the prevalence ranged from 2.8%–42.3%, with similar findings for major depression. What these figures don't show, of course, is whether mental illnesses are the cause or consequence of homelessness—or, as seems more likely, whether these conditions are mutually contributory and their causes interrelated. What the results do reinforce is that homeless individuals have substantial and complex health needs. Helen Herrman, professor of psychiatry at the University of Melbourne, Australia, notes in her Perspective on Fazel and colleagues' paper [4] that these needs are not well documented: " It is a stark finding that despite all that has been written about mental illness among homeless people, and all the speculation about the origin of the problem, the authors deemed only 29 studies relevant to their analysis. " And of course this paper only includes individuals in Western countries; worldwide, the health needs of an even more vulnerable group of homeless people—refugees and persons displaced by conflict—are even more challenging. Why are papers such as the one by Fazel and colleagues, which document these health needs, so important? If the health needs of groups are understudied and underrepresented in the medical literature, it is likely that their health needs are not being addressed equably by society as a whole. A case report from 1993 [5] of two homeless men whose condition improved substantially when they were diagnosed with schizophrenia and treated with antipsychotics illustrates that homeless individuals, simply by the …