Homelessness and Mental Health

The At Home/Chez Soi study was a multisite randomised controlled trial demonstrating the effectiveness of a “housing first” intervention in Canada. The “housing first” model is related to the Pathways to Housing model that originated in New York City. The concept is to immediately provide permanent housing at a location largely chosen by the participant and also to provide wrap-around supports. Positive results from the At Home/Chez Soi trial were previously summarised in The Canadian Journal of Psychiatry (CJP) by Aubry et al. People receiving the housing first intervention had superior housing outcomes and showed benefits in functioning and quality of life compared to a treatment-as-usual comparator. Such interventions, of course, are not a panacea. Earlier this year, Adair et al. reported the occurrence of both positive and negative housing trajectories in the housing first and treatment-as-usual arms of At Home/Chez Soi. In the current issue of the CJP, Aquin et al. examine 2 additional outcomes, suicidal ideation and attempts, in the At Home/Chez Soi cohort. Suicidal ideation was found to diminish over time, but no differences between the intervention and control groups were observed. No differences were found in suicide attempts either. The improvement in suicidal ideation may be due to regression to the mean. At Home/Chez Soi recruited its participants from shelters, hospitals, and agencies. At the time of recruitment, the participants may have had higher levels of suicidal ideation than is usual for them, something that could cause regression to the mean as those participants returned closer to their long-term baseline over time. Resources available to the respondents in both study groups (the treatment-as-usual group was not denied services) may also have led to improvement over time. Another possible explanation is the “Hawthorne effect”: the tendency for better outcomes to occur when one is aware that one is being observed, as in the context of a study. Another study published in this issue looked at suicides among homeless and precariously housed residents of Toronto. Coroner records were reviewed for all suicide deaths in Toronto from 1998 to 2012. The study found that 1.8% of people dying by suicide were homeless, a large number given that only about 0.2% of the Toronto population is homeless at a point in time. Homeless people dying by suicide were younger and more likely to be male than nonhomeless people dying by suicide. They were also more likely to have been seen by an emergency department or outpatient psychiatrist in the week prior to their death and to have died by falling or jumping. These results provide a descriptive comparison of suicides by homeless and nonhomeless persons, which is valuable information for formulating preventive strategies. However, since inclusion in the study was restricted to those people who died by suicide, the study could not estimate or compare suicide rates in different population sub-groups. Because there are many causal pathways to suicide (it is a common outcome upon which many causal pathways “collide”), associations between various predictors are subject to distortion, and therefore are not reported. People who are marginally housed, something that is often associated with severe poverty, share many of the challenges of homeless persons. Marginal housing often coexists with extreme poverty, with both having major implications for health care delivery. These problems led to the initiation of the Hotel Study, findings from which are also reported in this issue. The study looked at data from a variety of sources, including hospital records, police records, and a prospective cohort study following 375 residents of Vancouver’s downtown east side between 2008 and 2015. The authors used a standardised mortality ratio (SMR) to quantify mortality in the cohort. This involves counting the observed and expected number of deaths in a cohort. The expected number of deaths is estimated using available ageand sex-specific mortality rates for the Canadian general population. The SMR is then calculated by dividing the observed number of deaths by the expected number of deaths. In this case, the SMR was 8.4, highlighting the vastly elevated risk of death in this population. Management of