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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

eer Review Comments/Author Responses

NTS - Epidemiological evidence regarding homelessness among Veterans

Comment Response

s, scope, and methods for this review clearly described?

ers and letters used in the research objectives are distracting. I would 

ullets for the sub questions.

We have revised the format of the document to comply with the standard VA Evidence-based Synthesis Program (ESP) style template. We think this should address the concerns of the reviewer.

ds section should precede the discussion on the structural causes of 

This has been corrected in a way that follows the template of the ESP program.

a sources could benefit from elaboration on limitations and that the 

ent research are a laundry list – are there key issues that you could 

We have added a more detailed section describing the limitations of the datasets and hope that this addresses the concerns of the reviewer.

arch questions.

ned are very cogent and relevant to the current policy issues and 

he evidence synthesis reflects a tremendous amount of work and the 

mmended.

 developed as part of this paper is nicely conceived and constructed 

more prominently represented in the paper as (1) a means of 

) a contextualizing in greater detail of the intermediate and mediating 

 paper. Toward both of these objectives, the schematic could be 

 to more clearly define these relational dynamics.

We thank the reviewer for their comments on the Conceptual Model. We have modified the model and hope that the relationships are easier to follow. We’ve also relocated the Figure and discussion of the model and hope that it acts, as the reviewer suggests, as a frame for organizing the subsequent discussion of the topic.

nsive.

cation of bias in our synthesis of the evidence?

and fair.

see comment 4.4 below.
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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

Comment Response

nd challenge with this synthesis is that for much of the research on 

homeless Veterans, there are inconsistent definitions, metrics for 

dologic rigor assigned to sampling, unmeasured population dynamics, 

 You do a very nice job of describing this at the beginning of the paper 

 prominently factored into some of the conclusions presented in the 

example of this is in the discussion about social support and its role 

at exposure, etc. There are objective measures of social and social 

used the Rand Social Support Network Survey in our studies) that 

lated with several features of homelessness. The surrogate measure 

weaker, nontemporal, and without any validation that I am aware 

out any conclusions being drawn off that metric. Similarly, as you 

esearch on substance use and abuse has historically been challenged 

ow use is measured, whether it reflects current use while homeless or 

re likely contributant use). There are also definite distinctions between 

and dependence and its impact on functioning, risk, and capacity to 

owing which studies employed any of the Addiction Severity index 

ir determinations would be helpful in considering the rigor of the data 

er attention to this level of detail is needed in the synthesis. This is an 

nd expanding the search beyond homeless veterans to homelessness in 

will be of help. The only other concern that needs to be addressed is 

data – inferences drawn from data that are now 20-25 years old may 

ynamics of homelessness today.

Corrected. We have included a more direct discussion describing the inconsistencies that we found among the various studies that examine the prevalence of substance abuse or mental illness among homeless Veterans. We have also identified additional measures that might provide better insights into issues of social support and social capital.

dies on the epidemiology of homelessness among Veterans that we have overlooked?

he most comprehensive that I’ve read.

ment of the literature and innovative use of emerging search programs

eam to consider is whether it is better to take well-constructed and 

ous studies about homelessness in the general population and apply 

rans over what are sometimes less well constructed or significantly 

f selection bias, validity/reliability of findings, etc.) that is specific to 

any of papers specific to homeless veterans are drawn from samples 

VA programs or services for homeless persons and reflect a level 

t and capacity that may not be reflective of the overall population 

 most of whom do not get there care in the VA. This is particularly 

y or dimensional relationships are being inferred or considered.

Because of the exploratory nature of this review, and because the purpose of the report was to provide background on what’s known about homelessness among Veterans, we felt it better addressed the goals of the report to identify and report on studies specifically about Veterans and to discuss the limitations of those studies. We supplemented this with a brief background discussion of the literature on homelessness more broadly and hope that this report will prove useful in identifying the need for more methodologically rigorous and broadly applicable studies about homelessness among Veterans.
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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

Comment Response

at the substance abuse prevalence section is a little light, I believe 

Also, the reference was from an older study. For example O’Connell, 

2010 report on HUD VASH client demographics and include data on 

 Rosenheck fairly frequently reports this data as well in his studies.

We have revised our discussion of the substance abuse issues and hope that it addresses the concerns of the reviewer.

tional suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

Report states Veterans are 2x the risk of homelessness compared 

on. Need to clarify comparison as children should not be included 

since men are more likely to be homeless (not just Veterans), 

o-thirds of all homeless adults, it is important to factor this into 

these adjustments it appears veteran status alone places individuals 

We have added language to address the reviewers comment.

Homeless Veterans are more likely to be African-American. This is 

We have included additional language addressing the over-representation of Blacks among the homeless and of the over-representation of Veterans, both Black and White among the homeless.

ng the minimum wage the paper uses 2004 as a reference point to 

 its declining value; however, the minimum wage was increased after 

he selection of 2004 appear to be used to bias the conclusion. Also, 

m wages higher than the federal minimum wage. It may be more 

he declining value of the minimum wage in relation to the increasing 

We have edited the text to provide a more general description of the declining value of the minimum wage in relation to the cost of housing. 

stion 1b: Paper states Veterans are more likely to be unsheltered than 

oes not state this as factual, only speculates that this is a possibility.

We have revised the language to indicate the speculative nature of this perspective.

 “Kuhn reports 24% increase in homeless families”. Need to clarify 

he reader to incorrectly conclude that this is the increase in overall 

This increase only reflects what VA staff report they have seen at 

We have revised the language here to be clearer that we are reporting on an increase in staff reports of increases in people seeking services.

: No mention is made on the impact of child support. Legal 

pport is ranked as the second highest unmet need in the CHALENG 

affordable child support obligations often act as a significant barrier 

o resume independent community living. This burden is particularly 

ders. The typical incarcerated parent owes $20,000 in child support 

ison, with payment schedules averaging $225 to $300 per month 

ocial Policy, 2008). Minimum wage workers have little hope of 

s while supporting themselves. Unresolved child support debts can 

bank accounts, denial of credit, inability to secure a lease, failure in 

mmonly a part of job applications, forfeiture of driver’s licenses, and 

We have expanded this section to address the issue of child support and thank the reviewer for their very helpful comment.
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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

Comment Response

ments are deducted automatically from paychecks, workers often quit 

shed, returning to the underground economy to avoid child support. 

cipation in the underground economy often means a return to illegal 

w and Social Policy, 2007). Hence, legal assistance around the issue 

 key to helping Veterans meet their obligations to society, while still 

void relapsing to homelessness.

a thorough copy edit. We agree and have done so.

and on the limitations of each data source. We have added a more detailed section describing the limitations of the 

datasets and hope that this addresses the concerns of the reviewer.

dry list and the narrative doesn’t flow. Is there a better structure? 

We agree that this section needed better organization. We have reorganized so that similar topics are addressed together, and, as suggested by the reviewer have added subheads to make clear how the topics are grouped together.

graph: double check the definition. I think the first line is inaccurate. 

 include those living in transitional housing as homeless.

We checked Perl (2009) and the McKinney-Vento Act. No change to our statement is needed. Currently, only those living in transitional housing for the mentally ill are included. The Hearth Act will add others living in transitional housing to the definition of homelessness.
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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

Comment Response

blems with your conceptual model:

D and Mental Illness together, in the center of the model, and directly 

omelessness (giving the association a strong arrow and two asterisks, 

t form of association you have in the model). This contradicts what 

aces in your report, where you say there is a lack of evidence directly 

melessness (e.g., pps 29 and 33). The problem here, obviously, is 

uld not be coupled like this. MI is of course a catchall term and 

gnosis. Associations with MI in general should best be broken down 

mponents. Even severe mental illness (which typically includes only 

or affective disorders) is a better designation than just MI. And 

own box, which, according to the evidence you review, should 

ociation with homelessness. Including the model as it is would be 

 as it would in effect create a PTSD-Homelessness link that future 

e from this review.

ubstance abuse have only weak, indirect associations with 

odel. This would contradict your text, where on p 28 you cite, 

el study and a Winkleby et al. study as finding such associations. 

a broad range of research among non-Veterans who make this 

ciation. If you mean to disassociate homelessness and SA, as you 

odel (and invite others to cite you), then you need to insert specific 

explicitly explains your decision to do this.

1) We thank the reviewer for sharing these concerns. Further discussion led to a substantial revision of the model for overall clarity. We dropped the use of the more general term “mental illness.” “Underlying psychiatric illness” was added to a box labeled “shared early life exposures,” since the strongest evidence on this issue for a homeless veteran population comes from Rosenheck and Fontana 1994, which used psychiatric treatment before age 18 as a variable. As our reports notes, it is unfortunate that few studies involving homeless veterans actually assess for schizophrenia, unless they are among individuals seeking treatment for mental illness, in which case the sampling frame raises serious issues for the generalizability of any associations found.There is now a box labeled “PTSD/Depression/Anxiety.” While frequent comorbidity might provide justification for this cluster, our model groups these conditions together because a) the veteran-specific evidence cited (Washington and Yano 2010) also groups PTSD and anxiety disorders together, and b) because the general homelessness literature cited finds associations between depression and homelessness (as well as psychiatric disorders). Our report states that “the evidence linking PTSD to homelessness remains limited by the small number, small size and/or nongeneralizable sampling methods of existing studies.” This is not the same thing as stating that there is no evidence, and we stand by the model’s representation of an association between PTSD/Depression/Anxiety and homelessness. Here as elsewhere in the revised model, we have added a black box along the association pathway to indicate that the mechanism for the association is poorly understood. We hope this will encourage users of our model to direct future efforts towards understanding mediating factors.2) We thank the reviewer for pointing out the discrepancy between the research that we site describing the association between substance abuse and homelessness and the weak link presented in the conceptual model. We have revised the model to indicate that substance abuse has a strong association with homelessness, but that the path through which substance abuse effects the risk of homelessness remains unknown. We also note in the text that evidence for substance abuse as a causal factor for homelessness has been inconsistent. Much of the research on substance abuse and homelessness employs a cross-sectional sampling frame, and thus, cannot demonstrate cause and effect. We discuss the limitations of studies examining substance abuse and homelessness in detail in our “Assessing the Limitations of the Current Research” section.
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e Regarding Homelessness among Veterans Evidence-based Synthesis Program

Comment Response

ALENGE and AHAR counts should do more to look at the 

ms involved in the estimates. CHALENGE, as you say, has traditionally 

expert assessments, which (as you never point out) is a notoriously 

ess homeless population size (plenty of cites available on this) and 

nt. This is not a slam on CHALENGE but a recognition that they were 

e limited data that was available and that the report primarily seeks 

eeds fulfillment among the homeless Vet population. AHAR on the 

 reliance on mainstream homeless services data, is biased towards 

, as you point out on 22, a substantial gap (52,000 to 107,000) in the 

stead of examining further, you sidestep by only saying both numbers 

s of the problem.” As I said earlier, the Vet-AHAR bridges these two 

its estimate and in its methodology, and needs to be included here.

your stating the overrepresentation of risk for homelessness among 

istinguish between studies such as were done by Rosenheck and his 

age adjust the populations to get a more accurate representation of risk, 

on’t.

We have expanded on the discussion in this section and have included a discussion of the recently released Veteran AHAR along with data from that report. However, we feel that we adequately discussed the methodological problems of the CHALENG and AHAR counts along with the strengths and weaknesses of the epidemiology of the homeless more generally.We understand the reviewer to be referring to the study by Rosenheck and Frishman (1994) of Vietnam-era Veterans that suggested that overrepresentation was attributable to disproportionate numbers of Veterans in the youngest cohorts (age 20-34) of homeless White males, and the follow-up study by Gamache and colleagues (2001). We do not disagree with the reviewer about this. However, we are suggesting that, for the reasons discussed in the section on Assessing the Limitations of the Current Research, more work needs to be done to understand why Veterans are over-represented.

estion #2a but don’t put any text to answer it. This is confusing, and the 

ut cannot be sure, that this question is answered in the text to 2b. Why 

tions, then, or at least signal somewhere that 2a is answered in 2b

We agree, this was confusing and have combined the questions as suggested by the reviewer.

ion that there appear to be “unique, military related pathways by 

e these risks [for homelessness]” yet there are NO specifics, and NO 

athways either in the response to Question #2b or in the response 

ction in which the author states these pathways will be taken up in 

weak finding by Rosenheck and colleagues between heavy combat 

e omission in offering up specific evidence to back up this assertion, 

Best Evidence Synthesis” is very surprising.

The concept of a pathway, as used in our report, is crucially different from a direct association. Given that the existing evidence does not find that Veterans differ substantially from non-Veterans in terms of the risk factors most strongly associated with homelessness in general, it is important to try to understand what, if anything, is qualitatively different about Veterans’ experiences that might increase their risk of these shared or common exposures. The conceptual model was revised to clarify how military specific exposures are associated with a number of other exposures that are in turn shared with the general population; these shared exposures are more often directly associated with homelessness, but the influence of military-specific exposures on the prevalence or severity of shared exposures may be significant. These chains of exposures are the pathways referenced. The discussion of these issues has been expanded under the section describing the evolution of the conceptual model on pages 13-14. More generally the section devoted to answering Key Question 3 is structured to explore the evidence for these pathways, which, as the report suggests, might include the specific salience, in a Veteran population, for examining military sexual trauma and/or combat exposure as precursors to PTSD/Anxiety/Depression, or post-deployment readjustment difficulties leading to low income.
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A Critical Review of the Literature

Regarding Homelessness among Veterans Evidence-based Synthesis Program

APPENDIX B. Technical Experts Consulted and

Reviewers

Technical Experts Consulted

Ted Amann

Director of Homeless Programs

Central City Concern

Portland, Oregon

Monica Beemer

Executive Director

Sisters of the Road

Portland, Oregon

Lillian Gelberg, M.D., MSPH

Professor of Family Medicine

UCLA Geffen School of Medicine

Los Angeles, California

Don Miller

Chief Counsel

Housing and Urban Development

Portland, Oregon

Fran Randolph

Director of the Division of Services and Systems Improvement

SAMHSA, Center for Mental Health Services

Jim Reuler, M.D. 

Professor, Department of Medicine

Oregon Health and Science University

Portland, Oregon

Robert Rosenheck, M.D.

Director, Northeast Program Evaluation Center and

Professor of Psychiatry and Public Health

Yale University School of Medicine

New Haven, Connecticut

Annetta C. Smith

Population Division

U.S. Census Bureau
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A Critical Review of the Literature

Regarding Homelessness among Veterans Evidence-based Synthesis Program

Reviewers

Mary K. Cunningham

Senior Research Associate

Urban Institute

Amy Kilbourne, Ph.D., MPH

VA Serious Mental Illness Treatment Resource and Evaluation Center

John Kuhn

National CHALENG Coordinator

Stephen Metraux, Ph.D.

National Center for Homelessness Among Veterans

Thomas O’Toole, M.D.

Providence VA Medical Center

David Smelson, Psy.D.

Bedford VA Medical Center