Tracking Change in Psychological Distress among Homeless Adults: An Examination of the Effect of Housing Status

Given the profound physical and social deprivations associated with homelessness, it is not surprising that earlier research has consistently documented higher levels of psychological distress among homeless people compared with members of the general population (Ritchey, La Gory, Fitzpatrick, & Mullis, 1990, Robertson, 1992; Robertson & Winkleby, 1996). The elevated levels of psychological distress have been interpreted as indicative of a link between mental health problems and homelessness. A critical but largely unexamined question is whether distress symptoms experienced by homeless people are endogenous to the psychiatric disorders that an individual may experience or are otherwise caused by environmental factors tied to the individual's homelessness (Koegel & Burnam, 1992). Given the high levels of distress symptoms reported in clinical studies of psychiatric patients (Husaini, Neff, Harrington, Hughes, & Stone, 1980; Wold, Rosenfield, & Dwight, 1982), it is reasonable to assume that symptoms experience d by homeless people with serious mental illness (SMI) constitute a rather enduring feature of their lives and are less responsive to objective circumstances such as change in housing status. On the other hand, among those who do not experience psychiatric problems, symptoms of distress are more likely to be attributable to stresses and strains emanating from their homelessness and should diminish when these individuals have made the transition to more favorable circumstances, such as the procurement of permanent housing arrangement. Using longitudinal data collected from a probability sample of adult homeless people, this article looks at the pattern of change in psychological distress over time among homeless people with SMI (including those with a co-occurring substance abuse disorder), homeless people with drug or alcohol problems (but not SMI), and homeless people with neither diagnosis. The article also examines the extent to which the change in levels of distress symptoms is associated with change in housing status among homeless people with different psychiatric diagnoses. MENTAL HEALTH AND HOMELESSNESS Since homelessness became a major social problem in the late 1970s and early 1980s, there has been an emerging consensus that mental health issues, broadly conceptualized, are linked to homelessness. An early wave of psychiatric-oriented studies found mental illness to be pervasive among members of the homeless population, documenting that as many as three-quarters of the homeless adult population had a diagnosable mental disorder (Arce, Tadlock, Vergare, & Shapiro, 1983; Lipton, Sabatini, & Katz, 1983). Although such estimates have been discarded as having questionable validity because of various methodological limitations, the prevailing image of homeless people as suffering disabling functional deficits from their psychiatric disorders has remained unchanged. Recent empirical studies have concurred that one-third of the adult homeless population has an SMI (Dennis, Buckner, Lipton, & Levine, 1991; Shlay & Rossi, 1992). Although this estimate is substantially higher than those reported in earlier studies, the rate of SMI among homeless people is considerably higher than that reported in the housed population (Wright, Rubin, & Devine, 1998). Moreover, using the Diagnostic Interview Schedule (DIS) from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition--Revised (DSM-III-R) (American Psychiatric Association, 1987) and other standardized diagnostic instruments, empirical studies have broadened the assessment of psychiatric disorders to include alcoholism and drug disorders. These studies found that problems of drug and alcohol abuse are more widespread than SMI and that there is a high rate of co-occurrence of substance abuse disorder among homeless individuals diagnosed with SMI (Cohen & Burt, 1990; Devine & Wright, 1997; Koegel, Burnam, & Farr, 1988; Struening & Padgett, 1990). …