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RESEARCH WEEKLY: Promoting a continuum of care for people with SMI who experience homelessness
By Shanti Silver
(July 5, 2023) The level of abuse, neglect, and incarceration among people with severe mental illness who are experiencing homelessness in the United States is “an unacceptable humanitarian crisis,” according to the authors of a recent article in the “Journal of the American Medical Association.” In this article, researchers from Harvard Medical School discuss the importance of providing a continuum of outpatient and inpatient care for people with severe mental illness who are experiencing homelessness.
Deinstitutionalization and the failure to provide a continuum of care
The current crisis of homelessness among people with severe mental illness began with deinstitutionalization. Deinstitutionalization refers to the rapid loss of psychiatric beds that began in the mid-1900s. The goal of deinstitutionalization was to move people with severe mental illness from state psychiatric hospitals to the community where they could receive treatment in a less restrictive setting.
However, when state institutions began to rapidly discharge people into the community, they rarely coordinated with community mental health centers to ensure people would continue receiving care, leaving many to fall through the cracks. In the years since deinstitutionalization, changes in federal policies such as the defunding of community-based care in the 1980s and a decrease in affordable housing options has left many people with severe mental illness in a cycle of ‘treat and street.’ In our current mental health system, people requiring emergency psychiatric care are often brought to hospitals and treated, only to be discharged from inpatient care without follow-up, leaving them to deteriorate to the point of once again needing emergency services.
The authors of this article propose that the recent attention given to the mental health treatment of people with severe mental illness who are experiencing homelessness from politicians such as Mayor Eric Adams in New York City and Governor Gavin Newsom in California presents an opportunity for us to learn from mistakes of the past. In order to ensure people with severe mental illness who are experiencing homelessness are able to access sustainable care and housing, the authors emphasize the need for a continuum of community-based care, inpatient treatment, and preventative policies.
Community-based care, hospitalization, and policies of prevention
There are several community-based services that have been shown to help many people with severe mental illness who experience homelessness to access mental health care and stable housing. However, while widespread implementation of these community interventions has the potential to help many people with severe mental illness, there will still be people with severe mental illness whose symptoms are severe enough that they require short- or long-term hospitalization to remain safe and begin their path to recovery, according to the authors. For people who require inpatient care, the authors say that it is necessary that a sufficient number of psychiatric hospital beds remain available, although they also note that institutions delivering inpatient care should be able to ensure that they deliver effective, compassionate, and quality care to all of their patients.
In addition to investing in community services and inpatient psychiatric beds, the authors also note that in order to prevent homelessness for people with severe mental illness in a way that is sustainable, these services will need to communicate and coordinate “to eliminate gaps that require patients to coordinate their care without support.” If we aim to reduce homelessness for people with severe mental illness, policies that aim to target systemic problems such as housing prices, income inequality, and barriers to mental health care, among other things, will also be necessary.
Implications
Currently, it is estimated that at least one in five people experiencing homelessness in the United States has a severe mental illness. The limited availability of care for this population, which was made worse by closures of psychiatric beds and social services during the COVID-19 pandemic, means that people with severe mental illness face alarming rates of incarceration, suicide, and premature death, all of which may be preventable through expanding access to a robust continuum of care for this population.
Reference
Koh, K. A., & Gorman, B. L. (April 2023). Reimagining Institutionalization and a Continuum of Care for People Experiencing Homelessness and Mental Illness. JAMA.
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