- Email: [email protected]
Extreme health inequalities: mortality in homeless people
Comment
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Vink MA, Dirksen MT, Suttorp MJ, et al. 5-year follow-up after primary percutaneous coronary intervention with a paclitaxel-eluting stent versus a bare-metal stent in acute ST-segment elevation myocardial infarction: a follow-up study of the PASSION (Paclitaxel-Eluting Versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation) trial. JACC Cardiovasc Interv 2011; 4: 24–29. Atary JZ, van der Hoeven BL, Liem SS, et al. Three-year outcome of sirolimus-eluting versus bare-metal stents for the treatment of ST-segment elevation myocardial infarction (from the MISSION! Intervention Study). Am J Cardiol 2010; 106: 4–12. Spaulding C, Teiger E, Commeau P, et al. Four-year follow-up of TYPHOON (trial to assess the use of the CYPHer sirolimus-eluting coronary stent in acute myocardial infarction treated with BallOON angioplasty). JACC Cardiovasc Interv 2011; 4: 14–23.
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Kaltoft A, Kelbaek H, Thuesen L, et al. Long-term outcome after drug-eluting versus bare-metal stent implantation in patients with ST-segment elevation myocardial infarction: 3-year follow-up of the randomized DEDICATION (Drug Elution and Distal Protection in Acute Myocardial Infarction) Trial. J Am Coll Cardiol 2010; 56: 641–45. Mauri L, Hsieh WH, Massaro JM, Ho KK, D’Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007; 356: 1020–29. Martinez AW, Chaikof EL. Microfabrication and nanotechnology in stent design. Wiley Interdiscip Rev Nanomed Nanobiotechnol 2011; 3: 256–68.
Extreme health inequalities: mortality in homeless people Published Online June 14, 2011 DOI:10.1016/S01406736(11)60885-4
Corbis
See Articles page 2205
2156
Over 1·5 million people, or one in 200 US citizens, were reported to have used homeless shelters or transitional housing over 12 months between 2008 and 2009.1 Half a million did so as part of a family, numbers that have increased since 2007. In Europe, although rates are lower, absolute numbers are high and have increased over the past few years. In the UK, for example, the number of rough sleepers seen by outreach workers increased 20% from 2006–07 to 2009–10.2 The state of being without a home has long been recognised as being associated with increased rates of physical and mental morbidity. Over the past decade, cohort studies have shown that these higher rates of morbidity translate into excess mortality.3,4 Because recent economic events might have increased the rates of homelessness as part of the fall-out of the sub-prime crisis, health services need to be ready to provide appropriate and effective services to this disadvantaged group.
In The Lancet, Sandra Nielsen and colleagues5 report a large register-based study of the prevalence of psychiatric disorders and mortality in homeless shelters in Denmark over 1999–2009. They replicate the wellknown finding of increased rates of psychiatric morbidity (particularly substance abuse),6 but also report vastly increased mortality rates. The standardised mortality ratio was 5·6 for men and 6·7 for women, albeit slightly lower than that in a Canadian cohort of 15 100 homeless people.4 Additionally, in the Danish cohort, homeless people with mental disorders did not have increased mortality compared with homeless people who were not mentally ill, although there was a relative increase in people with substance abuse. These are important facts and show that homeless people are at one extreme end of the spectrum of health inequalities. Methodologically, Nielsen and colleagues’ study shows the benefits of register-based data, which bring large numbers and precision to mortality estimates. However, partly because of their size, historical cohorts bring with them a degree of uncertainty about the accuracy of the measurement of exposures and outcomes that rely on administrative procedures. So, for example, homelessness in the Danish study was defined as a stay of at least one night in a homeless shelter for which a nominal fee was charged. This population is likely to be different from the truly itinerant “roofless” population who would be excluded from this study, are harder to study, and might have still higher rates of substance misuse and hence mortality.7 As such, the mortality estimates might well be conservative. Further, although diagnoses in the Danish psychiatric register are known to be reasonably reliable for severe mental illnesses such as schizophrenia, by definition they only www.thelancet.com Vol 377 June 25, 2011
Comment
detect treated episodes in primary and secondary care; and more detailed diagnostic information, such the specific substances used, must be viewed with a degree of caution. Furthermore, international comparison of studies of homelessness is made harder by the different social and housing systems between, for example, developing and more developed countries, and between small well-organised and highly socially integrated Nordic countries and larger more heterogeneous countries such as the USA. So, what can we conclude about the health associations of homelessness in general? First, there is a well-replicated increase in physical and mental illness and substantially increased mortality—even in countries with good safety nets for those with insecure accommodation. The situation is likely to be worse in countries with less well-organised welfare systems. Second, any additive risk between mental and physical illness on rates of mortality seems to be limited to substance abuse. This finding is interesting (and recently replicated in a Swedish study8) and might indicate that mentally ill homeless people who are not substance abusers have better access to health services than do homeless people without mental illness, perhaps as a result of specialist services introduced after the identification of the high rates of mental illness. Such an explanation was suggested in a small Swedish mortality study that had previously interviewed homeless persons.9 Mentally ill people who do not abuse substances might also spend less time homeless than do those with alcohol and drug problems, and substance abuse might be associated with a higher number of risk factors for natural and non-natural causes of death. Either way, this finding would benefit from replication in other settings and with use of other designs. Additionally, this result should not, as Nielsen and colleagues point out, detract from the fact that mortality risk is increased generally in people with schizophrenia, with median standardised mortality ratios between 2 and 3.10 Nielsen and colleagues’ study has important implications for health services. The findings suggest that integrated psychiatric and substance abuse
www.thelancet.com Vol 377 June 25, 2011
treatment is necessary to address inequalities, and further treatment trials on the best strategies to treat dual-diagnosis homeless patients and homeless young people11 are needed. Such enhanced treatment is likely to confer additional benefits, including reduction in violent crime, specific causes of mortality including suicide, and victimisation. Services need to be integrated and flexible: assertive community treatment could offer one approach,12 possibly with community support.13,14 *John R Geddes, Seena Fazel Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK [email protected] We declare that we have no conflicts of interest. 1
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US Department of Housing and Urban Development. The 2009 annual homeless assessment report to Congress 2009. June 18, 2010. http://www. hudhre.info/documents/5thHomelessAssessmentReport.pdf (accessed May 27, 2011). Broadway. Street to home: annual report for London 1st April 2009 to 31st March 2010. 2010. http://www.broadwaylondon.org/CHAIN/ NewsletterandReports/main_content/fullreport.pdf (accessed May 27, 2011). Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol 2009; 38: 877–83. Hwang SW, Wilkins R, Tjepkema M, O’Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009; 339: b4036. Nielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M. Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study. Lancet 2011; published online June 14. DOI:10.1016/S0140-6736(11)60747-2. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med 2008; 5: e225. Newton JR, Geddes JR, Bailey S, Freeman CP, McAleavy A, Young G. A survey of the health problems of the Edinburgh “roofless” population. Br J Psychiatry 1994; 165: 537–40. Beijer U, Andreasson S, Agren G, Fugelstad A. Mortality and causes of death among homeless women and men in Stockholm. Scand J Publ Health 2011; 39: 121–27. Beijer U, Andreasson A, Agren G, Fugelstad A. Mortality, mental disorders and addiction: a 5-year follow-up of 82 homeless men in Stockholm. Nord J Psychiatry 2007; 61: 363–68. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64: 1123–31. Altena AM, Brilleslijper-Kater SN, Wolf JL. Effective interventions for homeless youth: a systematic review. Am J Prev Med 2010; 38: 637–45. Coldwell CM, Bender WS. The effectiveness of assertive community treatment for homeless populations with severe mental illness: a meta-analysis. Am J Psychiatry 2007; 164: 393–99. Nelson G, Aubry T, Lafrance A. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. Am J Orthopsychiatry 2007; 77: 350–61. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med 2005; 29: 311–19.
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Vink MA, Dirksen MT, Suttorp MJ, et al. 5-year follow-up after primary percutaneous coronary intervention with a paclitaxel-eluting stent versus a bare-metal stent in acute ST-segment elevation myocardial infarction: a follow-up study of the PASSION (Paclitaxel-Eluting Versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation) trial. JACC Cardiovasc Interv 2011; 4: 24–29. Atary JZ, van der Hoeven BL, Liem SS, et al. Three-year outcome of sirolimus-eluting versus bare-metal stents for the treatment of ST-segment elevation myocardial infarction (from the MISSION! Intervention Study). Am J Cardiol 2010; 106: 4–12. Spaulding C, Teiger E, Commeau P, et al. Four-year follow-up of TYPHOON (trial to assess the use of the CYPHer sirolimus-eluting coronary stent in acute myocardial infarction treated with BallOON angioplasty). JACC Cardiovasc Interv 2011; 4: 14–23.
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Kaltoft A, Kelbaek H, Thuesen L, et al. Long-term outcome after drug-eluting versus bare-metal stent implantation in patients with ST-segment elevation myocardial infarction: 3-year follow-up of the randomized DEDICATION (Drug Elution and Distal Protection in Acute Myocardial Infarction) Trial. J Am Coll Cardiol 2010; 56: 641–45. Mauri L, Hsieh WH, Massaro JM, Ho KK, D’Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007; 356: 1020–29. Martinez AW, Chaikof EL. Microfabrication and nanotechnology in stent design. Wiley Interdiscip Rev Nanomed Nanobiotechnol 2011; 3: 256–68.
Extreme health inequalities: mortality in homeless people Published Online June 14, 2011 DOI:10.1016/S01406736(11)60885-4
Corbis
See Articles page 2205
2156
Over 1·5 million people, or one in 200 US citizens, were reported to have used homeless shelters or transitional housing over 12 months between 2008 and 2009.1 Half a million did so as part of a family, numbers that have increased since 2007. In Europe, although rates are lower, absolute numbers are high and have increased over the past few years. In the UK, for example, the number of rough sleepers seen by outreach workers increased 20% from 2006–07 to 2009–10.2 The state of being without a home has long been recognised as being associated with increased rates of physical and mental morbidity. Over the past decade, cohort studies have shown that these higher rates of morbidity translate into excess mortality.3,4 Because recent economic events might have increased the rates of homelessness as part of the fall-out of the sub-prime crisis, health services need to be ready to provide appropriate and effective services to this disadvantaged group.
In The Lancet, Sandra Nielsen and colleagues5 report a large register-based study of the prevalence of psychiatric disorders and mortality in homeless shelters in Denmark over 1999–2009. They replicate the wellknown finding of increased rates of psychiatric morbidity (particularly substance abuse),6 but also report vastly increased mortality rates. The standardised mortality ratio was 5·6 for men and 6·7 for women, albeit slightly lower than that in a Canadian cohort of 15 100 homeless people.4 Additionally, in the Danish cohort, homeless people with mental disorders did not have increased mortality compared with homeless people who were not mentally ill, although there was a relative increase in people with substance abuse. These are important facts and show that homeless people are at one extreme end of the spectrum of health inequalities. Methodologically, Nielsen and colleagues’ study shows the benefits of register-based data, which bring large numbers and precision to mortality estimates. However, partly because of their size, historical cohorts bring with them a degree of uncertainty about the accuracy of the measurement of exposures and outcomes that rely on administrative procedures. So, for example, homelessness in the Danish study was defined as a stay of at least one night in a homeless shelter for which a nominal fee was charged. This population is likely to be different from the truly itinerant “roofless” population who would be excluded from this study, are harder to study, and might have still higher rates of substance misuse and hence mortality.7 As such, the mortality estimates might well be conservative. Further, although diagnoses in the Danish psychiatric register are known to be reasonably reliable for severe mental illnesses such as schizophrenia, by definition they only www.thelancet.com Vol 377 June 25, 2011
Comment
detect treated episodes in primary and secondary care; and more detailed diagnostic information, such the specific substances used, must be viewed with a degree of caution. Furthermore, international comparison of studies of homelessness is made harder by the different social and housing systems between, for example, developing and more developed countries, and between small well-organised and highly socially integrated Nordic countries and larger more heterogeneous countries such as the USA. So, what can we conclude about the health associations of homelessness in general? First, there is a well-replicated increase in physical and mental illness and substantially increased mortality—even in countries with good safety nets for those with insecure accommodation. The situation is likely to be worse in countries with less well-organised welfare systems. Second, any additive risk between mental and physical illness on rates of mortality seems to be limited to substance abuse. This finding is interesting (and recently replicated in a Swedish study8) and might indicate that mentally ill homeless people who are not substance abusers have better access to health services than do homeless people without mental illness, perhaps as a result of specialist services introduced after the identification of the high rates of mental illness. Such an explanation was suggested in a small Swedish mortality study that had previously interviewed homeless persons.9 Mentally ill people who do not abuse substances might also spend less time homeless than do those with alcohol and drug problems, and substance abuse might be associated with a higher number of risk factors for natural and non-natural causes of death. Either way, this finding would benefit from replication in other settings and with use of other designs. Additionally, this result should not, as Nielsen and colleagues point out, detract from the fact that mortality risk is increased generally in people with schizophrenia, with median standardised mortality ratios between 2 and 3.10 Nielsen and colleagues’ study has important implications for health services. The findings suggest that integrated psychiatric and substance abuse
www.thelancet.com Vol 377 June 25, 2011
treatment is necessary to address inequalities, and further treatment trials on the best strategies to treat dual-diagnosis homeless patients and homeless young people11 are needed. Such enhanced treatment is likely to confer additional benefits, including reduction in violent crime, specific causes of mortality including suicide, and victimisation. Services need to be integrated and flexible: assertive community treatment could offer one approach,12 possibly with community support.13,14 *John R Geddes, Seena Fazel Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK [email protected] We declare that we have no conflicts of interest. 1
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US Department of Housing and Urban Development. The 2009 annual homeless assessment report to Congress 2009. June 18, 2010. http://www. hudhre.info/documents/5thHomelessAssessmentReport.pdf (accessed May 27, 2011). Broadway. Street to home: annual report for London 1st April 2009 to 31st March 2010. 2010. http://www.broadwaylondon.org/CHAIN/ NewsletterandReports/main_content/fullreport.pdf (accessed May 27, 2011). Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol 2009; 38: 877–83. Hwang SW, Wilkins R, Tjepkema M, O’Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009; 339: b4036. Nielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M. Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study. Lancet 2011; published online June 14. DOI:10.1016/S0140-6736(11)60747-2. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med 2008; 5: e225. Newton JR, Geddes JR, Bailey S, Freeman CP, McAleavy A, Young G. A survey of the health problems of the Edinburgh “roofless” population. Br J Psychiatry 1994; 165: 537–40. Beijer U, Andreasson S, Agren G, Fugelstad A. Mortality and causes of death among homeless women and men in Stockholm. Scand J Publ Health 2011; 39: 121–27. Beijer U, Andreasson A, Agren G, Fugelstad A. Mortality, mental disorders and addiction: a 5-year follow-up of 82 homeless men in Stockholm. Nord J Psychiatry 2007; 61: 363–68. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64: 1123–31. Altena AM, Brilleslijper-Kater SN, Wolf JL. Effective interventions for homeless youth: a systematic review. Am J Prev Med 2010; 38: 637–45. Coldwell CM, Bender WS. The effectiveness of assertive community treatment for homeless populations with severe mental illness: a meta-analysis. Am J Psychiatry 2007; 164: 393–99. Nelson G, Aubry T, Lafrance A. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. Am J Orthopsychiatry 2007; 77: 350–61. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med 2005; 29: 311–19.
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