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Psychosocial functioning of individuals with schizophrenia in community housing facilities and the psychiatric hospital in Zurich
Author’s Accepted Manuscript Psychosocial functioning of individuals with schizophrenia in community housing facilities and tHE PSYCHIATRIC HOSPITAL IN Zurich Matthias Jaeger, David Briner, Wolfram Kawohl, Erich Seifritz, Gabriela Baumgartner-Nietlisbach www.elsevier.com/locate/psychres
PII: DOI: Reference:
S0165-1781(15)30366-8 http://dx.doi.org/10.1016/j.psychres.2015.09.029 PSY9215
To appear in: Psychiatry Research Received date: 10 May 2015 Revised date: 30 July 2015 Accepted date: 18 September 2015 Cite this article as: Matthias Jaeger, David Briner, Wolfram Kawohl, Erich Seifritz and Gabriela Baumgartner-Nietlisbach, Psychosocial functioning of individuals with schizophrenia in community housing facilities and tHE PSYCHIATRIC HOSPITAL IN Zurich, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2015.09.029 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Psychosocial functioning of individuals with schizophrenia in community housing facilities and the psychiatric hospital in Zurich Matthias Jaegera*, David Brinerb*, Wolfram Kawohla, Erich Seifritza, Gabriela BaumgartnerNietlisbachb a
Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of
Psychiatry Zurich, Switzerland b
Psychiatric-psychological service, City of Zurich, Switzerland
*both first authors equally contributed to the manuscript
Corresponding author: Dr. med. Matthias Jaeger University Hospital of Psychiatry Zurich Department for Psychiatry, Psychotherapy and Psychosomatics Lenggstrasse 31 8032 Zurich Switzerland Email: [email protected] Phone: +41 (0)44 384 26 37 Fax: +41 (0)44 384 25 06
Abstract Individuals with severe mental illness frequently have difficulties in obtaining and maintaining adequate accommodation. If they are not willing or able to adapt to requirements of traditional supported housing institutions they may live in sheltered and emergency accommodation. Adequate mental health services are rarely available in these facilities. The aim of the present study was to evaluate mental health, functional and social status of individuals living in community sheltered housing facilities. A cross-sectional survey of n=338 individuals in sheltered housing compared to a sample of patients at intake in acute inpatient psychiatry (n=619) concerning clinical and social variables was carried out in the catchment area of Zurich. Matched subsamples of individuals with schizophrenia (n=168) were compared concerning functioning and impairments on the Health of the Nation Outcome Scales (HoNOS). Individuals with schizophrenia in sheltered housing (25% of the residents) have significantly more problems concerning substance use, physical illness,
psychopathological symptoms other than psychosis and depression, and relationships, daily activities and occupation than patients with schizophrenia at intake on an acute psychiatric ward. Community sheltered accommodation although conceptualized to prevent homelessness in the general population de facto serve as housing facilities for individuals with schizophrenia and other severe mental illness.
Keywords Epidemiology Quality of care Social psychiatry Supported housing Functional impairment
1. Introduction 1.1.
Housing situation of individuals with severe mental illness after the era of deinstitutionalization
During the process of deinstitutionalization long-term patients of psychiatric hospitals were supposed to be transferred to the communities with support of outpatient mental health and social services in order to enhance integration and inclusion (Killaspy, 2006). In practice many patients were mainly transferred to residential and nursing homes instead (Richter, 2003; Franz et al., 2010). The rehabilitative housing sector for individuals with psychotic disorders and other severe mental illness expanded considerably providing custodial housing settings with included treatment and care of different intensity (Fakhoury et al., 2002; Priebe et al., 2008; Tabol et al., 2010). This process can be regarded as ongoing in many countries (Bitter et al., 2009). Individuals who are reluctant to these settings and not able to find and keep adequate accommodation on their own are threatened with homelessness and lack
essential mental health care (Freyberger et al., 2008). These persons are likely to find their way to sheltered and emergency accommodations that are not specialized in handling severe mental illnesses sufficiently and do not have enough professional capacities at their disposal (Langle et al., 2001; McQuistion et al., 2003). Severe mental disorders among those individuals may therefore not be detected nor treated adequately.
1.2.
Housing conditions, mental health and psychiatric care
Poor housing conditions are associated with poor mental health and higher prevalence of mental disorders (Bashir, 2002; Latkin and Curry, 2003; Kyle and Dunn, 2008). Prevalence rates of mental disorders among homeless people are up to 90% with high rates of comorbidity, consistently higher prevalence rates for all major psychiatric diagnoses compared to the general population and a large proportion of substance abuse (Driessen and Dilling, 1997; Kellinghaus et al., 1999; Fichter and Quadflieg, 2001; Fazel et al., 2008). However, homeless individuals including those living in emergency and sheltered accommodations are difficult to reach by mental health services as they rarely seek help for themselves on a voluntary basis (Langle et al., 2005). Barriers to mental health care for the homeless are multifaceted including high level of exclusion criteria, lack of coordination among services, prejudices among staff, and problems in obtaining health insurance for homeless people (Canavan et al., 2012). Outreach services such as assertive community treatment (ACT), intensive case management (ICM) and related concepts aim at improving physical and mental health of individuals at risk of homelessness amongst others (Killaspy, 2007; Dieterich et al., 2010; Marshall and Lockwood, 2011), but are rarely implemented outside Anglophone countries, and neither in Switzerland. Sheltered housing facilities and emergency accommodation have scarce resources of consultant mental health professionals, if any. Therefore, access to mental health services is more likely to occur via involuntary admissions or emergency visits due to endangerment to oneself or others. During short-term acute inpatient treatment and crisis intervention it is difficult to achieve significant improvement of the care situation outside the hospital. Patients who do not agree to stay long enough to find an adequate accommodation and mental health support will be discharge in a similar precarious situation as before admission (Jaeger et al., 2013). This dissatisfying situation of care provision is perpetuated by the fragmented financing of health care and social support. Coordination and cooperation across sectors is scarce and not routinely implemented in most areas. Fragmentation of service organization is a common problem for mental health care in many developed countries resulting in discontinuation of treatment and the “revolving door” phenomenon, amongst others. In some countries multidisciplinary conference of several help providers or other options such as case management services
are implemented in order to compensate this problem. In Switzerland, these structures are scarcely implemented in few regions.
1.3.
Objectives
Individuals who do not exhibit obviously dangerous behavior frequently remain in shelters and may be undersupplied by mental health services. In a majority of regions including Switzerland, it can be expected that individuals living in the most low threshold residences such as emergency overnight accommodation or sheltered hostels would show a considerably impaired mental health status. The aim of this study was to evaluate mental health, functional and social status of individuals with schizophrenia and related psychotic disorder living in community sheltered housing facilities with minimal mental health care onsite (residents) and to compare them with a matched clinical sample at intake on an acute ward (patients). It was hypothesized that the residential sample would be at least equally impaired than the clinical sample. 2. Methods 2.1.
Study samples and procedures
A cross-sectional survey with two independent groups was conducted. The residential sample was recruited by approaching inhabitants of the four community sheltered housing facilities for homeless adults (in total 460 places, part of the social department, sector “Housing and Shelter”) as the biggest provider of sheltered housing for homeless individuals in Zurich (400’000 inhabitants, largest city of Switzerland). All facilities are not specialized for care of individuals with mental disorders in the first place. They are low-threshold, tolerate substance use, and exclude individuals only in case of violence and possession of firearms, drug dealing or prostitution on-site, and other serious violation of the house rules. In detail, one facility for supported housing (“Begleitetes Wohnen”) addresses socially disintegrated and substance dependent people who are not able to care for themselves. It provides 342 single rooms on various properties in Zurich including individualized support concerning personal hygiene, socially acceptable behavior and substance use, and administrative affairs. The staff-client-ration is about 1:35 corresponding to four hours support per month. A second facility for supportive housing (“Betreutes Wohnen City”) focusses on individuals with social and health-related disabilities who are not able to become integrated in residential or nursing homes. The service consists of 47 places on two sites and provides continuous onsite support on miscellaneous personal matters with the exception of intensive physical or mental care. Psychiatric care is provided once per week by a consultant psychiatrist of the psychiatric-psychological outreach services of the City of Zurich. The third institution is an emergency overnight accommodation (“Notschlafstelle”) that provides shelter for the night as
well as counselling, provision of information for support, and basic medical care. It is open every day between 8 p.m. and 10 a.m. and holds 52 places in shared rooms available. Repeated use of the facility is possible up to four months. The fourth institution included in the study is a hostel (“Nachtpension”) for 20 persons that repeatedly made use of the emergency accommodation described before. It is closed during the day, the stay is restricted to one year and the inhabitants are mainly supported in finding a more permanent accommodation. Around 1400 individuals reside in these institutions per year. We included the 460 individuals living in the facilities at a reference date in 2012, i.e. one inhabitant per place. Exclusion criteria were acute psychotic episode requiring inpatient treatment, acute intoxication, and delirium. An interpreter was involved in case of insufficient capability of the German language. Eligible residents were informed extensively about purpose and procedure of the study and signed written informed consent if they were willing to participate. Subsequently, they underwent a structured 45 minutes interview that consisted of the measures described below. n =338 (73%) of the eligible 460 residents participated. Six residents were not included due to acute psychotic condition and/or intoxication. The other residents refused to participate. Participants received an incentive of 20 Swiss Francs. The clinical sample consisted of individuals at admission on an acute psychiatric ward of the University Hospital of Psychiatry in Zurich in 2012. There were eight acute wards with equal structural conditions (capacities of 16 to 21 patients, closed door most of the time, duration of stay 25 days on average, all diagnoses, comprehensive treatment options including pharmacology, short-term psychotherapy, occupational, vocational, physical therapies, amongst others). Data derived from routine medical documentation. Data on the first episode per patient in 2012 were available for 1712 patients. Complete data sets (no missing data) were included only, resulting in n=619 (36%). 50% of the patients were involuntarily admitted. The selected subsample did not differ from the whole cohort in terms of gender (44.3 vs. 43% female), age (mean 42.5 vs. 41.4, SD 12.9 vs. 13.6), and legal status at intake (50.0 vs. 49.6% involuntary). Sociodemographic and clinical parameters of the two samples were compared by statistical procedures for independent groups as described below. Afterwards, a subsample of individuals with schizophrenia or related psychotic disorders of the residential group was matched by age and gender with individuals with the same diagnosis of the clinical sample in order to create approximately homogeneous groups concerning sociodemographics and diagnosis. Because of the relatively small number of individuals with psychosis in the residential group (n =84) matching was executed manually. Subjects of both groups were sorted by gender and age. If more than one patient matched to a resident, we chose the patient who corresponded best with respect to nationality and marital status. If no patient had
exactly the same age as a particular resident, we chose the one who matched closest. However, this was rarely necessary as the number of patients with psychosis was three times higher than the residential subsample. As additional variables in the residential sample the self-assessed health status and health care service use were requested. In the clinical sample the percentage of involuntary admissions was registered. The matched pairs sample (n =168) was assessed for group differences concerning problems and functioning. The study was conducted according to the principles of Good Clinical Practice (GCP). The local ethics committee has confirmed the study in accordance with the Declaration of Helsinki and its later amendments.
2.2.
Measures
Sociodemographic and clinical factors were derived from routine documentation in both samples (age, gender, marital status, education, employment, financial status, nationality, and medication). Clinical diagnoses of the residential sample were assessed by trained researchers according to the ICD-10 criteria using the Mini International Neuropsychiatric Interview, M.I.N.I. (Sheehan et al., 1998). Diagnoses of the clinical sample were part of the routine clinical charts and consistently achieved by clinical assessment according to ICD-10 criteria by a psychiatrist. Global and differentiated problems and functioning were assessed by the Global Assessment of Functioning, GAF (APA, 1994) and the Health of the Nation Outcome Scales, HoNOS (Andreas et al., 2010; Theodoridou et al., 2011). GAF is a onedimensional score between 0 and 100 (low to high global functioning). HoNOS consists of 12 items to be rated on 5-point scales (0 to 4, no to severe problems in the respective area) and refers to problems due to symptoms and behavior as well as environmental factors. All interviewers were trained in using the standardized instruments M.I.N.I., GAF and HoNOS. The self-assessed health status and health care service use was evaluated by the questions (i) Do you have a permanent health problem? (ii) What kind of problem is it (physical, mental, both, neither)? (iii) Did you attend a medical service within the past 6 months? (iv) Did you see a psychiatrist/ psychologist?
2.3.
Data analysis
The data were analyzed using SPSS Statistics Version 20 (Statistical Package for the Social Sciences, IBM Corporation, 2011). Categorical variables were compared between groups using cross-tabulations and chi-square tests as well as Cramer’s V as a measure of effect size. Continuous variables were tested for normal distribution (Q-Q-diagram, skewness and kurtosis) and compared by t-test and non-parametric Mann-Whitney-U-test if not normally distributed. HoNOS was also regarded as interval scale. The significance level was set at p=0.05 (two-tailed).
3. Results 3.1.
Clinical and demographic characteristics of residents and acute inpatients
The sociodemographic and clinical characteristics of the two samples are displayed in table 1. Compared to the clinical sample, the residents were older (range 20 to 82 years of age), more frequently male, single, lower educated, and unemployed. Almost none of them had an own income and they were less likely to receive disability of retirement pensions. Most of them were financed by the welfare system. There was no difference in nationality (divided into three overarching categories).
Insert table 1 about here.
Regarding clinical characteristics the number of diagnoses (including primary and secondary diagnoses) in the residential sample was higher than in the clinical sample (Median 2 versus 1; Mean rank 594 versus 416; Mann-Whitney-U 65.695,5, p<0.001). Only 4% of the residential sample had no psychiatric diagnosis. Schizophrenia and related disorders were diagnosed in the clinical sample more frequently. All other diagnostic categories according to ICD-10 (F1, F3, F4, and F6) were overrepresented in the residential sample. The most considerable discrepancy was found concerning substance-related disorders that were diagnosed in more than 80% of the residents compared to one third of the patients. The results concerning drug treatment show that residents are treated due to somatic disorders more frequently and about three quarters of both samples were treated with psychopharmacological drugs. With regard to the respective drug categories it appears that the clinical sample is treated more frequently with all kinds of psychopharmacological drugs with the exception of opioid maintenance.
3.2.
Psychosocial functioning of individuals with schizophrenia in residential and clinical setting
As a second step of the analyses the individuals of the residential sample diagnosed with schizophrenia or related psychotic disorder according to ICD-10 category F2 (n =84) were matched with individuals with psychosis of the clinical sample with respect to age and gender. In both subsamples 36% were female and mean age was 46.6 (standard deviation 10.5). There were only slight differences concerning nationality and marital status but considerable differences regarding social variables (table 2). Again, individuals with psychotic disorders in the residential sample were considerably less educated. More than half of them were unemployed and only two worked in the competitive labor market while about 10% of the clinical sample was unemployed and more than one third had a regular job.
Also, the financial status differed between groups with the residents having an own income and disability pensions to a lesser extent. Education, employment and financial status showed moderate to strong effect sizes. In the clinical sample 67% were involuntarily admitted. In the residential sample, 68% stated to have a permanent health problem, and 51% said that it was a mental problem. 81% have been at medical service of any kind within the past 6 months. 25% have seen a psychiatrist and 4% a psychologist. No data on frequency and length of the consultations was available.
Insert table 2 about here.
Global functioning was lower on average and the items and subscales of HoNOS showed considerably more problems in the residential than in the clinical sample (table 3). In detail these problems concern alcohol and drug abuse, physical health, mental health other than depression and psychotic symptoms, and social functioning such as relationships, daily activities and occupation. Aggressive behavior was the only item that revealed more problems among clinical patients. No differences were detected concerning self-injury, cognition, depression, hallucinations and delusions, and living conditions.
Insert table 3 about here.
4. Discussion The main result of the present study is that individuals with schizophrenia living in the most low-threshold accommodations in Zurich with basic social support but minimal health care are more functionally impaired than patients with schizophrenia at intake on an acute psychiatric ward (of which two third had been admitted involuntarily). They have more problems concerning substance use, physical illness, psychopathological symptoms other than psychosis and depression, and relationships, daily activities and occupation. Only 25% had seen a psychiatrist within the last 6 months although 51% stated that they had a permanent mental problem. This finding has to be discussed against the background of the local mental health service structure and can therefore not be generalized to other catchment areas offhand. However, the general developments of mental health care provision in several countries across Europe have certain similarities as illustrated in the introduction and the consequences for the most mentally disabled individuals might be comparable internationally.
4.1.
Housing facilities in the Zurich catchment area
In Zurich, as in many other catchment areas, a large sector of specialized rehabilitative housing facilities for individuals with severe mental illnesses has developed within the last decennia. These institutions provide combined housing and care of graduated intensity concerning various dimensions e.g. restriction to autonomy, personal support in housing related skills, and treatment, occupational or vocational programs on-site. Most of these institutions have in common that access is restricted to those individuals who are willing and able to conform to the institution’s house rules, to comply with psychiatric treatment and/or medication, and to join the occupational program and the collective activities. These preconditions have partly been established in order to provide more stability of institutional processes as a result of perceived lack of collaboration with psychiatric institutions in case of crisis and difficult behavior of clients (Jaeger et al., 2014). Individuals who cannot or do not wish to adapt to those requirements only find shelter in the low-threshold transitional housing facilities inquired in the present study. Alongside the reduced requirements to the residents, the intensity of (mental health) care in these facilities is also low.
4.2.
Access to mental health services
There are important consequences for service provision related to the present results. No quantitative data on frequency and length of service use was included, but only 25% of participants of the residential sample have seen a psychiatrist although 51% stated to have a mental problem indicating low help seeking behavior. According to the well evaluated group of “high utilizers” (Roick et al., 2004), the “low utilizers” stand at the (opposite) edge concerning intensity of service use. Next to patient-related factors it is likely that servicerelated factors, i.e. barriers to care, are responsible for the aberrant service use (Canavan et al., 2012). If there is a considerable number of individuals with equal distress due to psychotic symptoms and even more physical, functional and social problems living in a surrounding that provides much less health support than a psychiatric hospital, it has to be questioned if resources for mental health care are adequately allocated. Access to enhanced psychiatric care in mental health care systems as currently established in many European countries is restricted to those who make use of it voluntarily or is reserved to those who are involuntarily admitted due to disruptive or suicidal behavior. Those who do not disturb the community and are too impaired or reluctant to seek for help have to rely on minimal – mostly social – support. The focus on institutional interests has to be challenged in order to be able to establish or enhance alternative structures based on the needs of those who currently do not have full access to the support system. Although the present data are not eligible to conclude that particular interventions have to be implemented in the catchment area of interest, the following paragraph discusses ACT and related interventions may improve the provision of mental health care of the assessed residential sample.
4.3.
Barriers for the implementation of assertive outreach interventions
In order to enhance mental and general health care for those individuals living in sheltered and emergency accommodation, coordination and communication between different providers of care and support of both, the social and health care sector is essential. ACT and other forms of ICM are eligible services that rely on integration and continuity and target on individuals who are difficult to reach by other services. The effectiveness of these interventions has generally been proven but is highly related to local conditions (Dieterich et al., 2010; Marshall and Lockwood, 2011). ACT can reduce the probability and the length of inpatient treatment episodes. Furthermore, individuals treated with ACT lived more autonomously in the community and were less likely to face homelessness (Coldwell and Bender, 2007; Nelson et al., 2007). International guidelines therefore explicitly recommend the implementation of ACT for homeless people and other individuals who are difficult to reach by traditional services (NICE, 2009; DGPPN, 2013). Other promising models of care for homeless individuals with mental illness are “Housing First” and related concepts that offer their clients (subsidized) accommodation without time limit or preconditions in terms of mandatory treatment or care (Goering et al., 2011; Somers et al., 2013). Nevertheless, in the Zurich catchment area team-based interventions such as ACT or alternative services to congregate supported housing are not available. The community psychiatricpsychotherapeutic outreach service provides visits in the institutions in order to improve clients’ mental and general health care utilization and counselling of staff indeed, but has only very limited personal capacity that does not allow regular intensive on-site treatment. The overall spectrum of services in the Zurich catchment area includes outpatient clinics, a high density of psychiatrists and psychologists in private practice, several day-hospitals including one for acute treatment, a night-clinic, crisis intervention, supported employment, amongst others (Rossler and Kawohl, 2013). This advanced range of services serves as an argument against the implementation of a new service such as ACT in discussions on mental health policy. The willingness to make additional resources available is very limited as is the willingness to release resources from inpatient capacities. However, there is a high unmet need for mental care even in highly developed countries, which may not be covered by reallocating existing healthcare resources (Alonso et al., 2007). New needs-adapted services can make the mental health care system accessible for individuals who did not make use of it before (Goldman et al., 2001). Another barrier for the implementation of ACT or ICM is based on the fragmented financing situation of and the insufficient coordination and communication between the social and medical care sectors. Mental health providers tend to assume that if patients are placed in sheltered or supported housing facilities, adequate health care would be secured. Social
services on the other hand might leave the implementation of social support especially housing to the psychiatric institutions once a patient is admitted to the hospital. A continuous effort to enhance these individuals’ engagement, implementation of intensive care at the right time followed by ongoing rehabilitation mostly fails due to the gap between both sectors (McQuistion et al., 2003).
4.4.
Limitations of the study
There are a number of limitations attached to the present study next to those already mentioned before. Methodologically, the study was conducted as a cross-sectional survey of two independent groups which is a limitation to direct comparability of the results. The evaluation of especially the HoNOS items concerning social aspects might be biased by a halo-effect. This means that some problems of individuals on an acute ward might appear less severe in the light of the problems that generally have to be handled in acute and emergency psychiatry while in sheltered housing facilities the opposite might be the case. In both samples the same instruments and variables were applied, only diagnoses were obtained in different ways, i.e. using the M.I.N.I. in the residential sample and by clinical routines in the clinical sample. This might be an explanatory factor for the different rates of most diagnostic groups, in particular for substance disorders as these might be underreported among inpatients and are not always systematically assessed at intakes. Both samples were not examined by the same investigators, but all of them were trained in using the instruments. In the clinical sample only one third of the eligible data sets were included due to missing data in the other two thirds. However, no obvious selection bias is suspected as a result of the exclusion of incomplete data sets, and the selected subsample did not significantly differ from the whole cohort concerning age, gender and percentage of involuntary admissions.
5. Conclusion Community sheltered accommodation in Zurich although conceptualized to prevent homelessness in the first place de facto serve as housing facilities for individuals with severe mental illness. Individuals living in these facilities are even more impaired concerning social problems, physical health, substance abuse, and some psychiatric symptoms than patients at intake on an acute psychiatric ward. It should be a major concern of mental health policy to enable adequate mental health care for those individuals who are not able or willing to access traditional institution-based services. Outreach services such as ACT and related concepts are likely to reach more persons with severe mental disorders who have an increased risk for homelessness and are therefore recommended by clinical guidelines (NICE, 2009; DGPPN, 2013) to be implemented as standard services.
Epidemiological studies concerning “low utilizers”, i.e. individuals with severe mental illness and functional impairment, are scarce in European countries. Future research should address barriers to care for these individuals and appropriate needs-oriented psychiatric and psychosocial services. The implementation and evaluation of conjoint projects of mental health and social services that are adapted to local structural conditions and flexible to reach these persons are required. Conflict of interest The authors declare that they have no conflict of interest.
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Kyle, T.,Dunn, J.R., 2008. Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: a review. Health Soc Care Community 16, 1-15. Langle, G., Egerter, B., Albrecht, F., Petrasch, M.,Buchkremer, G., 2005. Prevalence of mental illness among homeless men in the community--approach to a full census in a southern German university town. Soc Psychiatry Psychiatr Epidemiol 40, 382-390. Langle, G., Mayenberger, M.,Gunthner, A., 2001. [Community-based rehabilitation for severely ill psychiatric patients?]. Rehabilitation (Stuttg) 40, 21-27. Latkin, C.A.,Curry, A.D., 2003. Stressful neighborhoods and depression: a prospective study of the impact of neighborhood disorder. J Health Soc Behav 44, 34-44. Marshall, M.,Lockwood, A., 2011. Assertive community treatment for people with severe mental disorders. Cochrane Database Syst Rev, CD001089. McQuistion, H.L., Finnerty, M., Hirschowitz, J.,Susser, E.S., 2003. Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatr Serv 54, 669-676. Nelson, G., Aubry, T.,Lafrance, A., 2007. 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 77, 350-361. NICE. (2009) Schizophrenia. Core interventions in the treatment and management of schizophrenia in adults in primary and secundary care. www.nice.org.uk. Priebe, S., Frottier, P., Gaddini, A., Kilian, R., Lauber, C., Martinez-Leal, R., MunkJorgensen, P., Walsh, D., Wiersma, D.,Wright, D., 2008. Mental health care institutions in nine European countries, 2002 to 2006. Psychiatr Serv 59, 570-573. Richter, D. (2003) Psychisches System und soziale Umwelt: Soziologie psychischer Störungen in der Ära der Biowissenschaften, Bonn: Psychiatrie-Verlag. Roick, C., Heider, D., Kilian, R., Matschinger, H., Toumi, M.,Angermeyer, M.C., 2004. Factors contributing to frequent use of psychiatric inpatient services by schizophrenia patients. Soc Psychiatry Psychiatr Epidemiol 39, 744-751. Rossler, W., Kawohl, W. (2013) Soziale Psychiatrie - Das Handbuch für die psychosoziale Praxis, Stuttgart: W. Kohlhammer. Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R.,Dunbar, G.C., 1998. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59 Suppl 20, 22-33;quiz 34-57. Somers, J. M., Rezansoff, S. N., Moniruzzaman, A., Palepu, A., Patterson M., 2013. Housing first reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial. PLoS One 8: e72946.
Tabol, C., Drebing, C.,Rosenheck, R., 2010. Studies of "supported" and "supportive" housing: a comprehensive review of model descriptions and measurement. Eval Program Plann 33, 446-456. Theodoridou, A., Jaeger, M., Ketteler, D., Kawohl, W., Lauber, C., Hoff, P.,Rossler, W., 2011. The concurrent validity and sensitivity of change of the German version of the health of the nation outcome scales in a psychiatric inpatient setting. Psychopathology 44, 391-397. Table 1 Sociodemographic and clinical characteristics by sample Variable
Age* Gender Female Marital status Single Married/Civil union Divorced/widowed Education None Basic school/ apprenticeship Higher education Employment None Competitive Sheltered Financial status Own income Pension° Welfare Nationality Swiss Schengen area Non-Schengen Diagnosis (ICD-10) Substance-related disorder (F1) Schizophrenia and related disorder (F2) Affective disorder (F3) Neurotic and adjustment disorder (F4) Personality disorder (F6) Drug treatment Any somato-pharmacological
Residential sample (n=338) % M(SD)*
Clinical sample (n=619) % M(SD)*
Statistics 2 Chi -test t-test* Chi T*
df
p
45.1 (10.1)
42.5 (12.9)
3.3
955
0.001
24.6
44.3
36.3
1
<0.001
60.1 8.3 31.6
53.8 17.9 28.3
17.7
3
<0.001
12.5 81.3 6.3
10.6 51.7 37.7
121.0
4
<0.001
60.4 2.8 37
28.9 54.1 16.9
188.8
3
<0.001
1.5 42.6 54.5
19.2 54.6 15.0
174.0
4
<0.001
71.9 11.8 16.3
66.7 14.5 18.7
2.8
2
0.250
83.4
29.7
252.5
1
<0.001
24.9
39.7
21.5
1
<0.001
38.5 16.6
23.4 11.6
24.2 4.6
1 1
<0.001 0.032
15.4
9.4
7.7
1
<0.05
43.0
20.1
56.8
1
<0.001
2
Any psycho-pharmacological drug Antipsychotics Depot antipsychotics Antidepressants Anxiolytics Hypnotics Mood Stabilizer Opioid maintenance Anti-craving
73.3
76.7
1.4
1
0.237
25.2 1.8 24.0 27.0 13.4 3.3 42.7 1.5
55 5.0 32.4 46.6 21.4 9.1 5.8 0.8
78.4 6.2 7.3 34.9 9.3 11.3 194.1 0.96
1 1 1 1 1 1 1 1
<0.001 <0.050 <0.010 <0.001 <0.010 <0.001 <0.001 0.320
*t-test: M=Mean; SD=Standard Deviation; df=degree of freedom °Most individuals received disability pensions, retirement pensions accounted for 2.7% in the residential and 1.2% in the clinical sample.
Table 2 Sociodemographic and clinical characteristics of individuals with psychosis (matched pairs) Variable
Nationality Swiss Schengen area Non-Schengen Marital status Single Married/Civil union Divorced/widowed Education None Basic school/ apprenticeship Higher education Employment None Competitive Sheltered Financial status Own income Pension° Welfare
Residential sample (n=84) %
Clinical sample (n=84) %
Statistics Chi2-test Chi2
df
p
Cramer’s V*
72.6 4.8 22.6
78.6 4.8 16.7
1.0
2
0.621
0.075
64.3 9.5 26.2
59.7 16.9 23.4
4.6
3
0.207
0.168
20.5 74.7
8.3 66.7
16.7
4
0.002
0.375
4.8
25.0
55.8 2.6 41.6
9.0 36.4 54.5
33.6
3
<0.001
0.583
1.2 63.1 35.7
12.3 75.5 12.3
17.4
4
0.002
0.352
df=degree of freedom *Cramer’s V= Effect size °Most individuals received disability pensions, retirement pensions accounted for 4.8% in the residential and 1.8% in the clinical sample.
Table 3 Functioning and problems of individuals with psychosis (matched pairs) Variable
GAF score HoNOS items (number) Aggressive behavior (1) Self-injury (2) Drink/drug problems (3) Cognitive problems (4) Physical problems (5) Hallucinations/delusion s (6) Depressed mood (7) Other mental health problems (8) Relationships (9) Activities of daily living (10) Living conditions (11) Occupation/leisure (12) HoNOS total score HoNOS subscales Behavior (1-3) Impairment (4-5) Symptoms (6-8) Functioning (9-12)
Residential sample (n=84) M(SD)
Clinical sample (n=84) M(SD)
Statistics t-test t
df
p
29.3 (6.8)
37.2 (14.3)
-4.6
165
<0.001
1.3 (1.3)
1.9 (1.4)
-2.6
164
0.011
0.3 (0.7) 2.4 (1.5)
0.3 (0.7) 1.3 (1.4)
MWU 4.6
156
0.308 <0.001
1.8 (1.4) 1.5 (1.4) 2.6 (1.3)
1.7 (1.2) 1.0 (1.2) 2.6 (1.2)
0.7 2.9 0.1
161 160 163
0.471 0.004 0.882
2.2 (1.2) 2.8 (1.4)
1.9 (1.1) 2.2 (1.3)
1.8 2.8
164 151
0.080 0.005
2.7 (1.0) 2.6 (0.9)
2.1 (1.2) 1.9 (1.2)
3.2 4.2
157 159
0.002 <0.001
1.4 (1.2) 3.0 (1.1) 2.1 (0.7)
1.4 (1.3) 1.3 (1.4) 1.6 (0.5)
0.2 9.1 4.8
158 155 158
0.856 <0.001 <0.001
1.4 (0.9) 1.7 (1.2) 2.5 (1.1) 2.4 (0.7)
1.2 (0.8) 1.2 (1.0) 2.2 (0.8) 1.7 (1.0)
1.9 2.7 2.3 5.9
161 156 165 158
0.053 0.009 0.021 <0.001
M=Mean; SD=Standard Deviation; df=degree of freedom MWU=Mann-Whitney-U-Test
Highlights
96% of individuals in sheltered housing have psychiatric diagnosis.
Individuals with schizophrenia more functionally impaired than inpatients.
In particular concerning social problems, physical health, substance abuse.
PII: DOI: Reference:
S0165-1781(15)30366-8 http://dx.doi.org/10.1016/j.psychres.2015.09.029 PSY9215
To appear in: Psychiatry Research Received date: 10 May 2015 Revised date: 30 July 2015 Accepted date: 18 September 2015 Cite this article as: Matthias Jaeger, David Briner, Wolfram Kawohl, Erich Seifritz and Gabriela Baumgartner-Nietlisbach, Psychosocial functioning of individuals with schizophrenia in community housing facilities and tHE PSYCHIATRIC HOSPITAL IN Zurich, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2015.09.029 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Psychosocial functioning of individuals with schizophrenia in community housing facilities and the psychiatric hospital in Zurich Matthias Jaegera*, David Brinerb*, Wolfram Kawohla, Erich Seifritza, Gabriela BaumgartnerNietlisbachb a
Department for Psychiatry, Psychotherapy and Psychosomatics, University Hospital of
Psychiatry Zurich, Switzerland b
Psychiatric-psychological service, City of Zurich, Switzerland
*both first authors equally contributed to the manuscript
Corresponding author: Dr. med. Matthias Jaeger University Hospital of Psychiatry Zurich Department for Psychiatry, Psychotherapy and Psychosomatics Lenggstrasse 31 8032 Zurich Switzerland Email: [email protected] Phone: +41 (0)44 384 26 37 Fax: +41 (0)44 384 25 06
Abstract Individuals with severe mental illness frequently have difficulties in obtaining and maintaining adequate accommodation. If they are not willing or able to adapt to requirements of traditional supported housing institutions they may live in sheltered and emergency accommodation. Adequate mental health services are rarely available in these facilities. The aim of the present study was to evaluate mental health, functional and social status of individuals living in community sheltered housing facilities. A cross-sectional survey of n=338 individuals in sheltered housing compared to a sample of patients at intake in acute inpatient psychiatry (n=619) concerning clinical and social variables was carried out in the catchment area of Zurich. Matched subsamples of individuals with schizophrenia (n=168) were compared concerning functioning and impairments on the Health of the Nation Outcome Scales (HoNOS). Individuals with schizophrenia in sheltered housing (25% of the residents) have significantly more problems concerning substance use, physical illness,
psychopathological symptoms other than psychosis and depression, and relationships, daily activities and occupation than patients with schizophrenia at intake on an acute psychiatric ward. Community sheltered accommodation although conceptualized to prevent homelessness in the general population de facto serve as housing facilities for individuals with schizophrenia and other severe mental illness.
Keywords Epidemiology Quality of care Social psychiatry Supported housing Functional impairment
1. Introduction 1.1.
Housing situation of individuals with severe mental illness after the era of deinstitutionalization
During the process of deinstitutionalization long-term patients of psychiatric hospitals were supposed to be transferred to the communities with support of outpatient mental health and social services in order to enhance integration and inclusion (Killaspy, 2006). In practice many patients were mainly transferred to residential and nursing homes instead (Richter, 2003; Franz et al., 2010). The rehabilitative housing sector for individuals with psychotic disorders and other severe mental illness expanded considerably providing custodial housing settings with included treatment and care of different intensity (Fakhoury et al., 2002; Priebe et al., 2008; Tabol et al., 2010). This process can be regarded as ongoing in many countries (Bitter et al., 2009). Individuals who are reluctant to these settings and not able to find and keep adequate accommodation on their own are threatened with homelessness and lack
essential mental health care (Freyberger et al., 2008). These persons are likely to find their way to sheltered and emergency accommodations that are not specialized in handling severe mental illnesses sufficiently and do not have enough professional capacities at their disposal (Langle et al., 2001; McQuistion et al., 2003). Severe mental disorders among those individuals may therefore not be detected nor treated adequately.
1.2.
Housing conditions, mental health and psychiatric care
Poor housing conditions are associated with poor mental health and higher prevalence of mental disorders (Bashir, 2002; Latkin and Curry, 2003; Kyle and Dunn, 2008). Prevalence rates of mental disorders among homeless people are up to 90% with high rates of comorbidity, consistently higher prevalence rates for all major psychiatric diagnoses compared to the general population and a large proportion of substance abuse (Driessen and Dilling, 1997; Kellinghaus et al., 1999; Fichter and Quadflieg, 2001; Fazel et al., 2008). However, homeless individuals including those living in emergency and sheltered accommodations are difficult to reach by mental health services as they rarely seek help for themselves on a voluntary basis (Langle et al., 2005). Barriers to mental health care for the homeless are multifaceted including high level of exclusion criteria, lack of coordination among services, prejudices among staff, and problems in obtaining health insurance for homeless people (Canavan et al., 2012). Outreach services such as assertive community treatment (ACT), intensive case management (ICM) and related concepts aim at improving physical and mental health of individuals at risk of homelessness amongst others (Killaspy, 2007; Dieterich et al., 2010; Marshall and Lockwood, 2011), but are rarely implemented outside Anglophone countries, and neither in Switzerland. Sheltered housing facilities and emergency accommodation have scarce resources of consultant mental health professionals, if any. Therefore, access to mental health services is more likely to occur via involuntary admissions or emergency visits due to endangerment to oneself or others. During short-term acute inpatient treatment and crisis intervention it is difficult to achieve significant improvement of the care situation outside the hospital. Patients who do not agree to stay long enough to find an adequate accommodation and mental health support will be discharge in a similar precarious situation as before admission (Jaeger et al., 2013). This dissatisfying situation of care provision is perpetuated by the fragmented financing of health care and social support. Coordination and cooperation across sectors is scarce and not routinely implemented in most areas. Fragmentation of service organization is a common problem for mental health care in many developed countries resulting in discontinuation of treatment and the “revolving door” phenomenon, amongst others. In some countries multidisciplinary conference of several help providers or other options such as case management services
are implemented in order to compensate this problem. In Switzerland, these structures are scarcely implemented in few regions.
1.3.
Objectives
Individuals who do not exhibit obviously dangerous behavior frequently remain in shelters and may be undersupplied by mental health services. In a majority of regions including Switzerland, it can be expected that individuals living in the most low threshold residences such as emergency overnight accommodation or sheltered hostels would show a considerably impaired mental health status. The aim of this study was to evaluate mental health, functional and social status of individuals with schizophrenia and related psychotic disorder living in community sheltered housing facilities with minimal mental health care onsite (residents) and to compare them with a matched clinical sample at intake on an acute ward (patients). It was hypothesized that the residential sample would be at least equally impaired than the clinical sample. 2. Methods 2.1.
Study samples and procedures
A cross-sectional survey with two independent groups was conducted. The residential sample was recruited by approaching inhabitants of the four community sheltered housing facilities for homeless adults (in total 460 places, part of the social department, sector “Housing and Shelter”) as the biggest provider of sheltered housing for homeless individuals in Zurich (400’000 inhabitants, largest city of Switzerland). All facilities are not specialized for care of individuals with mental disorders in the first place. They are low-threshold, tolerate substance use, and exclude individuals only in case of violence and possession of firearms, drug dealing or prostitution on-site, and other serious violation of the house rules. In detail, one facility for supported housing (“Begleitetes Wohnen”) addresses socially disintegrated and substance dependent people who are not able to care for themselves. It provides 342 single rooms on various properties in Zurich including individualized support concerning personal hygiene, socially acceptable behavior and substance use, and administrative affairs. The staff-client-ration is about 1:35 corresponding to four hours support per month. A second facility for supportive housing (“Betreutes Wohnen City”) focusses on individuals with social and health-related disabilities who are not able to become integrated in residential or nursing homes. The service consists of 47 places on two sites and provides continuous onsite support on miscellaneous personal matters with the exception of intensive physical or mental care. Psychiatric care is provided once per week by a consultant psychiatrist of the psychiatric-psychological outreach services of the City of Zurich. The third institution is an emergency overnight accommodation (“Notschlafstelle”) that provides shelter for the night as
well as counselling, provision of information for support, and basic medical care. It is open every day between 8 p.m. and 10 a.m. and holds 52 places in shared rooms available. Repeated use of the facility is possible up to four months. The fourth institution included in the study is a hostel (“Nachtpension”) for 20 persons that repeatedly made use of the emergency accommodation described before. It is closed during the day, the stay is restricted to one year and the inhabitants are mainly supported in finding a more permanent accommodation. Around 1400 individuals reside in these institutions per year. We included the 460 individuals living in the facilities at a reference date in 2012, i.e. one inhabitant per place. Exclusion criteria were acute psychotic episode requiring inpatient treatment, acute intoxication, and delirium. An interpreter was involved in case of insufficient capability of the German language. Eligible residents were informed extensively about purpose and procedure of the study and signed written informed consent if they were willing to participate. Subsequently, they underwent a structured 45 minutes interview that consisted of the measures described below. n =338 (73%) of the eligible 460 residents participated. Six residents were not included due to acute psychotic condition and/or intoxication. The other residents refused to participate. Participants received an incentive of 20 Swiss Francs. The clinical sample consisted of individuals at admission on an acute psychiatric ward of the University Hospital of Psychiatry in Zurich in 2012. There were eight acute wards with equal structural conditions (capacities of 16 to 21 patients, closed door most of the time, duration of stay 25 days on average, all diagnoses, comprehensive treatment options including pharmacology, short-term psychotherapy, occupational, vocational, physical therapies, amongst others). Data derived from routine medical documentation. Data on the first episode per patient in 2012 were available for 1712 patients. Complete data sets (no missing data) were included only, resulting in n=619 (36%). 50% of the patients were involuntarily admitted. The selected subsample did not differ from the whole cohort in terms of gender (44.3 vs. 43% female), age (mean 42.5 vs. 41.4, SD 12.9 vs. 13.6), and legal status at intake (50.0 vs. 49.6% involuntary). Sociodemographic and clinical parameters of the two samples were compared by statistical procedures for independent groups as described below. Afterwards, a subsample of individuals with schizophrenia or related psychotic disorders of the residential group was matched by age and gender with individuals with the same diagnosis of the clinical sample in order to create approximately homogeneous groups concerning sociodemographics and diagnosis. Because of the relatively small number of individuals with psychosis in the residential group (n =84) matching was executed manually. Subjects of both groups were sorted by gender and age. If more than one patient matched to a resident, we chose the patient who corresponded best with respect to nationality and marital status. If no patient had
exactly the same age as a particular resident, we chose the one who matched closest. However, this was rarely necessary as the number of patients with psychosis was three times higher than the residential subsample. As additional variables in the residential sample the self-assessed health status and health care service use were requested. In the clinical sample the percentage of involuntary admissions was registered. The matched pairs sample (n =168) was assessed for group differences concerning problems and functioning. The study was conducted according to the principles of Good Clinical Practice (GCP). The local ethics committee has confirmed the study in accordance with the Declaration of Helsinki and its later amendments.
2.2.
Measures
Sociodemographic and clinical factors were derived from routine documentation in both samples (age, gender, marital status, education, employment, financial status, nationality, and medication). Clinical diagnoses of the residential sample were assessed by trained researchers according to the ICD-10 criteria using the Mini International Neuropsychiatric Interview, M.I.N.I. (Sheehan et al., 1998). Diagnoses of the clinical sample were part of the routine clinical charts and consistently achieved by clinical assessment according to ICD-10 criteria by a psychiatrist. Global and differentiated problems and functioning were assessed by the Global Assessment of Functioning, GAF (APA, 1994) and the Health of the Nation Outcome Scales, HoNOS (Andreas et al., 2010; Theodoridou et al., 2011). GAF is a onedimensional score between 0 and 100 (low to high global functioning). HoNOS consists of 12 items to be rated on 5-point scales (0 to 4, no to severe problems in the respective area) and refers to problems due to symptoms and behavior as well as environmental factors. All interviewers were trained in using the standardized instruments M.I.N.I., GAF and HoNOS. The self-assessed health status and health care service use was evaluated by the questions (i) Do you have a permanent health problem? (ii) What kind of problem is it (physical, mental, both, neither)? (iii) Did you attend a medical service within the past 6 months? (iv) Did you see a psychiatrist/ psychologist?
2.3.
Data analysis
The data were analyzed using SPSS Statistics Version 20 (Statistical Package for the Social Sciences, IBM Corporation, 2011). Categorical variables were compared between groups using cross-tabulations and chi-square tests as well as Cramer’s V as a measure of effect size. Continuous variables were tested for normal distribution (Q-Q-diagram, skewness and kurtosis) and compared by t-test and non-parametric Mann-Whitney-U-test if not normally distributed. HoNOS was also regarded as interval scale. The significance level was set at p=0.05 (two-tailed).
3. Results 3.1.
Clinical and demographic characteristics of residents and acute inpatients
The sociodemographic and clinical characteristics of the two samples are displayed in table 1. Compared to the clinical sample, the residents were older (range 20 to 82 years of age), more frequently male, single, lower educated, and unemployed. Almost none of them had an own income and they were less likely to receive disability of retirement pensions. Most of them were financed by the welfare system. There was no difference in nationality (divided into three overarching categories).
Insert table 1 about here.
Regarding clinical characteristics the number of diagnoses (including primary and secondary diagnoses) in the residential sample was higher than in the clinical sample (Median 2 versus 1; Mean rank 594 versus 416; Mann-Whitney-U 65.695,5, p<0.001). Only 4% of the residential sample had no psychiatric diagnosis. Schizophrenia and related disorders were diagnosed in the clinical sample more frequently. All other diagnostic categories according to ICD-10 (F1, F3, F4, and F6) were overrepresented in the residential sample. The most considerable discrepancy was found concerning substance-related disorders that were diagnosed in more than 80% of the residents compared to one third of the patients. The results concerning drug treatment show that residents are treated due to somatic disorders more frequently and about three quarters of both samples were treated with psychopharmacological drugs. With regard to the respective drug categories it appears that the clinical sample is treated more frequently with all kinds of psychopharmacological drugs with the exception of opioid maintenance.
3.2.
Psychosocial functioning of individuals with schizophrenia in residential and clinical setting
As a second step of the analyses the individuals of the residential sample diagnosed with schizophrenia or related psychotic disorder according to ICD-10 category F2 (n =84) were matched with individuals with psychosis of the clinical sample with respect to age and gender. In both subsamples 36% were female and mean age was 46.6 (standard deviation 10.5). There were only slight differences concerning nationality and marital status but considerable differences regarding social variables (table 2). Again, individuals with psychotic disorders in the residential sample were considerably less educated. More than half of them were unemployed and only two worked in the competitive labor market while about 10% of the clinical sample was unemployed and more than one third had a regular job.
Also, the financial status differed between groups with the residents having an own income and disability pensions to a lesser extent. Education, employment and financial status showed moderate to strong effect sizes. In the clinical sample 67% were involuntarily admitted. In the residential sample, 68% stated to have a permanent health problem, and 51% said that it was a mental problem. 81% have been at medical service of any kind within the past 6 months. 25% have seen a psychiatrist and 4% a psychologist. No data on frequency and length of the consultations was available.
Insert table 2 about here.
Global functioning was lower on average and the items and subscales of HoNOS showed considerably more problems in the residential than in the clinical sample (table 3). In detail these problems concern alcohol and drug abuse, physical health, mental health other than depression and psychotic symptoms, and social functioning such as relationships, daily activities and occupation. Aggressive behavior was the only item that revealed more problems among clinical patients. No differences were detected concerning self-injury, cognition, depression, hallucinations and delusions, and living conditions.
Insert table 3 about here.
4. Discussion The main result of the present study is that individuals with schizophrenia living in the most low-threshold accommodations in Zurich with basic social support but minimal health care are more functionally impaired than patients with schizophrenia at intake on an acute psychiatric ward (of which two third had been admitted involuntarily). They have more problems concerning substance use, physical illness, psychopathological symptoms other than psychosis and depression, and relationships, daily activities and occupation. Only 25% had seen a psychiatrist within the last 6 months although 51% stated that they had a permanent mental problem. This finding has to be discussed against the background of the local mental health service structure and can therefore not be generalized to other catchment areas offhand. However, the general developments of mental health care provision in several countries across Europe have certain similarities as illustrated in the introduction and the consequences for the most mentally disabled individuals might be comparable internationally.
4.1.
Housing facilities in the Zurich catchment area
In Zurich, as in many other catchment areas, a large sector of specialized rehabilitative housing facilities for individuals with severe mental illnesses has developed within the last decennia. These institutions provide combined housing and care of graduated intensity concerning various dimensions e.g. restriction to autonomy, personal support in housing related skills, and treatment, occupational or vocational programs on-site. Most of these institutions have in common that access is restricted to those individuals who are willing and able to conform to the institution’s house rules, to comply with psychiatric treatment and/or medication, and to join the occupational program and the collective activities. These preconditions have partly been established in order to provide more stability of institutional processes as a result of perceived lack of collaboration with psychiatric institutions in case of crisis and difficult behavior of clients (Jaeger et al., 2014). Individuals who cannot or do not wish to adapt to those requirements only find shelter in the low-threshold transitional housing facilities inquired in the present study. Alongside the reduced requirements to the residents, the intensity of (mental health) care in these facilities is also low.
4.2.
Access to mental health services
There are important consequences for service provision related to the present results. No quantitative data on frequency and length of service use was included, but only 25% of participants of the residential sample have seen a psychiatrist although 51% stated to have a mental problem indicating low help seeking behavior. According to the well evaluated group of “high utilizers” (Roick et al., 2004), the “low utilizers” stand at the (opposite) edge concerning intensity of service use. Next to patient-related factors it is likely that servicerelated factors, i.e. barriers to care, are responsible for the aberrant service use (Canavan et al., 2012). If there is a considerable number of individuals with equal distress due to psychotic symptoms and even more physical, functional and social problems living in a surrounding that provides much less health support than a psychiatric hospital, it has to be questioned if resources for mental health care are adequately allocated. Access to enhanced psychiatric care in mental health care systems as currently established in many European countries is restricted to those who make use of it voluntarily or is reserved to those who are involuntarily admitted due to disruptive or suicidal behavior. Those who do not disturb the community and are too impaired or reluctant to seek for help have to rely on minimal – mostly social – support. The focus on institutional interests has to be challenged in order to be able to establish or enhance alternative structures based on the needs of those who currently do not have full access to the support system. Although the present data are not eligible to conclude that particular interventions have to be implemented in the catchment area of interest, the following paragraph discusses ACT and related interventions may improve the provision of mental health care of the assessed residential sample.
4.3.
Barriers for the implementation of assertive outreach interventions
In order to enhance mental and general health care for those individuals living in sheltered and emergency accommodation, coordination and communication between different providers of care and support of both, the social and health care sector is essential. ACT and other forms of ICM are eligible services that rely on integration and continuity and target on individuals who are difficult to reach by other services. The effectiveness of these interventions has generally been proven but is highly related to local conditions (Dieterich et al., 2010; Marshall and Lockwood, 2011). ACT can reduce the probability and the length of inpatient treatment episodes. Furthermore, individuals treated with ACT lived more autonomously in the community and were less likely to face homelessness (Coldwell and Bender, 2007; Nelson et al., 2007). International guidelines therefore explicitly recommend the implementation of ACT for homeless people and other individuals who are difficult to reach by traditional services (NICE, 2009; DGPPN, 2013). Other promising models of care for homeless individuals with mental illness are “Housing First” and related concepts that offer their clients (subsidized) accommodation without time limit or preconditions in terms of mandatory treatment or care (Goering et al., 2011; Somers et al., 2013). Nevertheless, in the Zurich catchment area team-based interventions such as ACT or alternative services to congregate supported housing are not available. The community psychiatricpsychotherapeutic outreach service provides visits in the institutions in order to improve clients’ mental and general health care utilization and counselling of staff indeed, but has only very limited personal capacity that does not allow regular intensive on-site treatment. The overall spectrum of services in the Zurich catchment area includes outpatient clinics, a high density of psychiatrists and psychologists in private practice, several day-hospitals including one for acute treatment, a night-clinic, crisis intervention, supported employment, amongst others (Rossler and Kawohl, 2013). This advanced range of services serves as an argument against the implementation of a new service such as ACT in discussions on mental health policy. The willingness to make additional resources available is very limited as is the willingness to release resources from inpatient capacities. However, there is a high unmet need for mental care even in highly developed countries, which may not be covered by reallocating existing healthcare resources (Alonso et al., 2007). New needs-adapted services can make the mental health care system accessible for individuals who did not make use of it before (Goldman et al., 2001). Another barrier for the implementation of ACT or ICM is based on the fragmented financing situation of and the insufficient coordination and communication between the social and medical care sectors. Mental health providers tend to assume that if patients are placed in sheltered or supported housing facilities, adequate health care would be secured. Social
services on the other hand might leave the implementation of social support especially housing to the psychiatric institutions once a patient is admitted to the hospital. A continuous effort to enhance these individuals’ engagement, implementation of intensive care at the right time followed by ongoing rehabilitation mostly fails due to the gap between both sectors (McQuistion et al., 2003).
4.4.
Limitations of the study
There are a number of limitations attached to the present study next to those already mentioned before. Methodologically, the study was conducted as a cross-sectional survey of two independent groups which is a limitation to direct comparability of the results. The evaluation of especially the HoNOS items concerning social aspects might be biased by a halo-effect. This means that some problems of individuals on an acute ward might appear less severe in the light of the problems that generally have to be handled in acute and emergency psychiatry while in sheltered housing facilities the opposite might be the case. In both samples the same instruments and variables were applied, only diagnoses were obtained in different ways, i.e. using the M.I.N.I. in the residential sample and by clinical routines in the clinical sample. This might be an explanatory factor for the different rates of most diagnostic groups, in particular for substance disorders as these might be underreported among inpatients and are not always systematically assessed at intakes. Both samples were not examined by the same investigators, but all of them were trained in using the instruments. In the clinical sample only one third of the eligible data sets were included due to missing data in the other two thirds. However, no obvious selection bias is suspected as a result of the exclusion of incomplete data sets, and the selected subsample did not significantly differ from the whole cohort concerning age, gender and percentage of involuntary admissions.
5. Conclusion Community sheltered accommodation in Zurich although conceptualized to prevent homelessness in the first place de facto serve as housing facilities for individuals with severe mental illness. Individuals living in these facilities are even more impaired concerning social problems, physical health, substance abuse, and some psychiatric symptoms than patients at intake on an acute psychiatric ward. It should be a major concern of mental health policy to enable adequate mental health care for those individuals who are not able or willing to access traditional institution-based services. Outreach services such as ACT and related concepts are likely to reach more persons with severe mental disorders who have an increased risk for homelessness and are therefore recommended by clinical guidelines (NICE, 2009; DGPPN, 2013) to be implemented as standard services.
Epidemiological studies concerning “low utilizers”, i.e. individuals with severe mental illness and functional impairment, are scarce in European countries. Future research should address barriers to care for these individuals and appropriate needs-oriented psychiatric and psychosocial services. The implementation and evaluation of conjoint projects of mental health and social services that are adapted to local structural conditions and flexible to reach these persons are required. Conflict of interest The authors declare that they have no conflict of interest.
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Tabol, C., Drebing, C.,Rosenheck, R., 2010. Studies of "supported" and "supportive" housing: a comprehensive review of model descriptions and measurement. Eval Program Plann 33, 446-456. Theodoridou, A., Jaeger, M., Ketteler, D., Kawohl, W., Lauber, C., Hoff, P.,Rossler, W., 2011. The concurrent validity and sensitivity of change of the German version of the health of the nation outcome scales in a psychiatric inpatient setting. Psychopathology 44, 391-397. Table 1 Sociodemographic and clinical characteristics by sample Variable
Age* Gender Female Marital status Single Married/Civil union Divorced/widowed Education None Basic school/ apprenticeship Higher education Employment None Competitive Sheltered Financial status Own income Pension° Welfare Nationality Swiss Schengen area Non-Schengen Diagnosis (ICD-10) Substance-related disorder (F1) Schizophrenia and related disorder (F2) Affective disorder (F3) Neurotic and adjustment disorder (F4) Personality disorder (F6) Drug treatment Any somato-pharmacological
Residential sample (n=338) % M(SD)*
Clinical sample (n=619) % M(SD)*
Statistics 2 Chi -test t-test* Chi T*
df
p
45.1 (10.1)
42.5 (12.9)
3.3
955
0.001
24.6
44.3
36.3
1
<0.001
60.1 8.3 31.6
53.8 17.9 28.3
17.7
3
<0.001
12.5 81.3 6.3
10.6 51.7 37.7
121.0
4
<0.001
60.4 2.8 37
28.9 54.1 16.9
188.8
3
<0.001
1.5 42.6 54.5
19.2 54.6 15.0
174.0
4
<0.001
71.9 11.8 16.3
66.7 14.5 18.7
2.8
2
0.250
83.4
29.7
252.5
1
<0.001
24.9
39.7
21.5
1
<0.001
38.5 16.6
23.4 11.6
24.2 4.6
1 1
<0.001 0.032
15.4
9.4
7.7
1
<0.05
43.0
20.1
56.8
1
<0.001
2
Any psycho-pharmacological drug Antipsychotics Depot antipsychotics Antidepressants Anxiolytics Hypnotics Mood Stabilizer Opioid maintenance Anti-craving
73.3
76.7
1.4
1
0.237
25.2 1.8 24.0 27.0 13.4 3.3 42.7 1.5
55 5.0 32.4 46.6 21.4 9.1 5.8 0.8
78.4 6.2 7.3 34.9 9.3 11.3 194.1 0.96
1 1 1 1 1 1 1 1
<0.001 <0.050 <0.010 <0.001 <0.010 <0.001 <0.001 0.320
*t-test: M=Mean; SD=Standard Deviation; df=degree of freedom °Most individuals received disability pensions, retirement pensions accounted for 2.7% in the residential and 1.2% in the clinical sample.
Table 2 Sociodemographic and clinical characteristics of individuals with psychosis (matched pairs) Variable
Nationality Swiss Schengen area Non-Schengen Marital status Single Married/Civil union Divorced/widowed Education None Basic school/ apprenticeship Higher education Employment None Competitive Sheltered Financial status Own income Pension° Welfare
Residential sample (n=84) %
Clinical sample (n=84) %
Statistics Chi2-test Chi2
df
p
Cramer’s V*
72.6 4.8 22.6
78.6 4.8 16.7
1.0
2
0.621
0.075
64.3 9.5 26.2
59.7 16.9 23.4
4.6
3
0.207
0.168
20.5 74.7
8.3 66.7
16.7
4
0.002
0.375
4.8
25.0
55.8 2.6 41.6
9.0 36.4 54.5
33.6
3
<0.001
0.583
1.2 63.1 35.7
12.3 75.5 12.3
17.4
4
0.002
0.352
df=degree of freedom *Cramer’s V= Effect size °Most individuals received disability pensions, retirement pensions accounted for 4.8% in the residential and 1.8% in the clinical sample.
Table 3 Functioning and problems of individuals with psychosis (matched pairs) Variable
GAF score HoNOS items (number) Aggressive behavior (1) Self-injury (2) Drink/drug problems (3) Cognitive problems (4) Physical problems (5) Hallucinations/delusion s (6) Depressed mood (7) Other mental health problems (8) Relationships (9) Activities of daily living (10) Living conditions (11) Occupation/leisure (12) HoNOS total score HoNOS subscales Behavior (1-3) Impairment (4-5) Symptoms (6-8) Functioning (9-12)
Residential sample (n=84) M(SD)
Clinical sample (n=84) M(SD)
Statistics t-test t
df
p
29.3 (6.8)
37.2 (14.3)
-4.6
165
<0.001
1.3 (1.3)
1.9 (1.4)
-2.6
164
0.011
0.3 (0.7) 2.4 (1.5)
0.3 (0.7) 1.3 (1.4)
MWU 4.6
156
0.308 <0.001
1.8 (1.4) 1.5 (1.4) 2.6 (1.3)
1.7 (1.2) 1.0 (1.2) 2.6 (1.2)
0.7 2.9 0.1
161 160 163
0.471 0.004 0.882
2.2 (1.2) 2.8 (1.4)
1.9 (1.1) 2.2 (1.3)
1.8 2.8
164 151
0.080 0.005
2.7 (1.0) 2.6 (0.9)
2.1 (1.2) 1.9 (1.2)
3.2 4.2
157 159
0.002 <0.001
1.4 (1.2) 3.0 (1.1) 2.1 (0.7)
1.4 (1.3) 1.3 (1.4) 1.6 (0.5)
0.2 9.1 4.8
158 155 158
0.856 <0.001 <0.001
1.4 (0.9) 1.7 (1.2) 2.5 (1.1) 2.4 (0.7)
1.2 (0.8) 1.2 (1.0) 2.2 (0.8) 1.7 (1.0)
1.9 2.7 2.3 5.9
161 156 165 158
0.053 0.009 0.021 <0.001
M=Mean; SD=Standard Deviation; df=degree of freedom MWU=Mann-Whitney-U-Test
Highlights
96% of individuals in sheltered housing have psychiatric diagnosis.
Individuals with schizophrenia more functionally impaired than inpatients.
In particular concerning social problems, physical health, substance abuse.