A study in Western societies found mental illness, alcoholism, and drug dependency to be more prevalent among homeless people than among the general population. A 2009 US study estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Other estimates vary. One 2003 study out of California suggests that 20-40% of the homeless have a severe mental illness. A 2024 systematic review and meta-analysis by JAMA (the Journal of the American Medical Association), consisting principally of Canadian, German, and American studies, found that 67% of the unhoused had a mental health disorder, with a 77% lifetime mental health disorder prevalence among those who are or have been homeless. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at any given time, 45% of the American homeless—250,000 individuals—were mentally ill and that at least 25% of the homeless—140,000 individuals—were seriously mentally ill, with even higher numbers if these were annual counts rather than point-in-time counts. Being chronically homeless also means that people with mental illnesses are more likely to experience catastrophic health crises requiring medical intervention or resulting in institutionalization in the criminal justice system. Though most homeless people do not have a mental illness, those facing homelessness are struggling with psychological and emotional distress. The Substance Abuse and Mental Health Services Administration found that, in 2010, 26.2 percent of sheltered homeless people had a severe mental illness. Research across seven western countries, including the United Kingdom, found that people in emergency accommodation, predominately ment in shelters and hostels, experience diagnosable mental health conditions at a far higher rate than the general population of the same age. Estimate rates include psychotic illness (12.7%), major depression (11.4%) and personality disorder (23.1%). A Scottish study found that people experiencing homelessness are admitted to mental health services at almost five times the rate of people living in the most deprived areas and twenty times the rate of people in least deprived areas. Studies have found that there is a correlation between homelessness and incarceration. Those with mental illness or substance abuse problems were found to be incarcerated more often than the general population. Fischer and Breakey have identified the chronically mentally ill as one of the four main subtypes of homeless persons, the others being street people, chronic alcoholics, and the situationally distressed. The first documented case of a psychiatrist addressing the issue of homelessness and mental health was that of Karl Wilmanns in 1996.
Historical context
United States In the United States, there are broad patterns of reform within the history of psychiatric care for persons with mental illness. These patterns are currently categorized into three major cycles of reform. The first recognized cycle was the emergence of moral treatment and asylums, the second consists of the mental hygiene movement and the psychopathic (state) hospital, and most recent cycle includes deinstitutionalization and community mental health. In a 1986 article addressing the historical developments and reforms of treatment for the mentally ill, Joseph Morrissey and Howard Goldman acknowledged the current regression of public social welfare for mentally ill populations. They specifically state that the "historical forces that led to the transinstitutionalization of the mentally ill from almshouses to the state mental hospitals in the nineteenth and twentieth centuries have now been reversed in the aftermath of recent deinstitutionalization policies".
Asylums
Within the context of transforming schemas of moral treatment during the early nineteenth century, the humanitarian focus of public intervention was linked with the establishment of asylums or snake pits for treatment of the mentally ill. The ideology that emerged in Europe disseminated to America, in the form of a social reformation based on the belief that new cases of insanity could be treated by isolating the ill into "small, pastoral asylums" for humane treatment. These asylums were meant to combine medical attention, occupational therapy, socialization activities and religious support, all in a warm environment. In America, Friends Asylum (1817) and the Hartford Retreat (1824) were among the first asylums within the private sector, yet public asylums were soon encouraged, with Dorothea Dix as one of its key lobbyists. The effectiveness of asylums was dependent on a collection of structural and external conditions, conditions that proponents began to recognize were unfeasible to maintain around the mid-nineteenth century. For example, with the proliferation of immigrants throughout industrialization, the original purpose of asylums as small facilities transformed into their actualized use as "large, custodial institutions" throughout the late 1840s. Overcrowding severely inhibited the therapeutic capacity, inciting a political reassessment period about alternatives to asylums around the 1870s. The legislative purpose of state asylums soon met the role society had funneled them toward; they primarily became institutions for community protection, with treatment secondary.
Deinstitutionalization Toward the end of World War II, the influx of soldiers diagnosed with "war neurosis" incited a new public interest in community care. In addition to this, the view that asylums and state hospitals exacerbated symptoms of mental illness by being "inherently dehumanizing and antitherapeutic" spread through the public consciousness. When psychiatric drugs like neuroleptics stabilized behavior and milieu therapy proved effective, state hospitals began discharging patients, with hope that federal programs and community support would counterbalance the effects of institutionalization. Furthermore, economic responsibility for disabled people began to shift, as religious and non-profit organization assumed the role of supplying basic needs. The modern results of deinstitutionalization show the dissonance between policy expectations and the actualized reality.
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