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Complex needs and histories of homeless people

Available data, existing literature and the consultations for this current study suggest a higher than average prevalence of psychiatric disorders, substance use issues and trauma (including being a victim of crime) among people experiencing homelessness, particularly among those entrenched in homelessness.

Mental Illness

A high prevalence of psychiatric disorders among those in the homeless population has been reported in the literature and anecdotally by people working in the field.⁷⁶ However, actual estimates vary considerably with the definitions and methodologies employed to collect the data, and particularly with the population of homeless people from which the study sample was drawn.

A 1998 study by Hodder, Teeson and Buhrich reported that about 75% of homeless people contacted through inner-city hostels in Sydney had at least one significant mental disorder (as defined by formal diagnostic tests). The prevalence was higher for women (81%) than men (73%).⁷⁷ The expected prevalence rate of at least one mental disorder in the Australian population is 18%.⁷⁸ It should be noted that these estimates are drawn from a group of people entrenched in homelessness and cannot necessarily be generalised to other groups of homeless people (e.g. women escaping domestic violence and living with other family members, young people living temporarily with friends, people renting in caravan parks because they are poor).

In the Project i study, of a sample of 403 homeless people aged 12–20 years, 26% reported a level of psychological distress indicative of a psychiatric disorder. Fourteen per cent reported clinical levels of depression, 12% had clinical levels of anxiety, 12% had clinical levels of psychosis, and nearly 35% of the sample had attempted suicide, 11% in the past three months.⁷⁹ Thirty-one per cent of the sample group had been out of home for more than 12 months, and 42% for 4–6 months.⁸⁰

Different mental illnesses tend to be more prevalent among different demographic groups. As Parker et al. observe:

Younger age is more strongly associated with schizophrenia, major depression and alcohol disorders. Males have a higher prevalence of alcohol disorder, but women exhibit almost twice as much
major depression. Single or separated people are more likely to suffer alcohol disorders and separated people have higher rates of depression.⁸¹

This may be reflected in the different types of mental health issues reported in different demographic groups in the homeless population as well. Parker et al. observe that while affective and non-psychotic disorders are seen as less severe than ‘major’ mental illnesses, “their incidence in the homeless population far exceeds that in other groups”.⁸²

Turning to another sector of the homeless population, the Select Committee on Mental Health reported that an estimated 40% of people in licensed boarding houses have a mental illness.⁸³ In a submission to the committee, the NSW Office of the Public Guardian observed that boarding houses were often the only option for people with a mental illness who could not be placed within the very limited number of community-based options for people with special needs.⁸⁴

Finally, HPIC⁸⁵ statistics indicated that the most commonly self-reported client characteristic recorded for 2002–03 was ‘mental/psychiatric illness’. This characteristic was recorded for 30% of all the 43 962 calls (rather than individual callers).⁸⁶

Alcohol and other drug use

Alcohol and other drug dependency are also reported as highly prevalent disorders among some groups of homeless people.⁸⁷ In their study of 201 homeless people in inner-city Sydney, Hodder et al. found:

• 49% of men in the sample had an alcohol use disorder, with 42% alcohol-dependent. Fifteen per cent of women had an alcohol use disorder and 13% were alcohol-dependent. This compares to general population rates of 9% of men and 4% of women with alcohol use disorders⁸⁸
• 34% were dependent on drugs, with 19% of men and 23% of women using or dependent on opiates including heroin. An estimated 2% of the general population used heroin⁸⁹
• more than 70% of the sample aged 18–44 years had some type of substance use disorder.⁹⁰

The Project i study reported “high levels of substance use among the homeless young people interviewed”, noting the level of injecting drug use as ‘alarming’. Twenty-eight per cent of participants self-reported injecting drugs in the past three months (including heroin, amphetamines, crack/cocaine and sedatives). In contrast, 0.6% of young people (14–19 years of age) in the general population were reported to inject an illicit drug in the previous 12 months.⁹¹

Another issue reported in the literature and in the consultations with stakeholders in the current study, was the extent of ‘dual diagnosis’ where people have both substance abuse and other mental health issues. Again, these issues were most commonly reported among people entrenched in homelessness.⁹²

However, the relationship between alcohol and other drug dependency and/or mental health on the one hand and homelessness on the other does not appear to be straightforward or ‘causal’. For instance, MacKenzie and Chamberlain point out that some young people in particular may leave home to escape the mental health and substance abuse issues of family members and that some people may develop substance use or mental illness issues after becoming homeless.⁹³ Indeed, housing crisis, family breakdown and the experience of being homeless may, of themselves, trigger or exacerbate mental health or substance use issues. Parker et al. observe:

Once there, the stress of being homeless—exposure to violence, sexual abuse, concomitant substance abuse, and a range of physical health problems—promotes high rates of emotional distress. Depression and distress, two to eight times more likely to occur in homeless people, dramatically exacerbate the symptoms of original mental illness and hamper an individual’s ability to exit from homelessness.⁹⁴

Thus, rather than necessarily causing homelessness, it has been argued that drug and alcohol dependency and mental illness can put people at greater risk of ‘chronic homelessness’.⁹⁵ It is also reasonable to expect that the prevalence of mental health and alcohol and other drug issues will vary within the homeless population (e.g. among SAAP residents compared to those living with family and friends).

Histories of trauma

Hodder et al. found that 93% of their sample of 210 homeless people in inner-city Sydney reported at least one experience of major trauma in their lives. Trauma could include sexual or physical assault, witnessing someone being badly injured or killed, life-threatening accidents or disasters, war, torture or terrorism. Trauma was reported by 100% of women and 91% of men, with multiple experiences of extreme trauma reported as ‘common’.⁹⁶ The traumatic events may have pre-dated their homelessness (e.g. through family violence).

The vulnerability of homeless young people to being a victim of sexual assault is discussed in Rossiter et al,⁹⁷ and the vulnerability of homeless people to being a victim of any crime is discussed in Chapter 4 of this report.