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1.  The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis 
PLoS Medicine  2008;5(12):e225.
There are well over a million homeless people in Western Europe and North America, but reliable estimates of the prevalence of major mental disorders among this population are lacking. We undertook a systematic review of surveys of such disorders in homeless people.
Methods and Findings
We searched for surveys of the prevalence of psychotic illness, major depression, alcohol and drug dependence, and personality disorder that were based on interviews of samples of unselected homeless people. We searched bibliographic indexes, scanned reference lists, and corresponded with authors. We explored potential sources of any observed heterogeneity in the estimates by meta-regression analysis, including geographical region, sample size, and diagnostic method. Twenty-nine eligible surveys provided estimates obtained from 5,684 homeless individuals from seven countries. Substantial heterogeneity was observed in prevalence estimates for mental disorders among the studies (all Cochran's χ2 significant at p < 0.001 and all I2 > 85%). The most common mental disorders were alcohol dependence, which ranged from 8.1% to 58.5%, and drug dependence, which ranged from 4.5% to 54.2%. For psychotic illness, the prevalence ranged from 2.8% to 42.3%, with similar findings for major depression. The prevalence of alcohol dependence was found to have increased over recent decades.
Homeless people in Western countries are substantially more likely to have alcohol and drug dependence than the age-matched general population in those countries, and the prevalences of psychotic illnesses and personality disorders are higher. Models of psychiatric and social care that can best meet these mental health needs requires further investigation.
Seena Fazel and colleagues show, through a systematic review and meta-regression analysis, that homeless people in Western countries have a higher prevalence of alcohol and drug dependence and mental disorders.
Editors' Summary
In 2007, it was estimated that there were more than 1 million homeless people worldwide. The true magnitude of the problem is difficult to estimate with no internationally agreed definition for homelessness and with the different approaches taken by countries and organizations in counting homeless people.
What we do know is that this is a diverse group of people who have poorer physical and mental health than the general population, leading to premature death. We also know that addressing barriers to health care and behavioral interventions for alcohol and drug dependence and mental health problems in this population can lead to lasting health gains.
Why Was This Study Done?
Health care for the homeless is a major public health challenge. Public policy and health service development depend on reliable estimates of the prevalence (how common a particular characteristic, e.g., a disease, is in a specific group of people or a specific population) of illnesses. By using statistical methods, the researchers aimed to provide a quantitative synthesis of the available evidence on mental health problems in this population and explore reasons for the differences in reported prevalence rates of serious mental disorders between studies, neither which have been done previously.
What Did the Researchers Do and Find?
The researchers systematically searched for surveys that estimated the prevalence of mental disorders in homeless people. Their final sample of 29 studies included a total of 5,684 homeless individuals based in the US, UK, mainland Europe, and Australia. Their main finding was that the prevalences of serious mental disorders were raised compared with expected rates in the general population, and many orders of magnitude higher than age-matched community estimates for psychosis, alcohol dependence, and drug dependence. In addition, the analysis found that alcohol and drug dependence is the most common mental disorder in the homeless (compared to psychosis, depression, and personality disorder). Also, the prevalence estimates of psychosis were found to be as high as those for depression. This latter finding contrasts with community estimates and other “at risk” populations such as prisoners and refugees, where depression is more common. The authors found substantial variation in the prevalence rates for these various disorders, and demonstrated that participation rates were associated with these variations for psychosis, depression, and personality disorder and that studies conducted more recently reported higher rates of alcohol dependence.
What Do These Findings Mean?
This review raises a number of implications for health services for the homeless and research for this population. First, traditional models of service delivery, which focus on those with severe mental illness, may not meet the mental health needs of most homeless people who suffer from alcohol and drug dependence and personality disorder. Second, an integrated approach to treatment may be beneficial and should take into account mental health, alcohol and drug abuse, welfare, and housing needs. Finally, future research should include studies that follow a group over time to help us better understand the risks and pathways into (and out of) homelessness, particularly in non-Western populations where there appears to be a paucity of information.
Additional Information.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Helen Herrman
“How can health care systems effectively deal with the major health care needs of homeless people?” is a WHO initiative aimed at tackling the health care needs of homeless people
FEANTSA, the European Federation of National Organizations Working with the Homeless, is an umbrella of not-for-profit organizations that participate in or contribute to the fight against homelessness in Europe
The National Alliance to End Homelessness is a nonpartisan, mission-driven organization committed to preventing and ending homelessness in the US
Information and good practice solutions for the homelessness service sector in Australia can be found on the National Homelessness Information Clearinghouse Web site
Homeless Link is the national membership organization for frontline homelessness agencies in England with a mission to catalyze an end to homelessness
Homeless Man Speaks provides an “on-the-street” perspective
PMCID: PMC2592351  PMID: 19053169
2.  Traumatic brain injury among men in an urban homeless shelter: observational study of rates and mechanisms of injury 
CMAJ Open  2014;2(2):E69-E76.
Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter.
We recruited participants from an urban men’s shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group.
A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27–81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse.
Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.
PMCID: PMC4084748  PMID: 25077132
3.  Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status 
BMC Public Health  2010;10:94.
Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.
Recruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses.
Forty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)).
Drug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.
PMCID: PMC2841106  PMID: 20181248
4.  Risk of Violent Crime in Individuals with Epilepsy and Traumatic Brain Injury: A 35-Year Swedish Population Study 
PLoS Medicine  2011;8(12):e1001150.
Seena Fazel and colleagues report findings from a longitudinal follow-up study in Sweden that evaluated the risks of violent crime subsequent to hospitalization for epilepsy, or traumatic brain injury. The researchers control for familial confounding with sibling controls. The analyses call into question an association between epilepsy and violent crime, although they do suggest that there may be a relationship between traumatic brain injury and violent crime.
Epilepsy and traumatic brain injury are common neurological conditions, with general population prevalence estimates around 0.5% and 0.3%, respectively. Although both illnesses are associated with various adverse outcomes, and expert opinion has suggested increased criminality, links with violent behaviour remain uncertain.
Methods and Findings
We combined Swedish population registers from 1973 to 2009, and examined associations of epilepsy (n = 22,947) and traumatic brain injury (n = 22,914) with subsequent violent crime (defined as convictions for homicide, assault, robbery, arson, any sexual offense, or illegal threats or intimidation). Each case was age and gender matched with ten general population controls, and analysed using conditional logistic regression with adjustment for socio-demographic factors. In addition, we compared cases with unaffected siblings.
Among the traumatic brain injury cases, 2,011 individuals (8.8%) committed violent crime after diagnosis, which, compared with population controls (n = 229,118), corresponded to a substantially increased risk (adjusted odds ratio [aOR] = 3.3, 95% CI: 3.1–3.5); this risk was attenuated when cases were compared with unaffected siblings (aOR = 2.0, 1.8–2.3). Among individuals with epilepsy, 973 (4.2%) committed a violent offense after diagnosis, corresponding to a significantly increased odds of violent crime compared with 224,006 population controls (aOR = 1.5, 1.4–1.7). However, this association disappeared when individuals with epilepsy were compared with their unaffected siblings (aOR = 1.1, 0.9–1.2). We found heterogeneity in violence risk by age of disease onset, severity, comorbidity with substance abuse, and clinical subgroups. Case ascertainment was restricted to patient registers.
In this longitudinal population-based study, we found that, after adjustment for familial confounding, epilepsy was not associated with increased risk of violent crime, questioning expert opinion that has suggested a causal relationship. In contrast, although there was some attenuation in risk estimates after adjustment for familial factors and substance abuse in individuals with traumatic brain injury, we found a significantly increased risk of violent crime. The implications of these findings will vary for clinical services, the criminal justice system, and patient charities.
Please see later in the article for the Editors' Summary
Editors' Summary
News stories linking mental illness (diseases that appear primarily as abnormalities of thought, feeling or behavior) with violence frequently hit the headlines. But what about neurological conditions—disorders of the brain, spinal cord, and nerves? People with these disorders, which include dementia, Parkinson's disease, and brain tumors, often experience stigmatization and discrimination, a situation that is made worse by the media and by some experts suggesting that some neurological conditions increase the risk of violence. For example, many modern textbooks assert that epilepsy—a neurological condition that causes repeated seizures or fits—is associated with increased criminality and violence. Similarly, various case studies have linked traumatic brain injury—damage to the brain caused by a sudden blow to the head—with an increased risk of violence.
Why Was This Study Done?
Despite public and expert perceptions, very little is actually known about the relationship between epilepsy and traumatic brain injury and violence. In particular, few if any population-based, longitudinal studies have investigated whether there is an association between the onset of either of these two neurological conditions and violence at a later date. This information might make it easier to address the stigma that is associated with these conditions. Moreover, it might help scientists understand the neurobiological basis of violence, and it could help health professionals appropriately manage individuals with these two disorders. In this longitudinal study, the researchers begin to remedy the lack of hard information about links between neurological conditions and violence by investigating the risk of violent crime associated with epilepsy and with traumatic brain injury in the Swedish population.
What Did the Researchers Do and Find?
The researchers used the National Patient Register to identify all the cases of epilepsy and traumatic brain injury that occurred in Sweden between 1973 and 2009. They matched each case (nearly 23,000 for each condition) with ten members of the general population and retrieved data on all convictions for violent crime over the same period from the Crime Register. They then linked these data together using the personal identification numbers that identify Swedish residents in national registries. 4.2% of individuals with epilepsy had at least one conviction for violence after their diagnosis, but only 2.5% of the general population controls did. That is, epilepsy increased the absolute risk of a conviction for violence by 1.7%. Using a regression analysis that adjusted for age, gender, and various socio-demographic factors, the researchers calculated that the odds of individuals with epilepsy committing a violent crime were 1.5 times higher than for general population controls (an adjusted odds ratio [aOR] of 1.5). The strength of this association was reduced when further adjustment was made for substance abuse, and disappeared when individuals with epilepsy were compared with their unaffected siblings (a sibling control study). Similarly, 8.8% of individuals with traumatic brain injury were convicted of a violent crime after their diagnosis compared to only 3% of controls, giving an aOR of 3.3. Again, the strength of this association was reduced when affected individuals were compared to their unaffected siblings (aOR = 2.0) and when adjustment was made for substance abuse (aOR = 2.3).
What Do These Findings Mean?
Although some aspects of this study may have affected the accuracy of its findings, these results nevertheless challenge the idea that there are strong direct links between epilepsy and violent crime. The low absolute rate of violent crime and the lack of any association between epilepsy and violent crime in the sibling control study argue against a strong link, a potentially important finding given the stigmatization of epilepsy. For traumatic brain injury, the reduced association with violent crime in the sibling control study compared with the general population control study suggests that shared familial features may be responsible for some of the association between brain injury and violence. As with epilepsy, this finding should help patient charities who are trying to reduce the stigma associated with traumatic brain injury. Importantly, however, these findings also suggest that some groups of patients with these conditions (for example, patients with head injuries who abuse illegal drugs and alcohol) would benefit from being assessed for their risk of behaving violently and from appropriate management.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Jan Volavka
The US National Institute of Neurological Disorders and Stroke provides detailed information about traumatic brain injury and about epilepsy (in English and Spanish)
The UK National Health Service Choices website provides information about severe head injury, including a personal story about a head injury sustained in a motor vehicle accident, and information about epilepsy, including personal stories about living with epilepsy
Healthtalkonline has information on epilepsy, including patient perspectives
MedlinePlus provide links to further resources on traumatic brain injury and on epilepsy (available in English and Spanish)
PMCID: PMC3246446  PMID: 22215988
5.  The health of homeless immigrants 
This study examined the association between immigrant status and current health in a representative sample of 1,189 homeless people in Toronto, Canada.
Multivariate regression analyses were performed to examine the relationship between immigrant status and current health status (assessed using the SF-12) among homeless recent immigrants (≤10 years since immigration), non-recent immigrants (>10 years since immigration), and Canadian-born individuals recruited at shelters and meal programs (response rate 73%).
After adjusting for demographic characteristics and lifetime duration of homelessness, recent immigrants were significantly less likely to have chronic conditions (RR 0.7, 95% CI 0.5 to 0.9), mental health problems (OR 0.4, 95% CI 0.2 to 0.7), alcohol problems (OR 0.2, 95% CI 0.1 to 0.5), and drug problems (OR 0.2, 95% CI 0.1 to 0.4) compared to non-recent immigrants and Canadian-born individuals. Recent immigrants were also more likely to have better mental health status (+3.4 points, SE ±1.6) and physical health status (+2.2 points, SE ±1.3) on scales with a mean of 50 and a standard deviation of 10 in the general population.
Homeless recent immigrants are a distinct group who are generally healthier and may have very different service needs compared to other homeless people.
PMCID: PMC2773541  PMID: 19654122
homelessness; migration and health
6.  A cross-sectional examination of the mental health of homeless mothers: does the relationship between mothering and mental health vary by duration of homelessness? 
BMJ Open  2014;4(12):e006174.
This study draws on baseline data from the At Home/Chez Soi demonstration project to examine the association between parenting status and mental health among homeless women and whether the association varies by duration of homelessness.
Structured interviews were conducted with participants in five cities across Canada including Moncton, Montreal, Toronto, Vancouver and Winnipeg.
Eligibility criteria included those with legal adult status, with a mental illness, and who lacked a regular, fixed shelter. All 713 women who participated in the larger project were selected for inclusion in this analysis.
The mental health conditions of interest include depression, post-traumatic stress disorder (PTSD), alcohol dependence and substance dependence.
The relationship between parenting status and depression, as well as PTSD, varied by duration of homelessness. Among women who had been homeless for less than 2 years, no relationship was found between parenting status and depression, or PTSD. However, among women who had been homeless for 2 or more years, the odds of depression was twice as high among parenting women compared with others (aOR=2.05, p≤0.05). A similar relationship was found between parenting status and PTSD (aOR=2.03, p≤0.05). The odds of substance dependence was found to be 2.62 times greater among parenting women compared with others and this relationship did not vary by duration of homelessness (aOR=2.62; 95% CI 1.86 to 3.69). No relationship was found between parenting and alcohol dependence.
Overall, the findings from this study suggest that there is a relationship between long-term homelessness and mothers’ risk of poor mental health. Given the multiple demands mothers face, a failure to recognise their unique needs is likely to contribute to intergenerational legacies of homelessness and mental health problems.
Trial registration number
World Health Organization's International Clinical Trials Registry Platform (ISRCTN66721740 and ISRCTN57595077).
PMCID: PMC4265095  PMID: 25492272
7.  Disparities in Health Care Utilization Among Urban Homeless in South Korea: A Cross-Sectional Study 
We examined health care disparities in Korean urban homeless people and individual characteristics associated with the utilization of health care.
We selected a sample of 203 homeless individuals at streets, shelters, and drop-in centers in Seoul and Daejeon by a quota sampling method. We surveyed demographic information, information related to using health care, and health status with a questionnaire. Logistic regression analysis was adopted to identify factors associated with using health care and to reveal health care disparities within the Korean urban homeless population.
Among 203 respondents, 89 reported that they had visited health care providers at least once in the past 6 months. Twenty persons (22.5%) in the group that used health care (n = 89) reported feeling discriminated against. After adjustment for age, sex, marital status, educational level, monthly income, perceived health status, Beck Depression Inventory score, homeless period, and other covariates, three factors were significantly associated with medical utilization: female sex (adjusted odds ratio [aOR, 15.95; 95% CI, 3.97 to 64.04], having three or more diseases (aOR, 24.58; 95% CI, 4.23 to 142.78), and non-street residency (aOR, 11.39; 95% CI, 3.58 to 36.24).
Health care disparities in Seoul and Daejeon homeless exist in terms of the main place to stay, physical illnesses, and gender. Under the current homeless support system in South Korea, street homeless have poorer accessibility to health care versus non-street homeless. To provide equitable medical aid for homeless people, strategies to overcome barriers against health care for the street homeless are needed.
PMCID: PMC3249266  PMID: 22143177
Health care; Health care disparity; Health status; Homeless persons
8.  Multidimensional Social Support and the Health of Homeless Individuals 
Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.
PMCID: PMC2729873  PMID: 19629703
Homelessness; Social support; Physical health; Mental health; Victimization; Canada
9.  Nutrition and health services needs among the homeless. 
Public Health Reports  1991;106(4):364-374.
This review discusses nutrition and related health problems among homeless Americans, summarizes recent information, and identifies needs for services and future research. The nature of homelessness today provides a context for the discussion. Many homeless persons eat fewer meals per day, lack food more often, and are more likely to have inadequate diets and poorer nutritional status than housed U.S. populations. Yet many homeless people eligible for food stamps do not receive them. While public and private agencies provide nutritious food and meals for homeless persons, availability of the services to homeless persons is limited. Many homeless people lack appropriate health care, and certain nutrition-related health problems are prevalent among them. Compared with housed populations, alcoholism, anemia, and growth problems are more common among homeless persons, and pregnancy rates are higher. The risks vary among homeless persons for malnutrition, nutrition-related health problems, drug and alcohol abuse, and mental illness. For example, among homeless persons, fewer heads of families than single adults are substance abusers, and mental illness varies in prevalence among single men, single women, and parents in homeless families. Homeless persons need improved access to food, nutrition, and health services. More nutrition education needs to be available to them and to service providers. Use of representative samples and validation of self-reported nutrition and health data will help future investigators to clarify the relationships between the characteristics of the homeless and their nutritional status.
PMCID: PMC1580272  PMID: 1908587
10.  Cognitive Performance in Late Adolescence and the Subsequent Risk of Subdural Hematoma: An Observational Study of a Prospective Nationwide Cohort 
PLoS Medicine  2011;8(12):e1001151.
Anna and Peter Nordström analyzed a prospective nationwide cohort of 440,742 Swedish men and found that reduced cognitive function in young adulthood was associated with increased risk of subdural hematoma later in life, whereas a higher level of education and physical fitness were associated with a decreased risk.
There are few identified risk factors for traumatic brain injuries such as subdural hematoma (SDH). The aim of the present study was to investigate whether low cognitive performance in young adulthood is associated with SDH later in life. A second aim was to investigate whether this risk factor was associated with education and physical fitness.
Methods and Findings
Word recollection, logical, visuospatial, and technical performances were tested at a mean age of 18.5 years in a prospective nation-wide cohort of 440,742 men. An estimate of global intelligence was calculated from these four tests. Associations between cognitive performance, education, physical fitness, and SDH during follow-up were explored using Cox regression analyses. During a median follow-up of 35 years, 863 SDHs were diagnosed in the cohort. Low global intelligence was associated with an increased risk of SDH during follow-up (hazard ratio [HR]: 1.33, per standard deviation decrease, 95% CI = 1.25–1.43). Similar results were obtained for the other measures of cognitive performance (HR: 1.24–1.33, p<0.001 for all). In contrast, a high education (HR: 0.27, comparing more than 2 years of high school and 8 years of elementary school, 95% CI = 0.19–0.39), and a high level of physical fitness (HR: 0.76, per standard deviation increase, 95% CI = 0.70–0.83), was associated with a decreased risk of suffering from a SDH.
The present findings suggest that reduced cognitive function in young adulthood is strongly associated with an increased risk of SDH later in life. In contrast, a higher level of education and a higher physical fitness were associated with a decreased risk of SDH.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, about 10 million people worldwide sustain a traumatic brain injury that needs medical attention or that proves fatal. Such injuries occur when the head is suddenly hit or jolted or when an object such as a bullet pierces the skull and enters the brain. Motor vehicle accidents are responsible for many traumatic brain injuries, but falls, assaults, and military action can also cause these serious injuries. The symptoms of a traumatic brain injury, which may not appear until many days after the injury, include loss of consciousness, headaches, dizziness, and nausea. Affected individuals can experience changes in their memory, concentration, or ability to think clearly (“cognitive” changes) and can have behavioral or emotional problems. Although the initial brain damage caused by trauma cannot be reversed, immediate medical treatment is essential to prevent further injury occurring. In particular, patients need to be monitored for “subdural hematoma,” a common outcome of traumatic brain injury in which blood from ruptured vessels collects between the brain and the skull. Subdural hematoma puts pressure on the brain and has to be removed surgically to prevent further brain damage.
Why Was This Study Done?
Not everyone who has a traumatic brain injury develops subdural hematoma. If the factors that increase a person's risk of developing subdural hematoma could be identified, it might be possible to devise public-health interventions that would reduce the incidence of subdural hematomas. In this prospective population-based analysis, the researchers investigate whether low cognitive performance in early adulthood is associated with subdural hematoma later in life. Impaired cognitive functioning is sometimes recorded as a symptom of subdural hematoma but the researchers hypothesize that these cognitive deficits might have been present before the traumatic head injury that led to subdural hematoma. Low cognitive performance is associated with a reduced ability to compare objects and patterns (perceptual speed) and with impaired judgment, planning, and risk behavior (executive functions), so low cognitive performance might increase a person's risk of having an accident that results in a head injury and subdural hematoma.
What Did the Researchers Do and Find?
The researchers calculated a global intelligence score for 440,742 male Swedish military conscripts (average age 18.5 years) from cognitive tests completed by the men between 1969 and 1978. They obtained information about diagnoses of subdural hematoma up to 40 years later among these men from medical records, and then used several statistical approaches to look for associations between cognitive performance, education (recorded during conscription assignment), physical fitness (measured during conscription assignment), and subsequent subdural hematoma. During the follow-up period, 863 subdural hematomas were diagnosed among the men. Conscripts with a low global intelligence score in early adulthood were more likely to develop subdural hematoma during later life than those with a high score. Specifically, when the men were divided into five groups (quintiles) on the basis of their global intelligence score, men with a score in the lowest quintile were more than twice as likely to develop subdural hematoma as those with a score in the highest quintile. By contrast, men who had had more than 2 years high school education were much less likely to develop subdural hematoma than those who had only had 8 years of elementary school education. A high level of physical fitness in early adulthood also reduced the risk of subdural hematoma.
What Do These Findings Mean?
These findings suggest that low cognitive function in early adulthood is associated with subdural hematoma later in life, whereas high levels of education and physical fitness is associated with a decreased risk of subdural hematoma. Because this study was observational, these findings do not prove that low cognitive performance, low education level, or low physical fitness is causally linked to subdural hematoma. Other unidentified factors (confounders) shared by people with these characteristics might actually be responsible for the observed association between these factors and subdural hematoma. For example, poorly educated people might work in more hazardous environments than those who attended high school. However, if these findings can to be confirmed in other large studies, an exploration of the mechanistic basis of the associations reported here might eventually inform the development of public-health interventions designed to reduce the occurrence of subdural hematoma.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institute of Neurological Disorders and Stroke provides detailed information about traumatic brain injury (in English and Spanish)
The US Centers for Disease Control and Prevention also provides detailed information about traumatic brain injury
The UK National Health Service Choices website has an article about severe head injury that includes a personal story about a head injury sustained in a motor vehicle accident, and an article about subdural hematoma
MedlinePlus provide links to further resources on traumatic brain injury and information on subdural hematoma; it also provides an interactive tutorial on traumatic brain injury (available in English and Spanish)
The UK charity Headway, which works to improve life after brain injury, has a collection of personal stories about brain injury
PMCID: PMC3246434  PMID: 22215989
11.  Traumatic brain injury among people who are homeless: a systematic review 
BMC Public Health  2012;12:1059.
Homelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research.
A systematic literature search was conducted in PsycINFO (1887–2012), Embase (1947–2012), and MEDLINE/Pubmed (1966–2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies.
Eight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature.
The rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.
PMCID: PMC3538158  PMID: 23216886
Traumatic brain injury; Homelessness; Systematic review
12.  Homelessness and drug abuse among young men who have sex with men in New York city: A preliminary epidemiological trajectory 
Journal of adolescence  2005;28(2):201-214.
The objective of this paper is to profile the role of homelessness in drug and sexual risk in a population of young men who have sex with men (YMSM). Data are from a cross-sectional survey collected between 2000 and 2001 in New York City (N = 569). With the goal of examining the import of homelessness in increased risk for the onset of drug and sexual risk, we compare and contrast three subgroups: (1) YMSM with no history of homelessness, (2) YMSM with a past history of homelessness but who were not homeless at the time of the interview, and (3) YMSM who were currently homeless. For each group, we describe the prevalence of a broad range of stressful life events (including foster care and runaway episodes, involvement in the criminal justice system, etc.), as well as selected mental health problems (including past suicide attempts, current depression, and selected help-seeking variables). Additionally, we examine the prevalence of selected drug and sexual risk, including exposure to a broad range of illegal substances, current use of illegal drugs, and prevalence of lifetime exposure to sex work. Finally, we use an event history analysis approach (time–event displays and paired t-test analysis) to examine the timing of negative life experiences and homelessness relative to the onset of drug and sexual risk. High levels of background negative life experiences and manifest mental health distress are seen in all three groups. Both a prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk. Onset of these risks occur earlier in both groups that have had an experience of housing instability (e.g., runaway, foster care, etc.) but are delayed or not present among YMSM with no history of housing instability. Few YMSM had used drug prior to becoming homeless. While causal inferences are subject to the limitations of a cross-sectional design, the findings pose an empirical challenge to the prevailing assumption that prior drug use is a dominant causal factor in YMSM becoming homeless. More broadly, the data illustrate the complexity of factors that must be accounted for, both in advancing our epidemiological understanding of the complexity of homelessness and its relationship to the onset of drug and sexual risk among high risk youth populations.
PMCID: PMC2755549  PMID: 15878043
13.  Lifetime Prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War  
PLoS Medicine  2008;5(4):e61.
There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon.
Methods and Findings
The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5–14.1), mood (OR 3.32, 95% CI 2.0–5.6), and impulse control disorders (OR 12.72, 95% CI 4.5–35.7).
About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.
In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.
Editors' Summary
Mental illnesses—persistent problems with thinking, with feelings, with behavior, and with coping with life—are very common. In the UK about a quarter, and in the US, almost half, of people have a mental illness at some time during their life. Depression, for example, persistently lowers a person's mood and can make them feel hopeless and unmotivated. Anxiety—constant, unrealistic worries about daily life—can cause sleep problems and physical symptoms such as stomach pains. People with impulse-control disorders, have problems with controlling their temper or their impulses which may sometimes lead to hurting themselves or other people. These and other mental illnesses seriously affect the work, relationships, and quality of life of the ill person and of their family. However, most people with mental illnesses can lead fulfilling and productive lives with the help of appropriate medical and nonmedical therapies.
Why Was This Study Done?
Recent epidemiological surveys (studies that investigate the factors that affect the health of populations) have provided important information about the burden of mental disorders in some industrialized countries. However, little is known about the global prevalence of mental disorders (the proportion of people in a population with each disorder at one time) or about how events such as wars affect mental health. This information is needed so that individual countries can provide effective mental-health services for their populations. To provide this information, the World Mental Health (WMH) Survey Initiative is undertaking large-scale psychiatric epidemiological surveys in more than 29 countries. As part of this Initiative, researchers have examined the prevalence and treatment of mental disorders in Lebanon and have asked whether war in this country has affected the risk of becoming mentally ill.
What Did the Researchers Do and Find?
The researchers randomly selected a sample of nearly 3,000 adults living in Lebanon and interviewed them using an Arabic version of the World Health Organization's “Composite International Diagnostic Interview” (CIDI 3.0). This interview tool generates diagnoses of mental disorders in the form of “DSM-IV codes,” the American Psychiatric Association's standard codes for specific mental disorders. The researchers also asked the study participants about their experience of war-related traumatic events such as being a civilian in a war zone or being threatened by a weapon. The researchers found that one in four Lebanese had had one or more DSM-IV disorder at some time during their life. Major depression was the single most common disorder. The researchers also calculated that by the age of 75 years, about one-third of the Lebanese would probably have had one or more DSM-IV disorder. Only half of the Lebanese with a mood disorder ever received professional help; treatment rates for other mental disorders were even lower. The average delay in treatment ranged from 6 years for mood disorders to 28 years for anxiety disorders. Finally, exposure to war-related events increased the risk of developing an anxiety, mood, or impulse-control disorder by about 6-fold, 3-fold, and 13-fold, respectively.
What Do These Findings Mean?
These findings indicate that the prevalence of mental illness in Lebanon is similar to that in the UK and the US, the first time that this information has been available for an Arabic-speaking country. Indeed, the burden of mental illness in Lebanon may actually be higher than these findings suggest, because the taboos associated with mental illness may have stopped some study participants from reporting their problems. The findings also show that in Lebanon exposure to war-related events greatly increases the risk of developing for the first time several mental disorders. Further studies are needed to discover whether this finding is generalizable to other countries. Finally, these findings indicate that many people in Lebanon who develop a mental illness never receive appropriate treatment. There is no shortage of health-care professionals in Lebanon, so the researchers suggest that the best way to improve the diagnosis and treatment of mental disorders in this country might be to increase the awareness of these conditions and to reduce the taboos associated with mental illness, both among the general population and among health-care professionals.
Additional Information.
Please access these Web sites via the online version of this summary at
Read a related PLoS Medicine Perspective article
IDRAAC has a database that provides access to all published research articles related to mental health in the Arab World
The UK charity Mind provides information on understanding mental illness
The US National Institute of Mental Health provides information on understanding, treating, and preventing mental disorders (mainly in English but some information in Spanish)
MedlinePlus provides a list of useful links to information about mental health
Wikipedia has a page on DSM-IV codes (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Mental Health Survey Initiative and the Lebanese WHM study are described on the organizations' Web pages
PMCID: PMC2276523  PMID: 18384228
14.  Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using capture-recapture analysis. 
BMJ : British Medical Journal  1994;308(6920):27-30.
OBJECTIVES--To use routinely collected data to provide a reliable estimate of the size and psychiatric morbidity of the homeless population of a given geographical area by using capture-recapture analysis. DESIGN--A multiple sample, log-linear capture-recapture method was applied to a defined area of central London during 6 months. The method calculates the total homeless population from the sum of the population actually observed and an estimate of the unobserved population. Data were collected from local agencies used by homeless people. SUBJECTS--Homeless people in north east Westminster residing in bed and breakfast accommodation and hotels or sleeping rough who had contacted statutory or voluntary agencies in the area. RESULTS--2150 contacts by 1640 homeless people were recorded. The estimated unobserved population was 3293, giving a total homeless population for the period of around 5000 (SD 1250). Mental health problems were significantly less prominent in the unobserved compared with the observed population (23% (754) v 40% (627), P < 0.0001). For both groups the prevalence varied greatly with age and sex. CONCLUSIONS--Capture-recapture techniques can overcome problems of ascertainment in estimating populations of homeless and homeless mentally ill people. Prevalences of mental illness derived from surveys that do not correct for ascertainment are likely to be falsely inflated while at the same time underestimating the total size of the homeless mentally ill population. Population estimates derived from capture-recapture techniques may usefully provide a good basis for including homeless populations in capitation calculations for allocating funds within health services.
PMCID: PMC2539171  PMID: 8298348
15.  Access to primary health care among homeless adults in Toronto, Canada: results from the Street Health survey 
Open Medicine  2011;5(2):e94-e103.
Despite experiencing a disproportionate burden of acute and chronic health issues, many homeless people face barriers to primary health care. Most studies on health care access among homeless populations have been conducted in the United States, and relatively few are available from countries such as Canada that have a system of universal health insurance. We investigated access to primary health care among a representative sample of homeless adults in Toronto, Canada.
Homeless adults were recruited from shelter and meal programs in downtown Toronto between November 2006 and February 2007. Cross-sectional data were collected on demographic characteristics, health status, health determinants and access to health care. We used multivariable logistic regression analysis to investigate the association between having a family doctor as the usual source of health care (an indicator of access to primary care) and health status, proof of health insurance, and substance use after adjustment for demographic characteristics.
Of the 366 participants included in our study, 156 (43%) reported having a family doctor. After adjustment for potential confounders and covariates, we found that the odds of having a family doctor significantly decreased with every additional year spent homeless in the participant’s lifetime (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86–0.97). Having a family doctor was significantly associated with being lesbian, gay, bisexual or transgendered (adjusted OR 2.70, 95% CI 1.04–7.00), having a health card (proof of health insurance coverage in the province of Ontario) (adjusted OR 2.80, 95% CI 1.61–4.89) and having a chronic medical condition (adjusted OR 1.91, 95% CI 1.03–3.53).
Less than half of the homeless people in Toronto who participated in our study reported having a family doctor. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage and having a chronic medical condition. Increased efforts are needed to address the barriers to appropriate health care and good health that persist in this population despite the provision of health insurance.
PMCID: PMC3148004  PMID: 21915240
16.  Psychosocial interventions for the prevention of disability following traumatic physical injury 
Traumatic physical injury can result in many disabling sequelae including physical and mental health problems and impaired social functioning.
To assess the effectiveness of psychosocial interventions in the prevention of physical, mental and social disability following traumatic physical injury.
Search methods
The search was not restricted by date, language or publication status. We searched the following electronic databases; Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Controlled Trials metaRegister (, AMED (Allied & Complementary Medicine), ISI Web of Science: Social Sciences Citation Index (SSCI), PubMed. We also screened the reference lists of all selected papers and contacted authors of relevant studies. The latest search for trials was in February 2008.
Selection criteria
Randomised controlled trials that consider one or more defined psychosocial interventions for the prevention of physical disability, mental health problems or reduced social functioning as a result of traumatic physical injury. We excluded studies that included patients with traumatic brain injury (TBI).
Data collection and analysis
Two authors independently screened the titles and abstracts of search results, reviewed the full text of potentially relevant studies, independently assessed the risk of bias and extracted data.
Main results
We included five studies, involving 756 participants. Three studies assessed the effect of brief psychological therapies, one assessed the impact of a self-help booklet, and one the effect of collaborative care. The disparate nature of the trials covering different patient populations, interventions and outcomes meant that it was not possible to pool data meaningfully across studies. There was no evidence of a protective effect of brief psychological therapy or educational booklets on preventing disability. There was evidence from one trial of a reduction in both post-traumatic stress disorder (PTSD) and depressive symptoms one month after injury in those who received a collaborative care intervention combined with a brief psycho-educational intervention, however this was not retained at follow up. Overall mental health status was the only disability outcome affected by any intervention. In three trials the psychosocial intervention had a detrimental effect on the mental health status of patients.
Authors’ conclusions
This review provides no convincing evidence of the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury. Taken together, our findings cannot be considered as supporting the provision of psychosocial interventions to prevent aspects of disability arising from physical injury. However, these conclusions are based on a small number of disparate trials with small to moderate sample sizes and are therefore necessarily cautious. More research, using larger sample sizes, and similar interventions and patient populations to enable pooling of results, is needed before these findings can be confirmed.
PMCID: PMC3428876  PMID: 19821365
Depression [prevention & control]; Disabled Persons [psychology]; Interpersonal Relations; Mental Disorders [prevention & control]; Pamphlets; Psychotherapy [methods]; Randomized Controlled Trials as Topic; Self Care [methods]; Social Support; Stress Disorders, Post-Traumatic [prevention & control]; Wounds and Injuries [psychology]; Humans
17.  A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults in three Canadian cities 
BMC Public Health  2013;13:577.
Homeless persons experience a high burden of health problems; yet, they face significant barriers in accessing health care. Less is known about unmet needs for care among vulnerably housed persons who live in poor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were to examine the prevalence of and factors associated with unmet needs for health care in a population-based sample of homeless and vulnerably housed adults in three major cities within a universal health insurance system.
Participants were recruited at shelters, meal programs, community health centers, drop-in centers, rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009. Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regression was used to identify factors associated with self-reported unmet needs for health care in the past 12 months.
Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses, factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months (AOR = 1.40, 95% CI = 1.03–1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24–3.79). Having higher health-related quality of life (AOR = 0.21, 95% CI = 0.09–0.53), improved mental (AOR = 0.97, 95% CI = 0.96–0.98) or physical health (AOR = 0.98, 95% CI = 0.96–0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46–0.85) decreased the odds of reporting unmet needs.
Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health care needs. Strategies to improve access to primary care and reduce barriers to accessing care in these populations are needed.
PMCID: PMC3691921  PMID: 23764199
Access to care; Homelessness; Housing; Primary care; Public health policy
18.  Prevalence and Risk of Homelessness Among US Veterans 
Understanding the prevalence of and risk for homelessness among veterans is prerequisite to preventing and ending homelessness among this population. Homeless veterans are at higher risk for chronic disease; understanding the dynamics of homelessness among veterans can contribute to our understanding of their health needs.
We obtained data on demographic characteristics and veteran status for 130,554 homeless people from 7 jurisdictions that provide homelessness services, and for the population living in poverty and the general population from the American Community Survey for those same jurisdictions. We calculated prevalence of veterans in the homeless, poverty, and general populations, and risk ratios (RR) for veteran status in these populations. Risk for homelessness, as a function of demographic characteristics and veteran status, was estimated by using multivariate regression models.
Veterans were overrepresented in the homeless population, compared with both the general and poverty populations, among both men (RR, 1.3 and 2.1, respectively) and women (RR, 2.1 and 3.0, respectively). Veteran status and black race significantly increased the risk for homelessness for both men and women. Men in the 45- to 54-year-old age group and women in the 18- to 29-year-old age group were at higher risk compared with other ages.
Our findings confirm previous research associating veteran status with higher risk for homelessness and imply that there will be specific health needs among the aging homeless population. This study is a basis for understanding variation in rates of, and risks for, homelessness in general population groups, and inclusion of health data from US Department of Veterans Affairs records can extend these results to identifying links between homelessness and health risks.
PMCID: PMC3337850  PMID: 22280960
19.  Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings 
Research on discrimination in healthcare settings has primarily focused on health implications of race-based discrimination among ethno-racial minority groups. Little is known about discrimination experiences of other marginalized populations, particularly groups facing multiple disadvantages who may be subjected to other/multiple forms of discrimination. Objectives: (1) To examine the prevalence of perceived discrimination due to homelessness/poverty, mental illness/alcohol/drug related problems, and race/ethnicity/skin color while seeking healthcare in the past year among racially diverse homeless adults with mental illness; (2) To identify whether perceiving certain types of discrimination is associated with increased likelihood of perceiving other kinds of discrimination; and (3) To examine association of these perceived discrimination experiences with socio-demographic characteristics, self-reported measures of psychiatric symptomatology and substance use, and Emergency Department utilization.
We used baseline data from the Toronto site of the At Home/Chez Soi randomized controlled trial of Housing First for homeless adults with mental illness (n = 550). Bivariate statistics and multivariable logistic regression models were used for the analysis.
Perceived discrimination related to homelessness/poverty (30.4%) and mental illness/alcohol/substance use (32.5%) is prevalent among ethnically diverse homeless adults with mental illness in healthcare settings. Only 15% of the total participants reported discrimination due to race/ethnicity/skin color. After controlling for relevant confounders and presence of psychosis, all types of discrimination in healthcare settings were associated with more frequent ED use, a greater - 3 - severity of lifetime substance abuse, and mental health problems. Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination.
Understanding the experience of discrimination in healthcare settings and associated healthcare utilization is the first step towards designing policies and interventions to address health disparities among vulnerable populations. This study contributes to the knowledge base in this important area.
Trial registration number
This study has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374.
PMCID: PMC4176588  PMID: 25196184
Racial discrimination; Social discrimination; Homeless persons; Prejudice; Racism; Healthcare; Adult; Canada; Mentally Ill persons; Substance-related disorders
20.  Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review 
BMC Public Health  2011;11:638.
Research on interventions to positively impact health and housing status of people who are homeless has received substantially increased attention over the past 5 years. This rapid review examines recent evidence regarding interventions that have been shown to improve the health of homeless people, with particular focus on the effect of these interventions on housing status.
A total of 1,546 articles were identified by a structured search of five electronic databases, a hand search of grey literature and relevant journals, and contact with experts. Two reviewers independently screened the first 10% of titles and abstracts for relevance. Inter-rater reliability was high and as a result only one reviewer screened the remaining titles and abstracts. Articles were included if they were published between January 2004 and December 2009 and examined the effectiveness of an intervention to improve the health or healthcare utilization of people who were homeless, marginally housed, or at risk of homelessness. Two reviewers independently scored all relevant articles for quality.
Eighty-four relevant studies were identified; none were of strong quality while ten were rated of moderate quality. For homeless people with mental illness, provision of housing upon hospital discharge was effective in improving sustained housing. For homeless people with substance abuse issues or concurrent disorders, provision of housing was associated with decreased substance use, relapses from periods of substance abstinence, and health services utilization, and increased housing tenure. Abstinent dependent housing was more effective in supporting housing status, substance abstinence, and improved psychiatric outcomes than non-abstinence dependent housing or no housing. Provision of housing also improved health outcomes among homeless populations with HIV. Health promotion programs can decrease risk behaviours among homeless populations.
These studies provide important new evidence regarding interventions to improve health, housing status, and access to healthcare for homeless populations. The additional studies included in this current review provide further support for earlier evidence which found that coordinated treatment programs for homeless persons with concurrent mental illness and substance misuse issues usually result in better health and access to healthcare than usual care. This review also provides a synthesis of existing evidence regarding interventions that specifically support homeless populations with HIV.
PMCID: PMC3171371  PMID: 21831318
21.  Suicidality, Bullying and Other Conduct and Mental Health Correlates of Traumatic Brain Injury in Adolescents 
PLoS ONE  2014;9(4):e94936.
Our knowledge on the adverse correlates of traumatic brain injuries (TBI), including non-hospitalized cases, among adolescents is limited to case studies. We report lifetime TBI and adverse mental health and conduct behaviours associated with TBI among adolescents from a population-based sample in Ontario.
Method and Findings
Data were derived from 4,685 surveys administered to adolescents in grades 7 through 12 as part of the 2011 population-based cross-sectional Ontario Student Drug Use and Health Survey (OSDUHS). Lifetime TBI was defined as head injury that resulted in being unconscious for at least 5 minutes or being retained in the hospital for at least one night, and was reported by 19.5% (95%CI:17.3,21.9) of students. When holding constant sex, grade, and complex sample design, students with TBI had significantly greater odds of reporting elevated psychological distress (AOR = 1.52), attempting suicide (AOR = 3.39), seeking counselling through a crisis help-line (AOR = 2.10), and being prescribed medication for anxiety, depression, or both (AOR = 2.45). Moreover, students with TBI had higher odds of being victimized through bullying at school (AOR = 1.70), being cyber-bullied (AOR = 2.05), and being threatened with a weapon at school (AOR = 2.90), compared with students who did not report TBI. Students with TBI also had higher odds of victimizing others and engaging in numerous violent as well as nonviolent conduct behaviours.
Significant associations between TBI and adverse internalizing and externalizing behaviours were found in this large population-based study of adolescents. Those who reported lifetime TBI were at a high risk for experiencing mental and physical health harms in the past year than peers who never had a head injury. Primary physicians should be vigilant and screen for potential mental heath and behavioural harms in adolescent patients with TBI. Efforts to prevent TBI during adolescence and intervene at an early stage may reduce injuries and comorbid problems in this age group.
PMCID: PMC3988100  PMID: 24736613
22.  How can health services effectively meet the health needs of homeless people? 
Homelessness affects many people in contemporary society with consequences for individuals and the wider community. Homeless people experience poorer levels of general physical and mental health than the general population and there is a substantial international evidence base which documents multiple morbidity. Despite this, they often have problems in obtaining suitable health care.
To critically examine the international literature pertaining to the health care of homeless people and discuss the effectiveness of treatment interventions.
Design of study
Review and synthesis of current evidence.
Medline (1966–2003), EMBASE (1980–2003), PsycINFO (1985–2003), CINAHL (1982–2003), Web of Science (1981–2003) and the Cochrane Library (Evidence Based Health) databases were reviewed using key terms relating to homelessness, intervention studies, drug misuse, alcohol misuse and mental health. The review was not limited to publications in English. It included searching the internet using key terms, and grey literature was also accessed through discussion with experts.
Internationally, there are differing models and services aimed at providing health care for homeless people. Effective interventions for drug dependence include adequate oral opiate maintenance therapy, hepatitis A, B and tetanus immunisation, safer injecting advice and access to needle exchange programmes. There is emerging evidence for the effectiveness of supervised injecting rooms for homeless injecting drug users and for the peer distribution of take home naloxone in reducing drug-related deaths. There is some evidence that assertive outreach programmes for those with mental ill health, supportive programmes to aid those with motivation to address alcohol dependence and informal programmes to promote sexual health can lead to lasting health gain.
As multiple morbidity is common among homeless people, accessible and available primary health care is a pre-requisite for effective health interventions. This requires addressing barriers to provision and multi-agency working so that homeless people can access the full range of health and social care services. There are examples of best practice in the treatment and retention of homeless people in health and social care and such models can inform future provision.
PMCID: PMC1832238  PMID: 16611519
alcoholism; health care delivery; homeless persons; mental health; primary care; substance related disorders
23.  Burden of mental disorders and unmet needs among street homeless people in Addis Ababa, Ethiopia 
BMC Medicine  2014;12(1):138.
The impact of mental disorders among homeless people is likely to be substantial in low income countries because of underdeveloped social welfare and health systems. As a first step towards advocacy and provision of care, we conducted a study to determine the burden of psychotic disorders and associated unmet needs, as well as the prevalence of mental distress, suicidality, and alcohol use disorder among homeless people in Addis Ababa, the capital of Ethiopia.
A cross-sectional survey was conducted among street homeless adults. Trained community nurses screened for potential psychosis and administered standardized measures of mental distress, alcohol use disorder and suicidality. Psychiatric nurses then carried out confirmatory diagnostic interviews of psychosis and administered a locally adapted version of the Camberwell Assessment of Needs Short Appraisal Schedule.
We assessed 217 street homeless adults, about 90% of whom had experienced some form of mental or alcohol use disorder: 41.0% had psychosis, 60.0% had hazardous or dependent alcohol use, and 14.8% reported attempting suicide in the previous month. Homeless people with psychosis had extensive unmet needs with 80% to 100% reporting unmet needs across 26 domains. Nearly 30% had physical disability (visual and sensory impairment and impaired mobility). Only 10.0% of those with psychosis had ever received treatment for their illness. Most had lived on the streets for over 2 years, and alcohol use disorder was positively associated with chronicity of homelessness.
Psychoses and other mental and behavioural disorders affect most people who are street homeless in Addis Ababa. Any programme to improve the condition of homeless people should include treatment for mental and alcohol use disorders. The findings have significant implications for advocacy and intervention programmes, particularly in similar low income settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12916-014-0138-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4147171  PMID: 25139042
Homelessness; Rooflessness; Mental illness; Severe mental disorder; Prevalence; Unmet needs; Low- and middle-income country; Ethiopia
24.  Sheltered Versus Nonsheltered Homeless Women 
To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and non-sheltered environments.
Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items.
Shelters (N = 47) and outdoor locations in Los Angeles.
One thousand fifty-one homeless women.
Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment.
There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments.
PMCID: PMC1495574  PMID: 10940149
homeless women; shelter status; health service utilization
25.  The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. 
Health Services Research  2000;34(6):1273-1302.
OBJECTIVES: (1) To present the Behavioral Model for Vulnerable Populations, a major revision of a leading model of access to care that is particularly applicable to vulnerable populations; and (2) to test the model in a prospective study designed to define and determine predictors of the course of health services utilization and physical health outcomes within one vulnerable population: homeless adults. We paid particular attention to the effects of mental health, substance use, residential history, competing needs, and victimization. METHODS: A community-based probability sample of 363 homeless individuals was interviewed and examined for four study conditions (high blood pressure, functional vision impairment, skin/leg/foot problems, and tuberculosis skin test positivity). Persons with at least one study condition were followed longitudinally for up to eight months. PRINCIPAL FINDINGS: Homeless adults had high rates of functional vision impairment (37 percent), skin/leg/foot problems (36 percent), and TB skin test positivity (31 percent), but a rate of high blood pressure similar to that of the general population (14 percent). Utilization was high for high blood pressure (81 percent) and TB skin test positivity (78 percent), but lower for vision impairment (33 percent) and skin/leg/foot problems (44 percent). Health status for high blood pressure, vision impairment, and skin/leg/foot problems improved over time. In general, more severe homeless status, mental health problems, and substance abuse did not deter homeless individuals from obtaining care. Better health outcomes were predicted by a variety of variables, most notably having a community clinic or private physician as a regular source of care. Generally, use of currently available services did not affect health outcomes. CONCLUSIONS: Homeless persons are willing to obtain care if they believe it is important. Our findings suggest that case identification and referral for physical health care can be successfully accomplished among homeless persons and can occur concurrently with successful efforts to help them find permanent housing, alleviate their mental illness, and abstain from substance abuse.
PMCID: PMC1089079  PMID: 10654830

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