StrongVeterans.com BlogHow Can We Help Persons With SMI and SUD Permanently Exit Homelessness?

During my psychiatry training, I worked at a community service agency, treating chronically homeless patients with serious mental illness (SMI) and substance use disorders (SUD) as they transitioned into supported housing. Naively, I equated supported housing to a path that would universally allow my patients to permanently exit homelessness. Instead, I witnessed a diverse range of housing outcomes and discovered a dearth of knowledge surrounding factors affecting exits from homelessness. Today, as a psychiatrist on an assertive community treatment team for veterans who have experienced homelessness, my patients continue to inspire important research questions: What are the long-term housing outcomes of persons who have experienced homelessness? What factors allow us to predict these housing outcomes? What services are needed to facilitate permanent exits from homelessness?

My colleagues and I aimed to answer these questions in our recent study. We used VA administrative data to identify persons with SMI and SUD who had experienced homelessness. For 36 of these individuals, we gathered retrospective housing histories over an average of 2.5 years. We also collected information on a range of factors that might predict housing outcomes, like psychiatric symptoms, community supports, and cognition (eg, memory, attention, planning abilities, and speed of information processing).

Each of the individuals we studied fell into 1 of 3 long-term housing outcomes. Some achieved stable housing—they were able to successfully exit homelessness. That is, they spent most days in stable housing arrangements, like their own apartments or permanent residences with family or friends. Others were unstably housed, spending most days vacillating between settings not intended for people to live in (like vehicles or abandoned buildings) or short-term housing arrangements (like homeless shelters or transitional housing). The third group was continuously enrolled in a housing program, sequentially enrolling in different housing programs on VA grounds.

In statistical analyses, we found that 2 salient factors predicted which of these housing outcomes an individual achieved. Those who were continuously enrolled in a housing program had very poor cognition. Among individuals with better cognition, those in stable housing had fewer difficulties interacting with other people than persons who were unstably housed.

In clinical practice, many of our patients with SMI and/or SUD who have trouble achieving stable housing have cognitive problems like difficulty with planning, attention, or memory. Many also have labile mood, psychotic symptoms, and related challenges that impair interaction with peers, family/friends, and treatment providers. Our study findings suggest a potential role for cognitive and/or social skills training to help this vulnerable population successfully exit homelessness. These treatment approaches are not commonly found within services for homeless consumers; future research may allow us to effectively integrate these services to add to our “toolbox” of treatments for people with mental illness who have experienced homelessness.

Financial disclosure:Dr Gabrielian has received grant/research support from VA Health Services Research and Development. ​