Mental illness in homelessness: What are the determinants?

Female gender, chronic disease and food insecurity are risk factors for major depressive disorder (MDD) and generalized anxiety disorder (GAD) in homeless individuals, while respect from others is a protective factor for both disorders, a territory-wide study has shown.

“Previous studies revealed a linkage between poor mental health and homelessness. [However,] there is limited research on homeless people in Hong Kong,” wrote the researchers. In view of this, the researchers analyzed data from the largest territory-wide survey of the homeless population in Hong Kong. [Int J Soc Psychiatry 2023;doi:10.1177/00207640231152208]

Data for the study were collected from the evening of 9 July 2021 to the early morning of 10 July 2021. More than 300 volunteers from nonprofit organizations, universities and tertiary institutions interviewed 1,103 homeless individuals (median age, 58.0 years; male, 83.8 percent; food insecurity, 62.4 percent; chronic disease, 39.0 percent) in different districts, with 708 questionnaires valid for analysis. Short versions of the Patient Health Questionnaire (PHQ) and GAD were used to assess the respondents’ mental health condition. PHQ-2 and GAD-2 scores ≥3 are recommended as cut-offs to screen for MDD and GAD, respectively.

“Results revealed a much higher prevalence of MDD and GAD among homeless people than the general population in Hong Kong [MDD, 28.7 percent vs 19.0 percent] [GAD, 26.3 percent vs 14.0 percent],” reported the researchers.

Female gender was associated with increased risk of MDD (odd ratios [ORs], 1.63–2.01) and GAD (ORs, 1.93–2.22) in both univariate and multivariate models. “Homeless females might feel more worried about personal safety, privacy, and exposure to the risk of harassment than males,” explained the researchers. “Additionally, as there were more homeless males than females [83.8 percent vs 16.2 percent], homeless females may feel more isolated and helpless.”

Chronic disease, which was more prevalent in homeless individuals vs the general population (39.0 percent vs 19.2 percent), was another risk factor for MDD (ORs, 1.66–2.01) and GAD (ORs, 1.94–2.27) in homeless people.

“The ORs for food insecurity [ie, worried about not having enough food to eat, and having to skip a meal] were the highest for both MDD [ORs, 2.66–3.30] and GAD [ORs, 3.16–4.31] among all independent variables in the logistic regression models, highlighting the importance of food security to homeless people’s mental health,” added the researchers.

Importantly, a high level of respect by others was a significant protective factor for MDD (OR, 0.37) and GAD (OR, 0.40) after controlling all other independent variables, such as economic and physical conditions.

The high prevalence of MDD and GAD in homeless individuals reflects inadequacies of current policies and services for the homeless population. Allocation of additional resources, such as temporary shelters for homeless females as well as medical services and food, is required to improve mental health of homeless individuals. “[Additionally,] respecting homeless people without discrimination is extremely important to protect them from mental illnesses,” highlighted the researchers. “This was a crucial reminder not only to the healthcare practitioners and government, but also to the general public.”