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Needs of homeless people for mental healthcare

  • Walid Khalid Abdul-Hamid (a1), Til Wykes (a2) and Stephen Stansfeld (a1)
Aims and method

To assess the individual needs for psychiatric services of a representative sample of homeless men living in hostels. A standardised procedure was used to assess the needs of 101 randomly selected homeless men.


The main mental health needs of the study sample were for psychiatric and social assessments and for alcohol and drug services. Men with psychotic problems had a high level of needs for psychiatric services and a higher proportion of unmet needs.

Clinical implications

Our findings support the need for community-based multidisciplinary services that work specifically with homeless people to meet their needs. These services should incorporate psychiatric, social and substance misuse services.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Walid Khalid Abdul-Hamid (
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1 Weller, BGA, Weller, MPI. Health care in a destitute population: Christmas 1985. Psychiatr Bull 1986; 10: 233–5.
2 Weller, BGA, Weller, MPI, Coker, E, Mahomed, S. Crisis at Christmas 1986. Lancet 1987; i: 553–4.
3 Timms, PW, Fry, AH. Homelessness and mental illness. Health Trends 1989; 21: 70–1.
4 Marshall, M. Collected and neglected: are Oxford hostels for the homeless filling up with disabled psychiatric patients? BMJ 1989; 299: 706–9.
5 Desai, MM, Rosenheck, RA. Unmet need for medical care among homeless adults with serious mental illness. Gen Hosp Psychiatry 2005; 27: 418–25.
6 Henderson, C, Bainbridge, J, Keaton, K, Kenton, M, Guz, M, Kanis, B. The use of data to assist in the design of a new service system for homeless veterans in New York City. Psychiatr Q 2008; 79: 317.
7 Kendell, RE. The Role of Diagnosis in Psychiatry. Blackwell, 1975.
8 Bebbington, PE. Population surveys of psychiatric disorder and the need for treatment. Soc Psychiatry Psychiatr Epidemiol 1990; 25: 3340.
9 Wykes, T, Creer, C, Sturt, E. Needs and the deployment of services. Psychol Med 1982; (suppl 2): 514.
10 Wing, JK. Meeting the needs of people with psychiatric disorders. Soc Psychiatry Psychiatr Epidemiol 1990; 25: 28.
11 Abdul-Hamid, W. The needs of the elderly homeless for mental health services. Int J Geriatr Psychiatry 1997; 12: 724–7.
12 Abdul-Hamid, W, Wykes, T, Stansfeld, S. The homeless mentally ill, myths and realities. Int J Soc Psychiatry 1993; 38: 237–54.
13 McQuistion, HL, Finnerty, M, Hirschowitz, J, Susser, ES. Challenges for psychiatry in serving homeless people with psychiatric disorders. Psychiatr Serv 2003; 54: 669–76.
14 Griffith, S. Assessing the Health Needs of Rough Sleepers. Office of the Deputy Prime Minister, Homelessness Directorate, 2002.
15 Wykes, T, Sturt, E, Creer, C. The assessment of patients' needs for community care. Soc Psychiatry 1985; 20: 7685.
16 Linhorst, DM. The use of single room occupancy (SRO) housing as a residential alternative for persons with a chronic mental illness. Commun Ment Health J 1991; 27: 135–44.
17 Satchell, M. Health and homelessness: a study of health problems in single homeless men. MSc Dissertation in Sociology, Polytechnic of South Bank, London, 1988.
18 Abdul-Hamid, W, McCarthy, M. Community psychiatric care for homeless people in inner London. Health Trends 1989; 21: 67–9.
19 First, RJ, Rife, JC, Kraus, STI. Case management with people who are homeless and mentally ill: preliminary findings from an NIMH demonstration project. Psychosoc Rehab J 1990; 14: 8791.
20 Homeless Group London Standing Conference. Health Services For Homeless People Within London. National Health Service, 2005.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
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Needs of homeless people for mental healthcare

  • Walid Khalid Abdul-Hamid (a1), Til Wykes (a2) and Stephen Stansfeld (a1)
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Psychiatric inpatients of no fixed abode

Joseph F Hayes, Clinical Training Fellow
01 September 2011

Patients classified as having "no fixed abode," pose particular challenges on admission to psychiatric wards. Those who have come from living on the streets or from hostels may have previously had difficultiesaccessing, or engaging with services, and continuing treatment. It has been recognised that a high percentage of the homeless population suffer with mental illness, with psychotic illness present in as much as 42% of the population (Fazel et al, 2008). This group is therefore challenging for psychiatric services to manage as they present with multiple and complex issues, and cost more as inpatients than their housed counterparts, because of longer stays and more frequent admissions (Turner& Haskins, 1993; Hwang et al, 2011). Given the current economic climate and attempts by all quarters to reduce spending, it is likely thatMental Health trusts will start to pay more attention to the nature and appropriate management of this population. They are also of interest from a clinical perspective, because of the challenges associated with caring for patients who may have difficulty engaging with, and continuing contactwith services. Literature searches involving relevant terms fail to produce much in the way of recent evidence to further our understanding ofthis population, but evidence of the scale of the present problem is beginning to emerge (Abdul-Hamid, Wykes, & Stansfeld, 2010). The last wave of interest in this field seems to have occurred in the late 1990s (Commander & Odell, 1998), and locally led to the development of the Focus Homeless Outreach Team.

To begin to consider how to address the needs of this group locally we carried out an audit of all patients classified as "no fixed abode" whowere admitted to inpatient wards in Camden and Islington NHS Foundation Trust over a six month period (from October 2009 to March 2010). The "no fixed abode" population is not a homogenous one, as is the case in most Trusts, the Camden and Islington "no fixed abode" population can be seen as two subgroups. There are true homeless no fixed abode (NFA) patients, identified as having no postcode, and there are those who live out of the catchment area of the trust, identified as having a non-Camden/Islington postcode (non-C&I). Non-C&I patients are recognised as a challenge locally, as they tend to use more resources; in information gathering, andbecause of the need for relocation. It was hypothesised that these two groups would have different characteristics, with the non-C&I group being more similar to the local "housed" population. However it is likely thereis also heterogeneity within these subgroups.

92 patients were identified in the six month study period; 40 NFA and52 non-C&I from a total of 1139 admissions to the trust (8%). There were no significant between-group differences for age, sex or ethnicity. However there were trends towards NFA patients being more likely to be male and of any black origin.

Despite the majority in both groups presenting themselves informally to services (70%), usually via Emergency Departments, the rate of detention under the Mental Health Act was high (57%) compared to all admissions to the Trust (38% under the Mental Health Act). This may reflect the complex way in which such patients engage with services because of their social situation. During admission both groups engaged equally well with their treatment plan, based on a combined measure of frequency of AWOL, deliberate self harm and concordance with medication.

The majority reported no history of mental health difficulties at thepoint of admission (71.7%). However at discharge 90.2% had a diagnosis that was likely to have been longstanding. This could be for a number of reasons, including lack of insight, a wish to withhold information, or a failure to engage with services previously. NFA patients were no more likely to withhold information about diagnosis at admission than non-C&I patients. At discharge 77.5% of the NFA group and 51.9% of the non-C&I group had a consultant assigned ICD-10 diagnosis of psychotic illness, andthis difference was statistically significant (P=0.0163). A high proportion of patients had comorbid substance misuse problems (55.0% NFA, 32.7% non-C&I (P=0.0361)). Non-C&I patients were initially more rapidly discharged (most frequently to their local inpatient service) , such that 46% were discharged within 7 days, compared to 20% of NFA patients(P=0.0145). However by 21 days 31% of the non-C&I and 28% of the NFA group remained as inpatients. The median length of stay for all admissions to Camden and Islington beds during the study period was 19 days (range 0-349).

Non-C&I patients' problems appear no less complex than NFA patients in terms of management planning, and they do appear different from our local housed population. The term "crisis-flight" has been used to describe a patient's way of finding a geographical solution to internal problems (Hiatt & Spurlock, 1970). Camden and Islington Boroughs contain a number of major UK transport hubs; we would therefore expect to see this patient type regularly. It has previously been reported that 10%of admissions to an inner London psychiatric hospital were overseas patients (Tannock & Turner, 1995). In our small sample 11% of patientsrequired repatriation overseas.

NFA patients pose a number of management issues, with higher rates ofpsychosis and substance misuse. However despite this they are conspicuously absent from recent UK policy and research in psychiatry. As the number of inpatient beds falls and Crisis Teams care for increasingly unwell and risky patients in their homes, these are the patients that are likely to fill our inpatient units more and more. It may be that homelessness is incompatible with adequately treating psychosis and substance misuse, However, that these patients are no less likely to accept psychiatric diagnosis and engage with care as inpatients than the non-C&I cohort in our sample holds the promise that innovative methods of service-provision could be employed to manage this population and relieve longer-term pressures on services resulting from repeated admissions.

Fazel S, Khosla V, Doll H & Geddes J.The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis. PloS Medicine 2008 5(12): e225.Turner S, & Haskins C. London capitation weighting: social deprivation, homelessness and mental health. Psychiatric Bulletin 1993 17:641-646

Hwang SW, Weaver J, Aubry T, & Hoch JS. Hospital Costs and Lengthof Stay Among Homeless Patients Admitted to Medical, Surgical, and Psychiatric Services. Medical Care 2011 49(4):350-354.

Abdul-Hamid WK, Wykes T, & Stansfeld S. Needs of homeless people for mental healthcare. The Psychiatrist (2010) 34: 334-337

Commander M, & Odell S. Admission of the homeless mentally ill inthe UK. Psychiatric Bulletin 1998, 22:207-210.

Hiatt CC, & Spurlock RE. Geographical flight and its relation to crisis theory. Amer J Orthopsychiat 1970, 40:53-57.

Tannock C, & Turner T. Psychiatric tourism is overloading London beds. BMJ 1995, 311:806

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Conflict of interest: None declared

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