The unhoused population in the U.S. is on the rise. According to the U.S. Department of Housing and Urban Development (HUD), the unhoused rate increased by 12% between 2022 and 2023 by approximately 70,650 people, reaching levels of approximately 653,100 people who experienced homelessness on a single night in 2023. Among them are a disproportionate number of people living with mental health conditions. In fact, about 1 in 5 unhoused individuals in the U.S. has a serious mental illness, including schizophrenia or bipolar disorder.
Some individuals living with a serious mental health condition may be without stable housing because their condition impacts their decision making. Or, these individuals may lack a support system, perhaps due to challenges with maintaining consistent functional relationships or because their symptoms made it difficult for family members to care for them.
For example, some of the symptoms of schizophrenia, such as cognitive deficits, paranoia, and delusions, may complicate a person’s ability to maintain stable housing. While symptoms vary per individual, the timing of this symptom manifestation (typically in early adulthood) often intersects with a period of newfound independence from parents or other support systems, which can already be sensitive and unstable, adding to the complex connectivity between serious mental illness and lack of housing.
The Brain & Behavior Research Foundation has reported the most common disorders seen among the unhoused community are affective disorders like depression, schizophrenia and anxiety disorders. Substance abuse is also common – the National Alliance to End Homelessness cites 24% of the unhoused population experiences this as a chronic issue. In 2022, the National Center for Biotechnology Information published research via the National Library of Medicine noting there is often a high prevalence of comorbidities in unhoused populations, including physical and mental health disorders, resulting in increased rates of morbidity and mortality, healthcare utilization and poor health outcomes.
The relationship between mental health and housing is complex and can make the challenges these individuals face even more difficult.
The Complex Feedback Loop
Unhoused individuals living with serious mental illness can be stuck in a complex feedback loop. While the consequences of mental illness can contribute to housing instability, being unhoused can itself exacerbate existing mental health conditions. The trauma associated with being unhoused can worsen feelings of shame, stress and depression.
In addition, serious mental health illnesses may come with symptoms that affect employment, relationships and activities of daily living, making it difficult to afford and maintain housing. Lack of support, potential childcare responsibilities and substance use disorders further compound these issues. It’s not uncommon for unhoused individuals to resort to risky behaviors to meet basic needs.
It’s imperative that healthcare professionals consider the best possible solutions for accessible treatment to meet the needs of this population. One of those solutions is via Assertive Community Treatment (ACT) programs.
ACT Programs
ACT programs are community-based treatment teams made up of medical, behavioral and rehabilitation professionals to meet the needs of those battling severe and persistent mental illness. The target of these teams is often to reduce the cycle of re-hospitalization and encourage a holistic approach to care. That may include mental well-being, comprehensive medication-assisted treatment and social service support to secure housing, food stamps, employment, resource groups and more.
The Canadian Observatory on Homelessness notes that an ACT team is typically made up of the following core positions:
- Clinical or medical staff, like a psychiatrist, doctor or nurse
- Supervisor, such as a counselor or social worker
- Peer support workers
- Generalist case managers
- Skills training staff for tasks like cooking, cleaning, etc.
- Other professionals, as needed, such as substance abuse specialists
There is generally one ACT team peer support worker assigned to a group of 10 patients, and the team is available to support 24/7 for real-time response. Since there are many environmental factors impacting the treatment journeys of patients in unhoused communities battling serious mental illnesses, a person-centered approach is key to care. As many patients undergoing treatment via an ACT team are dealing with persistent mental illness, which will endure throughout their lifetime, “success” looks different for each individual. This could be achieving medication adherence or reaching certain life goals. With a local ACT program, there are a few ways this often-overlooked community can receive more thoughtful, strategic and personalized care throughout their long-term treatment journey:
- Facilitating access to essential resources. ACT programs open up access to basic necessities such as housing, money and food. Teams can connect individuals with Social Security Income, employment opportunities and food pantries to improve their living conditions. They can further assist individuals with professional development and job hunting such as through writing and reviewing resumes and researching convenient modes of transportation.
- Delivering comprehensive psychiatric care. This includes medication management and symptom stabilization, and increasing access to care by meeting patients at their locations. ACT teams act as advocates for patients, helping foster trust and consistency in the care cycle. And, as many unhoused individuals struggle with high comorbidity rates, ACT teams typically have the ability to provide transdiagnostic care across a variety of mental illnesses like depression, anxiety, obsessive-compulsive disorder, schizoaffective disorder and more.
- Decreasing reliance on emergency hospital services. Ambulance rides cost money – and costs are only increasing. Just last year, the Fire Department of the City of New York ambulance rate rose by 54% to $1,385. Emergency services are out of many people’s price ranges, especially for the unhoused. ACT programs can provide community-based care and crisis intervention, freeing up hospitals to use resources for medical emergencies and minimize any potential monetary or mental trauma associated with emergency treatment.
- Exploring Treatment Options. The medication landscape is vast, so ACT team professionals are often involved with helping patients find a treatment regimen that works for them. This may include exploring different types of medication, such as oral options or long-acting injectables (LAIs). LAIs are medications administered by injection by a healthcare provider and can last weeks or even months. Because they do not need to be taken every day like most oral medications, LAIs may offer more flexibility and stability for a patient population that often experiences challenges with medication adherence. In addition, LAIs can provide healthcare providers with assurance that medication is in the patient’s system throughout the dosing interval. This consistency is critical as we know that individuals with serious mental illness like schizophrenia are prone to decompensation and symptomatic episodes, which can compound the severity of the illness.
- Treating patients with a person-first perspective: ACT teams allow for a personalized approach that isn’t necessarily guaranteed with other healthcare environments. Healthcare professionals on ACT teams meet their patients where they are, whether they live in a home or within an unhoused community, so participants within the program are getting treatment on their terms in an accessible way. After all, not every patient has access to reliable transportation, especially those who are unhoused.
Once individuals have more access to basic needs like housing, they may see a window of opportunity to motivate them to address various aspects of their health and lifestyle moving forward. There is no one-size-fits all solution to providing care to the unhoused community, so it’s essential for healthcare professionals to connect these individuals with appropriate resources tailored to their unique circumstances and location.
Key Considerations
Although beneficial, ACT programs also face common challenges such as staff shortages, adequate support, burnout, and a need for more training. A lack of manpower or professional training can strain program resources – a challenge the healthcare industry has been up against in recent years post-pandemic.
According to the Health Resources and Services Administration, the supply of psychiatrists is expected to decrease by 20% by 2030, but the demand of their services is expected to increase by 3%; this leaves a shortage of over 120,000 fully-trained psychiatrists. Due to the nature of working with patients who are diagnosed with serious mental illness, there is high turnover among staff members, which disrupts the continuity of care and could potentially erode the trust formed with existing clients. As many clients live with trauma and don’t trust the U.S. healthcare system, building trust needed to provide the most effective care may take more time than expected.
Obstacles may also differ depending on the location. In rural communities, geographical isolation and limited access to resources require healthcare professionals who are willing to travel and adapt to the unique needs of these populations. Rural areas experience shortages at a high rate, accounting for about two-thirds of the primary health professional shortage nationwide, while only 20% of Americans live in these regions. This illuminates an issue not just for the bandwidth for ACT teams, but the healthcare industry overall.
Consistent client engagement is of utmost importance. Health Recovery Solutions details that continual patient engagement results in better outcomes for the patients, including numerous benefits like reduced cost of care, increased satisfaction, enhanced trust and loyalty. This deeper engagement might be difficult at face-value, but by shifting perspective and thinking creatively, healthcare professionals can address these challenges head-on by exploring virtual visits, offering interpersonal trainings, and emphasizing nonverbal cues or body language.
So, in order to make an impact and break through the complex feedback cycle that unfortunately persists due to a variety of factors, ACT program professionals must work incredibly hard to build trust from the ground up – an uphill battle but certainly attainable.
The Path Ahead
In short, when working with unhoused individuals, healthcare professionals must utilize perspective as a part of their daily practice. Some of those within this community have chosen to live their life in this way, even if the reason for these choices do not seem logical. So when trying to help with housing or certain social supports, providers must understand that this chosen life may be a predictable, comfortable part of their patients’ routine, and change might be slow.
The biggest takeaway to grasp from ACT programs is that it can benefit individuals in a variety of ways, with treatment exploration and medication management at the forefront to help patients manage their mental health conditions, find treatment that works and help them reach their goals. By utilizing perspective, understanding it’s not a one-size-fits-all approach and practicing empathy, healthcare professionals can make a lasting impact on a population too often overlooked.
