Healthcare Barriers among Severely Mentally Ill Homeless Adults: Evidence from the Five-site Health and Risk Study

  • Mimi M. KimEmail author
  • Jeffrey W. Swanson
  • Marvin S. Swartz
  • Daniel W. Bradford
  • Sarah A. Mustillo
  • Eric B. Elbogen
Original Paper


Few studies have examined barriers to physical and mental healthcare among homeless mentally adults. Methods This study examined physical and mental healthcare barriers reported by 154 recently homeless mentally ill persons. Results Practical concerns (e.g. transportation and cost) were key components of barriers to accessing general medical care among uninsured men with poorer overall mental health, PTSD, and STD infections. Perceived stigma was an important component of mental healthcare barriers reported most frequently by those with greater psychiatric symptoms. Conclusion Focusing on individual characteristics underlying barriers to healthcare may lead to better interventions for improving access to needed care.


Mental illness Homelessness Physical healthcare 


  1. Association, A. P. (2000). (DSM-IV-TR) Diagnostic and statistical manual of mental disorders (4th ed., text revision ed.). Washington, DC: American Psychiatric Press, Inc.Google Scholar
  2. Bachrach, L. L. (1992). What we know about homelessness among mentally illy persons: An analytical review and commentary. Hospital and Community Psychiatry, 43, 453–464.PubMedGoogle Scholar
  3. Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998). Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. American Journal of Psychiatry, 155(11), 1561–1564.PubMedGoogle Scholar
  4. Bender, E. (2006). Hepatitis, TB rates found `Alarming’ among state hospital patients. Psychiatric News, 41(3), 5-a-27.Google Scholar
  5. Blanchard, E., Jones-Alexander, J., Buckley, T., & Forneris, C. (1996). Psychometric properties of the PTSD Checklist (PCL). Behavioral Research Therapy, 34, 669–673.CrossRefGoogle Scholar
  6. Bourgois, P., Prince, B., & Moss, A. (2004). The everyday violence of Hepatitis C among young women who inject drugs in San Francisco. Human Organization, 63(3), 253–265.PubMedGoogle Scholar
  7. Bradford, D. W., Gaynes, B. N., Kim, M. M., Kaufman, J. S., & Weinberger, M. (2005). Can shelter-based interventions improve treatment engagement in homeless individuals with psychiatric and/or substance misuse disorders? A randomized controlled trial. Medical Care August, 43(8), 763–768.CrossRefGoogle Scholar
  8. Clarke, P. N., Williams, C. A., Percy, M. A., & Kim, Y. S. (1995). Health and life problems of homeless men and women in the Southeast. Journal of Community Health Nursing, 12(2), 101–110.PubMedCrossRefGoogle Scholar
  9. D’Amore, J., Hung, O., Chiang, W., & Goldfrank, L. (2001). The Epidemiology of the homeless population and its impact on an urban emergency department. Acad Emerg Med, 8(11), 1051–1055.PubMedGoogle Scholar
  10. Faustman, W. (Ed.). (1999). Overall J. Brief Psychiatric Rating Scale (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates Inc.Google Scholar
  11. Fischer, P. J., & Breakey, W. R. (1991). The Epidemiology of Alcohol, Drug, and Mental Disorders Among Homeless Persons. American Psychologist November, 46(11), 1115–1128.CrossRefGoogle Scholar
  12. Folsom, D., Hawthorne, W., Lindamer, L., Gilmer, G., Bailey, A., & Golshan, S., et al. (2005). Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. The American Journal of Psychiatry, 162(2), 370.PubMedCrossRefGoogle Scholar
  13. Folsom, D., & Jeste, D. (2002). Schizophrenia in homeless persons: a systematic review of the literature. Acta Psychiatrica Scandinavica, 105(6), 404.PubMedCrossRefGoogle Scholar
  14. Gaba, R.J. (1997). Psychometric properties of the survey of children’s exposure to community violence: Screening version. Dissertation Abstracts International, 57, 4774.Google Scholar
  15. Gallagher, T. C., Andersen, R. M., Koegel, P., & Gelberg, L. (1997). Determinants of regular source of care among homeless adults in Los Angeles. Medical Care, 35(8), 814–830.PubMedCrossRefGoogle Scholar
  16. Gillis, L., & Singer, J. (1997). Breaking through the barriers: Healthcare for the homeless. Journal of Nursing Administration, 27(6), 30–34.PubMedCrossRefGoogle Scholar
  17. Goodman, L. A., Thompson, K. M., Weinfurt, K., Corl, S., Acker, P., & Mueser, K. T., et al. (1999). Reliability of reports of violent victimization and posttraumatic stress disorder among men and women with serious mental illness. Journal of Traumatic Stress October, 12(4), 587–599.CrossRefGoogle Scholar
  18. Guydish, J., Bucardo, J., Clark, G., & Bernheim, S. (1998). Evaluating needle exchange: A description of client characteristics, health status, program utilization, and HIV risk behavior. Substance Use & Misuse, 33(5), 1173–1196.CrossRefGoogle Scholar
  19. Hahm, H. C., & Segal, S. P. (2005). Failure to seek health care among the mentally ill. American Journal of Orthopsychiatry, 75(1), 54–62.PubMedCrossRefGoogle Scholar
  20. Hwang, S. (2001). Mental illness and mortality among homeless people. Acta Psychiatrica Scandinavica June 2002;105(6):404–413, 103, 81–82.Google Scholar
  21. Josephson, D. M., McDonell, M. B., & Anderson, S. A. (1996). Application of the SF36 and SF12 physical and mental health component summary scores in the VA outpatient setting. Journal of General Internal Medicine April, 1, 75.Google Scholar
  22. Kaiser, H. F. (1974). An index of factorial simplicity. Psychomtrica, 39, 31–36.CrossRefGoogle Scholar
  23. Koenker, R. (2003). Quantile regression for longitudinal data. Journal of Multivariate Analysis, 91, 74–89.CrossRefGoogle Scholar
  24. Kushel, M., Gupta, R., Gee, L., & Haas, J. (2005). Housing instability and food insecurity as barriers to health care: results from the national survey of American families. Journal of General Internal Medicine, 20(Supplement 1), 116–117.Google Scholar
  25. Lam, J. A., & Rosenheck, R. A. (1998). The effects of victimization on clinical outcomes of homeless persons with serious mental illness. Psychiatric Services, 49, 678–683.PubMedGoogle Scholar
  26. Langenbucher, J. W., Labouvie, E., Martin, C. S., Sanjuan, P. M., Bavly, L. & Kirisci, L., et al. (2004). An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV. Journal of Abnormal Psychology, 113(1), 72–80.PubMedCrossRefGoogle Scholar
  27. Lewis, J. H., Andersen, R. M., & Gelberg, L. M. D. M. (2003). Health care for homeless women: Unmet needs and barriers to care. Journal of General Internal Medicine, 18(11), 921–928.PubMedCrossRefGoogle Scholar
  28. Mojtabai, R. M. (2005). Perceived reasons for loss of housing and continued homelessness among homeless persons with mental illness. Psychiatric Services, 56(2), 172–178.PubMedCrossRefGoogle Scholar
  29. Muthen, B., & Muthen, L. (1998). MPlus. Los Angeles: Muthen & Muthen.Google Scholar
  30. North, C., & Smith, E. (1993). A systematic study of mental health services utilization by homeless men and women. Social Psychiatry and Psychiatric Epidemiology, 28, 77–83.PubMedCrossRefGoogle Scholar
  31. Padgett, D., & Streuning, E. (1990). Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Medical Care, 28, 805–821.PubMedCrossRefGoogle Scholar
  32. Padgett, D., Streuning, E., Andrews, H., & Pittman, J. (1995). Predictors of emergency room use by homeless adults in New York City: The influence of predisposing, enabling and need factors. Social Science & Medicine, 41(4), 547.CrossRefGoogle Scholar
  33. Pirl, W. F., Greer, J. A., Weissgarber, C. R., Liverant, G. M., & Safren, S. A. (2005). Screening for infectious diseases among patients in a state psychiatric hospital. Psychiatric Services, 56(12), 1614–1616.PubMedCrossRefGoogle Scholar
  34. Robertson, M. J. (1986). Mental disorder among homeless persons in the United States: An overview of recent empirical literature. Administration and Policy in Mental Health and Mental Health Services Research, 14(1), 14–27.Google Scholar
  35. Rosenberg, S., Brunette, M., Oxman, T., Marsh, B., Dietrich, A. & Mueser, K., et al. (2004). The STIRR model of best practices for blood-borne diseases among clients with serious mental illness. Psychiatric Services, 55(6), 660–665.PubMedCrossRefGoogle Scholar
  36. Rosenberg, S., Drake, R., Wolford, G., Mueser, K., Oxman, T. & Vidaver, R., et al. (1998). Dartmouth assessment of lifestyle instrument (DALI): A substance use disorder screen for people with severe mental illness. American Journal of Psychiatry February, 155(2), 232–238.Google Scholar
  37. Rosenberg, S., Goodman, L., Osher, F., Swartz, M., Essock, S. & Butterfield, M., et al. (2001). Prevalence of HIV, Hepatitis B, and Hepatitis C in people with severe mental illness. American Journal of Public Health Chronic Disease. January, 91(1), 31–37.Google Scholar
  38. Rosenheck, R. A., & Lam, J. A. (1997). Client and site characteristics as barriers to service use by homeless persons with serious mental illness. Psychiatric Services, 48(3), 387–390.PubMedGoogle Scholar
  39. Ryan, S. (1993). Psychometric analysis of the sexual abuse exposure questionnaire. Dissertation Abstracts International, (54), 2268.Google Scholar
  40. Salyers, M., Bosworth, H., Swanson, J., Lamb-Pagone, J., & Osher, F. (2000). Reliability and validity of the SF-12 health survey among people with severe mental illness. Medical Care, 38(11), 1141–1150.PubMedCrossRefGoogle Scholar
  41. Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The revised Conflict Tactics Scale (CTS2): Development and Preliminary Psychometric Data. Journal of Family Issues, (17), 283–316.Google Scholar
  42. Sullivan, G., Burnam, A., Koegel, P., & Hollenberg, J. (2000). Quality of life of homeless persons with mental illness: Results from the course-of-homelessness study. Psychiatric Services, 51(9), 1135–1141.PubMedCrossRefGoogle Scholar
  43. Swanson, J., Holzer, C., Ganju, V., & Jono, R. (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiologic catchment area surveys. Hospital and Community Psychiatry, 41, 761–770.PubMedGoogle Scholar
  44. Swanson, J., Swartz, M., Essock, S., Osher, F., Wagner, H. & Goodman, L., et al. (2002). The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health INDIGENOUS HEALTH. September, 92(9), 1523–1531.Google Scholar
  45. Swartz, M. S., Swanson, J. W., Hannon, M. J., Bosworth, H. S., Osher, F. C. & Essock, S. M., et al. (2003). Regular sources of medical care among persons with severe mental illness at risk of Hepatitits C Infection. Psychiatric Services, 54(6), 854–859.PubMedCrossRefGoogle Scholar
  46. Tessler, R., Rosenheck, R., & Gamache, G. (2001). Comparison of homeless veterans with other homeless men in a large clinical outreach program. Psychiatric Quarterly, 73, 109–119.CrossRefGoogle Scholar
  47. Ware, J. E., Kosinski, M., Turner-Bowker, D. M., & Gandek, B. (2002). How to Score Version 2 of the SF-12 Health Survey (With a Supplemental Documenting Version 1). Lincoln RI, Quality Metric Incorporated.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Mimi M. Kim
    • 1
    Email author
  • Jeffrey W. Swanson
    • 1
  • Marvin S. Swartz
    • 1
  • Daniel W. Bradford
    • 2
  • Sarah A. Mustillo
    • 1
  • Eric B. Elbogen
    • 1
  1. 1.Services Effectiveness Research Program in the Department of Psychiatry & Behavioral SciencesDuke University Medical CenterDurhamUSA
  2. 2.VA Center for Health Services Research in Primary CareDurhamUSA

Personalised recommendations