CLINICAL HANDBOOK OF SCHIZOPHRENIA

414 VI. SPECIAL POPULATIONS AND PROBLEMSThese disorders may exacerbate an existing psychiatric disorder and complicate its treatment.Furthermore, particularly due to the side effects of antipsychotic medications, includingthe metabolic effects of the now widely used second-generation, or “atypical,”antipsychotic medications, overall medical treatment of homeless people with schizophreniacan be quite challenging.Many observers have documented the degree to which jails and prisons have absorbedmuch of the custodial function previously provided to mentally ill persons by thestate hospital system. Put another way, the revolving door has shifted from the state hospitalto the state prison. Homelessness among mentally ill persons is strongly associatedwith incarceration and other contact with the criminal justice system. This relationship isa two-way street; homelessness places mentally ill people at higher risk of arrest and incarceration,whereas arrest and incarceration place mentally ill people at higher risk ofhomelessness. The latter process reflects the lack of continuity of care between jails andprisons, and the outside community, and the lack of housing options for persons withSMI and criminal histories.Interestingly, when individuals with and without mental illness have been asked fortheir own perceived reasons for becoming homeless, both groups point to insufficient income,unemployment, and lack of suitable housing. The presence of psychiatric or substanceabuse disorders, or the lack of treatment adherence, were not recognized as riskfactors for homelessness. In other words, there may be a discrepancy between a mentallyill person’s perception of why he or she became homeless and other contributing factorsthat providers might recognize, presenting a challenge to the treatment situation.TREATMENT APPROACHESThe Community Mental Health Act of 1963 was meant to address the outpatient needsof the thousands of chronically mentally ill individuals in the United States who otherwisemight have spent years, or even lifetimes, on the wards of state psychiatric facilities.Books such as E. Fuller Torrey’s Nowhere to Go document the failed implementation ofthis plan, setting the stage for the explosion in the population of people who were homelessand mentally ill, as affordable housing declined at a rate comparable to the downsizingof the state hospitals. New York City, for example, lost approximately 90% of its single-room-occupancyhotel units, and the number of hospital beds declined by roughly thesame 90% from its peak in the mid-1950s through the 1980s. Lack of adequate fundingand lack of appropriate services contributed to the failure of the community mentalhealth system to provide necessary care for individuals in the more severely mentally illpopulation.In discussing treatment approaches for mentally ill homeless persons, one mustbroaden one’s view of “treatment” to include outreach, housing, and other service approaches.This section summarizes several innovative models developed to help individualswith schizophrenia who have fallen into the unfortunate grip of homelessness.MODEL PROGRAMS AND BEST PRACTICESWe chose the model programs and best practices described below and listed in Table 40.1because they have empirical support and have become, or are becoming, widely utilized.In describing them, we emphasize some common guiding principles of treatment alongwith some differences in approach that remain controversial. These program models have