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Abstract

Objective: To review the prevalence literature on psychological distress and psychiatric disorders among homeless youth in Australia, and to compare these rates with Australian youth as a whole.

Method: Computerized databases were utilized to access all published Australian studies on psychological distress (as measured by standardized symptom scales and suicidal behaviour) and psychiatric disorders among homeless youth; in addition, unpublished Australian studies were utilized whenever accessible. A total of 14 separate studies were located, only three of which have included non-homeless control groups. In the current review, prevalence data from uncontrolled youth homelessness studies are compared with data from Australian community and student surveys.

Results: Homeless youth have usually scored significantly higher on standardized measures of psychological distress than all domiciled control groups. Youth homelessness studies have also reported very high rates of suicidal behaviour, but methodological limitations in these studies make comparisons with community surveys difficult. Furthermore, rates of various psychiatric disorders are usually at least twice as high among homeless youth than among youth from community surveys.

Conclusions: Homeless youth in Australia have extremely high rates of psychological distress and psychiatric disorders. As homeless youth are at risk of developing psychiatric disorders and possibly self-injurious behaviour the longer they are homeless, early intervention in relevant health facilities is required.

Keywords

Australia homeless youth prevalence psychiatric disorders psychological distress

Youth homelessness has existed in Australia for many years. However, it was not until 1989, with the release of the Burdekin report [1], that youth homelessness became more of a critical issue [2]. Estimates of the extent of youth homelessness in the late 1980s and early 1990s varied widely from 15 000–19 000 to 50 000–70 000 [1,3–6]. The most recent Australian homeless epidemiological survey estimated that on census night there were approximately 105 000 homeless individuals in Australia, of whom 35 000 were youths [7]. While there is no consensus on the number of homeless youth in Australia, there is no indication that the incidence of youth homelessness in Australia is declining [8].

There are many reasons for youth homelessness. The Commonwealth House of Representatives Standing Committee on Community Affairs [8] identified several factors contributing to youth homelessness. These include familial conflict (including family violence and abuse), familial poverty, high rates of youth unemployment resulting in increased dependency of youth within families, a history of state intervention and wardship, drug and alcohol abuse, and psychiatric illness.

Government enquiries [1, 8] have noted that great numbers of homeless youth have significant mental and physical health problems. While no empirical studies have been undertaken on the prevalence of physical disorders, several empirical studies have documented extremely high rates of mental health problems among this population. However, hitherto there has been no attempt to synthesize this literature. One way of making such a synthesis more meaningful may be to compare the prevalence of mental health problems experienced by homeless youth with Australian youth as a whole.

Method

For the purposes of the current review, youth has been defined as individuals aged 12 through 25. Index Medicus/MEDLINE, PsycINFO, Sociological Abstracts and AustHealth databases were utilized to access all published Australian studies on psychological distress and psychiatric disorders among homeless youth. Unpublished Australian youth homelessness studies were also utilized whenever accessible. A total of 14 separate studies [9–24, Fryar S: unpublished data], covering the period 1989–1998, were located. Eleven of these studies [9–12,14–20] deal specifically with homeless youth populations; three studies [23,24, Fryar S: unpublished data] have been conducted on homeless adults of all ages, but separate prevalence data have been provided for the youths included in these studies. Only three of the 14 studies in the current review have included non-homeless control groups [9, 15, 19].

Methodological issues in homelessness research

There are a number of methodological issues in homelessness research that may affect the prevalence of psychological and psychiatric morbidity data. One such issue is how homelessness is defined. For example, discrepant definitions of homelessness account for the aforementioned disparate estimates of the number of homeless youth in Australia [4] and might affect psychological and psychiatric morbidity data. Another factor which may affect psychiatric morbidity rates in homelessness research is sampling issues: prevalence data from studies utilizing representative sampling methods and those from studies using convenience samples may reveal discrepant prevalence data. An additional factor that may affect psychiatric prevalence rates is sample size.

For example, small sample size results in wide confidence limits for prevalence figures [25]. Furthermore, regional and temporal variations among homeless populations may affect prevalence data. For instance, young people recruited on the streets in one Australian city may have different characteristics to those recruited in another city [26]. For the purposes of the current review, homelessness has been defined as living on the street, in squats or shelters, lacking permanent residence, being at risk of homelessness, or frequenting inner city youth services. This very broad definition has been used because there appear to be very few differences in rates of psychological distress and psychiatric disorders among studies utilizing disparate definitions of homelessness. Furthermore, despite discrepant sampling approaches, the small sample sizes utilized, and regional and temporal variations, rates of psychological distress and psychiatric disorders are extremely consistent across homeless youth studies. Rates of psychological distress reported in published and unpublished Australian studies are also very consistent.

Factors such as the reliability and validity of self-report data may also affect psychiatric morbidity rates in homelessness research. Calsyn and his colleagues [27] have shown that the sociodemographic and service use data provided by homeless individuals, as well as their scores on standardized symptom scales, are fairly reliable and valid. Furthermore, measures of interrater and test–retest reliability were obtained on two of three homeless psychiatric studies in the current review [18, 22, 23], and were found to be generally good.

Duration of homelessness may also affect rates of psychiatric morbidity. For example, overseas cross-sectional studies which have found higher rates of psychiatric disorders, substance abuse and selfharming behaviour among those who have been homeless for long periods of time than those who are newly homeless [28–33]. Australian researchers [17], however, found that self-injurious behaviour increased over time only in non-abused, and not abused, homeless youth. These researchers also found that levels of self esteem and hopelessness did not change significantly across time among homeless teenagers [17].

A further factor that may affect psychiatric prevalence data is the heterogeneous nature of homeless youth. American research has shown that some subgroups of homeless youth such as those engaged in prostitution are at greater risk for mental and physical health problems, substance abuse and suicidal behaviour [34]. American researchers [35] have also indicated that homosexual and bisexual youth are at increased risk for attempting suicide. Unfortunately, there is little Australian research on subgroups of homeless youth that are particularly at risk.

Community/student comparison surveys

As there are very few controlled youth homelessness studies, in the current review psychological distress and psychiatric prevalence data from uncontrolled youth homelessness studies are compared with data from Australian community and student surveys. The community/ student surveys are described below.

Community/student surveys of suicidal behaviour

The studies utilized in the current review to indicate levels of suicidal behaviour among youth in the community are the Victorian survey of adolescent health [36] and the Western Australian Child Health Survey [37]. The Victorian adolescent health survey was a study of non-fatal suicidal behaviours among 1699 15–16-year-old students drawn from 44 schools throughout Victoria. In this study suicidal behaviours were measured for the 12 months prior to interview. The Western Australian Child Health Survey included 2737 children aged 4–16 drawn from a random sample of 1776 households throughout metropolitan and rural Western Australia. The Western Australian survey examined suicidal behaviour in the 6 months prior to interview.

Community surveys of psychiatric disorders

The Australian surveys utilized to indicate the rate of psychiatric disorders among youth in the community are the recent nationwide Survey of Mental Health and Wellbeing (SMHWB) [38] and Clayer et al.'s [39] Riverland rural South Australian survey. The SMHWB consisted of a random sample of 10 640 adults aged 18 and over living in private dwellings in all Australian states and territories. ICD-10 [40] and DSM-IV [41] anxiety, mood and substance-use disorder diagnoses were made using the Composite International Diagnostic Interview (CIDI). Prevalence data were provided for the 12 months prior to interview. To facilitate comparisons with youth homelessness psychiatric studies in Australia, which have all utilized DSM-III-R [42] or DSMIV diagnostic criteria, in the current review only DSM-IV (unpublished) prevalence data will be presented for the SMHWB. People currently residing in hotels, boarding houses and institutions, and homeless people were specifically excluded from the SMHWB. As a result of this exclusion, ‘it is… likely that the survey underestimates the prevalence of mental disorder in the Australian population’ [38], p.47].

The Riverland survey consisted of an age and gender stratified random sample of 1009 adults 18 years of age and older drawn from the South Australian state electoral roll [39]. Psychiatric diagnoses were made utilizing the Diagnostic Interview Schedule Screening Instrument (DISSI) for DSM-III [43]. The Riverland psychiatric survey, which does not appear to have included homeless individuals, provided lifetime and 6-month prevalence data. While the Riverland survey cannot be considered nationally representative, it has been utilized in the current review as it is the only psychiatric epidemiological survey in Australia to provide lifetime DSM prevalence data across a number of diagnostic categories and recent prevalence rates from this study are consistent with recent rates from the SMHWB [39, Australian Bureau of Statistics: unpublished data].

Comparisons of prevalence studies using different reporting frames

Australian youth homelessness studies and community surveys reporting recent rates of psychiatric disorders have sometimes utilized different temporal reporting frames. However, given the small number of youth homelessness studies and community surveys reporting recent rates of psychiatric disorders, it was decided to report recent prevalence data from all such studies together. Furthermore, Australian youth homelessness studies and community surveys reporting lifetime rates of psychiatric disorders have sometimes reported psychiatric disorders for different populations (either males or males and females combined). However, given the small number of youth homelessness studies and community surveys reporting lifetime rates of psychiatric disorders, it was decided to report prevalence data from all such studies together. Comparisons of studies utilizing different temporal reporting frames and different populations should thus be interpreted cautiously.

Results

Prevalence of psychological distress among homeless youth

Studies utilizing standardized symptom scales

An uncontrolled study indicated that homeless youths’ scores on the Rosenberg Self Esteem Inventory were as low as those obtained by unemployed Queensland adolescents [17]. This study [17] also found that homeless youth scored in the ‘moderate’ range on the Beck Hopelessness Scale. Another uncontrolled study [Fryar S: unpublished data] observed no differences between homeless teenage subjects and a non-patient adolescent normative sample on all Brief Symptoms Inventory scales. A further uncontrolled study [11] observed high scores on hostility (as measured by the Hostility and Direction of Hostility Questionnaire), depression (as measured by the Depression subscale of the Minnesota Multiphasic Personality Inventory), antisocial tendencies and social isolation (as measured by the Jessness Inventory) among both ‘runaways’ (those who leave home of their own volition) and ‘throwaways’ (those who are forced to leave home).

Findings from controlled studies indicate that homeless youth have scored significantly higher on measures of psychological distress than virtually all control groups. Compared with domiciled Australian youth, homeless youth in Australia have reported: significantly higher scores on the Youth Self-Report Form of the Child Behaviour Checklist [9, 19]; significantly more parental marital problems and less parental acceptance (as measured by the Children's Perception Questionnaire) [9]; and significantly more emotional, cultural and social deprivation and parental overprotection (as measured by the Parental Bonding Instrument and the Family Environment Scale) [9, 20]. Homeless youth have also scored significantly lower on the Offer Self-Image Questionnaire (indicating poorer adjustment) than every domiciled control group other than the unemployed [15].

Suicidal behaviour

There are no data on the prevalence of completed suicide among homeless youth in Australia. The prevalence of suicidal ideation among homeless youth has varied from 40% to 80% [10, 14] and rates of reported attempted suicide have varied from 23% to 67% [10, 12, 14, 16, 21]. While rates of suicidal ideation and attempted suicide appear lower in community/student surveys [36, 37], comparisons with youth homelessness studies are problematic for at least two reasons. First, prevalence data from community/student surveys have been reported for either the previous 6 or 12 months whereas youth homelessness studies appear to provide lifetime rates of suicidal behaviour. Second, as the term ‘suicide attempt’ usually has not been defined for subjects in youth homelessness studies, it is difficult to know if the prevalence figures reported in these studies accurately reflect the frequency of ‘true’ suicide attempts (i.e. those who were ‘seriously trying to end their life at that time’ [36]). This is in contrast to some community/student surveys, which have been careful to delineate the frequency of ‘true’ suicide attempts. For example, Patton et al. [36] found that only a small minority (i.e. 4%) of Victorian adolescents who had deliberately self-harmed in the 12 months prior to interview were ‘seriously trying to end their life at that time’.

Prevalence of psychiatric disorders among homeless youth

Lifetime psychiatric disorders

Table 1 indicates that the rate of having any lifetime psychiatric disorder is nearly twice as high among homeless youth than among domiciled peers. Compared with home-based youth, homeless youth also have considerably higher rates of mood disorders and substance-use disorders, especially for the other drug abuse/dependence category. Moreover, rates of dual diagnoses (comorbid substance-use and other psychiatric disorders) are very high among homeless youth (38% in one study [18] and 35% in another [23]). Unfortunately, comparable lifetime comorbidity data are not available for home-based Australian youth, but could not be higher than the base rate of any single disorder (i.e. alcohol abuse/dependence = 21.6%).

Table 1.

Lifetime prevalence of psychiatric disorders among homeless youth and youth from community surveys (%)

While Herrman et al. [23] reported that 25% of the homeless male youth in their study had a lifetime psychotic disorder, Reilly et al. [18] observed no psychotic disorders among homeless youths in their study. Reilly et al. [18] offered the explanation that the sources of accommodation from which they sampled may have excluded youths with psychotic illnesses. Support for the notion that Reilly et al. may have underestimated the rate of psychotic disorders comes from Hodder and her colleagues [24], who found that 26.7% of the homeless youth in their study had a psychotic disorder in the 12 months prior to interview, and from Virgona and his colleagues [44], who observed a lifetime rate of schizophrenia of 30% among homeless adult females in Sydney. The point prevalence of schizophrenia among homeless adult males in Sydney has ranged from 15% to 23% [45, 46].

Comparisons of lifetime rates of psychiatric disorders among Australian and American youth reveal very few differences [18, 23, 31, 33, 47, 48]. Moreover, the finding of higher rates of psychiatric disorders among homeless youth than among domiciled youths in Australia is consistent with the American literature. Compared with youths from the American Epidemiologic Catchment Area (ECA) study [49], homeless youth in the USA have at least three times the rate of affective and substance-use disorders, and at least eight times the rate of psychotic disorders. American studies have also observed rates of antisocial personality disorder among homeless youths to be at least three times higher than youth from the ECA survey [31, 33,47–49].

Recent psychiatric disorders

Table 2 shows that the rate of mood disorders, anxiety disorders, substance-use disorders and comorbid disorders are frequently at least twice as high among homeless youth than among domiciled youth in Australia, even though recent rates of psychiatric disorders may be reported for a shorter period in the homelessness studies. Furthermore, Herrman et al. [23] and Hodder et al. [24], but not Reilly et al. [18], reported very high recent rates of psychotic disorders among homeless youth. However, as discussed previously, the Reilly et al. study underestimates the prevalence of psychotic disorders among homeless youth in Australia.

Table 2.

Recent prevalence of psychiatric disorders among homeless youth and youth from the Survey of Mental Health and Wellbeing (SMHWB)(%)

The finding of elevated recent rates of psychiatric disorders among homeless youth relative to domiciled youth in Australia is not anomalous. Comparisons of American homeless youth and youth from the ECA survey indicate significantly elevated recent rates of mood and substance-use disorders among homeless youth [31, 50]. Furthermore, Australian 1-month psychiatric prevalence rates are similar to those reported in European homeless youth studies [18, 23, 51, 52]. Moreover, compared with males from Australian community surveys, homeless male adults in Australia across every age group usually have at least twice the rate of any psychiatric disorder, mood disorders, substanceuse disorders and comorbid disorders, even though homeless studies may have been utilizing shorter temporal reporting frames [23,24, Australian Bureau of Statistics: unpublished data].

Does homelessness precede the development of psychiatric disorders or vice versa?

There are at least four studies that have examined whether the onset of psychiatric disorders precedes or follows homelessness. A Melbourne study consisting primarily of adults found that the onset of one or more lifetime mood, psychotic or substance-use disorders preceded the onset of homelessness in 85% of subjects [53]. A recent youth homelessness study in London found that the onset of 70% of substance use and psychotic disorders preceded the first episode of homelessness [51, Craig TKJ: personal communication 2001]. Findings from American studies present a similar picture. North and Smith [54] observed that posttraumatic stress disorder preceded the onset of homelessness in nearly 75% of their primarily adult homeless subjects in St. Louis; a study conducted in San Francisco also found that substance-use disorders, psychiatric hospitalization and physical disorders preceded the onset of homelessness in 54% of homeless adults [28].

While the above studies indicate that psychiatric disorders precede homelessness in the majority of instances, it also appears that individuals with no psychiatric impairment when they first become homeless are at risk of developing a psychiatric diagnosis the longer they are homeless [28]. Increasing duration of homelessness also appears to be a risk factor for substance use and possibly selfinjurious behaviour [17, 29, 33].

Utilization of health services

Findings from the SMHWB indicate that the majority (59%) of Australians with a DSM-IV anxiety, mood or substance-related disorder had not utilized health services during the survey year. Only 50.8% of respondents with a mood disorder, 42.7% with an anxiety disorder, and 7.7% with a substance-related disorder had utilized treatment services in the prior 12 months [Australian Bureau of Statistics: unpublished data]. Individuals were more likely to seek treatment if they had comorbid disorders (72%; [Australian Bureau of Statistics: unpublished data]). The reason that people with comorbid disorders seek treatment more often is that they have two conditions to present about.

Homeless youth tend to view many existing treatment services as ‘unapproachable, irrelevant or frightening’ [13]. Herrman et al. [23, 53] found that only one-third of homeless youths with psychotic disorders were taking antipsychotic medications. This compares with 85% of adults in the Study of Low Prevalence Disorders component of the SMHWB [55]. Reilly et al. [18] also found that only 29% of homeless youths with lifetime depression had received counselling. However, consistent with the findings of the SMHWB, only a small minority of homeless youth (9%) had received treatment for a substance-use disorder [18].

Discussion

One of the implications of the above findings is that health services must be perceived to be attractive, approachable and user-friendly by homeless youth. They also need to be perceived to be relevant and have the resources and mandate to deal with the multifaceted problems of homeless youth. Brown has indicated the difficulties in treating substance use in isolation in such clientele [56], p.51]:

… until emotional concerns related to the family, school, work, friends and peers are addressed, and until physical privations such as a lack of food and shelter are at least partially alleviated, then there is little likelihood that such young people shall be induced to divest themselves of one of the few past-times that allow them to momentarily depart from reality into a more comfortable and carefree experience.

What appear to be required are multidisciplinary health facilities specific to homeless youth which offer medical, psychiatric, psychological, drug and alcohol and social work services.

While it is clear that homeless youth in Australia have much higher rates of psychological distress and psychiatric disorders than domiciled youth, much more psychiatric and psychological data are required. More, larger studies using structured psychiatric diagnostic interviews such as the Structured Clinical Interview for DSM disorders (SCID) or CIDI are required. More research is also required on service utilization and ‘attempted suicide’ among homeless youth in Australia. At present, it is not possible to differentiate between ‘true’ suicide attempts and other forms of deliberate self-harm in the youth homelessness literature. Researchers in the youth homelessness field should define potentially ambiguous terms and take care in specifying the period for which prevalence data is gathered.

Research is also required on subgroups of homeless youth. At present there is little Australian research on even basic subgroups of homeless youth concerning gender differences or delineating particularly at-risk subgroups. More research is needed on gender differences among homeless youth, as well as those who are involved in prostitution, identify as homosexual or bisexual, are aboriginal, or are intellectually disabled.

Footnotes

Acknowledgements

The support of the Adelaide Central Mission, and in particular that of Michael Colin (Manager, Adolescent Services), is gratefully acknowledged.

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Prevalence of Psychological Distress and Psychiatric Disorders Among Homeless Youth in Australia: A Comparative Review

Abstract

Keywords

Method

Methodological issues in homelessness research

Community/student comparison surveys

Community/student surveys of suicidal behaviour

Community surveys of psychiatric disorders

Comparisons of prevalence studies using different reporting frames

Results

Prevalence of psychological distress among homeless youth

Studies utilizing standardized symptom scales

Suicidal behaviour

Prevalence of psychiatric disorders among homeless youth

Lifetime psychiatric disorders

Recent psychiatric disorders

Does homelessness precede the development of psychiatric disorders or vice versa?

Utilization of health services

Discussion

Footnotes

Acknowledgements

References