Mental health conditions and substance use disorders can play significant roles in pathways to homelessness, particularly when appropriate treatment and support services are unavailable or inaccessible. While it's important to avoid oversimplifying the relationship between these health conditions and homelessness—as discussed in our myths section—understanding this pathway is crucial for developing effective prevention and intervention strategies.
The Complex Relationship
The relationship between mental health, substance use, and homelessness is multifaceted:
Prevalence Among People Experiencing Homelessness
- Approximately 25-30% of people experiencing homelessness have serious mental health conditions
- About 30-35% have substance use disorders
- Many individuals experience co-occurring mental health and substance use disorders
- These rates are higher than in the general population but do not represent the majority of people experiencing homelessness
Important Context
While mental health and substance use issues are overrepresented in the homeless population, it's critical to recognize that the majority of people with these conditions never become homeless. The pathway to homelessness typically involves the intersection of these health conditions with other factors, particularly poverty and lack of affordable housing.
How Mental Health Conditions Can Contribute to Housing Loss
Several mechanisms connect untreated mental health conditions to increased risk of homelessness:
Functional Impairments
- Employment challenges: Symptoms can interfere with obtaining or maintaining employment
- Financial management difficulties: Cognitive impairments may affect ability to manage finances and pay rent on time
- Social isolation: Reduced social networks can limit access to support during housing crises
- Self-care challenges: Difficulty maintaining housing conditions or addressing maintenance needs
Treatment-Related Factors
- Inadequate community-based services: Limited access to outpatient treatment
- Gaps after psychiatric hospitalization: Insufficient discharge planning and follow-up
- Medication access and adherence challenges: Difficulty maintaining treatment regimens
- High treatment costs: Financial burden of care, even with insurance
Systemic Barriers
- Housing discrimination: Landlords may be reluctant to rent to people with known mental health conditions
- Insufficient disability income: SSI/SSDI benefits often inadequate for market-rate housing
- Limited supportive housing: Long waiting lists for housing with mental health supports
- Fragmented systems: Poor coordination between mental health and housing services
How Substance Use Can Contribute to Housing Loss
Substance use disorders can increase vulnerability to homelessness through several pathways:
Direct Financial Impact
- Resource allocation: Funds directed to obtaining substances rather than housing costs
- Employment instability: Difficulty maintaining consistent employment
- Legal costs: Expenses related to arrests, court fees, and legal representation
Housing-Specific Challenges
- Eviction for substance-related behaviors: Noise, disturbances, or illegal activities
- Housing program exclusions: Many programs require sobriety for entry or continued residence
- Relationship strain: Conflict with household members or landlords
Treatment Gaps
- Limited treatment availability: Long waiting lists for detox and rehabilitation programs
- Insurance barriers: Inadequate coverage for substance use treatment
- Lack of harm reduction approaches: Abstinence-only requirements that create barriers to engagement
- Insufficient recovery support: Limited ongoing support after acute treatment
Historical Context: Deinstitutionalization and Its Aftermath
The current relationship between mental health and homelessness cannot be understood without examining the historical context of deinstitutionalization:
The Deinstitutionalization Movement
- Beginning in the 1950s and accelerating in the 1960s-70s, large state psychiatric hospitals began closing
- Driven by concerns about poor conditions, civil rights considerations, and the development of psychiatric medications
- Intended to shift care to community-based settings that would be more humane and effective
The Implementation Gap
- Promised community mental health centers were never adequately funded or developed
- Housing supports for people with mental illness were insufficient
- Responsibility shifted from state to federal level, creating fragmentation
- Coincided with reductions in affordable housing and social safety nets
A Policy Failure, Not a Treatment Failure
Deinstitutionalization itself was not the problem—community-based care can be more effective and humane than institutional care. The failure was in not providing adequate community-based services, housing, and supports to replace the functions that institutions had served, however imperfectly.
The Bidirectional Relationship
While mental health and substance use issues can contribute to homelessness, the experience of homelessness itself often creates or exacerbates these conditions:
Homelessness as a Trauma
- The experience of becoming homeless is itself traumatic
- Living without stable housing creates ongoing stress and hypervigilance
- Exposure to violence and victimization is common while homeless
- These traumatic experiences can trigger or worsen mental health conditions
Practical Barriers to Wellness
- Sleep deprivation: Difficulty finding safe places to sleep, leading to cognitive impairment
- Medication management: Challenges storing and taking medications consistently
- Nutrition: Limited access to adequate nutrition affects brain function
- Exposure: Weather extremes create physical stress that impacts mental health
Substance Use as Coping
- Substances may be used to cope with the trauma and hardship of homelessness
- Self-medication for untreated mental health symptoms or physical pain
- Substances sometimes used to stay awake (for safety) or to stay warm
- Social connections in homeless communities may center around substance use
This bidirectional relationship creates a cycle that can be difficult to break without addressing both housing and health needs simultaneously.
Treatment System Failures
Several specific failures in mental health and substance use treatment systems contribute to homelessness:
Access Barriers
- Insurance gaps: Many people lack coverage for needed services
- Provider shortages: Insufficient mental health professionals, especially in rural areas
- Transportation challenges: Difficulty reaching treatment locations
- Complex navigation: Fragmented systems that are difficult to access
Quality and Appropriateness Issues
- One-size-fits-all approaches: Lack of culturally responsive or trauma-informed care
- High threshold requirements: Expectations that create barriers to engagement
- Limited evidence-based practices: Many programs don't use approaches proven to be effective
- Inadequate dual diagnosis treatment: Few programs effectively address co-occurring disorders
Continuity of Care Gaps
- Discharge without adequate follow-up: People released from hospitals without connections to ongoing care
- Short-term focus: Brief interventions without long-term support
- Siloed systems: Poor coordination between different types of care
- Crisis-oriented systems: Focus on acute needs rather than prevention and maintenance
The Revolving Door
Many people cycle between brief hospitalizations, homelessness, emergency rooms, and jails—a costly and ineffective pattern that fails to address underlying needs. This "revolving door" reflects system failures rather than individual failures.
Vulnerable Populations
Some groups face heightened vulnerability to this pathway:
Transition-Age Youth
- Mental health conditions often emerge in late adolescence and early adulthood
- This coincides with transitions from family homes or foster care
- Limited experience navigating treatment systems independently
- Developmental challenges in seeking help
Veterans
- Higher rates of PTSD, TBI, and other service-related conditions
- Challenges transitioning from military to civilian healthcare systems
- Substance use sometimes developed during service
- Difficulty accessing VA benefits and services
Older Adults
- Fixed incomes that don't keep pace with housing costs
- Age-related cognitive changes that may affect housing maintenance
- Increasing physical health needs that impact mental health
- Social isolation after loss of partners or friends
Effective Approaches
Several approaches have proven effective in addressing this pathway to homelessness:
Housing First with Supportive Services
- Provides immediate access to permanent housing without treatment preconditions
- Combines housing with voluntary, flexible support services
- Demonstrates high housing retention rates (80-90%) even for people with serious mental illness and substance use disorders
- Creates stability that makes addressing health needs more feasible
Integrated Treatment Models
- Assertive Community Treatment (ACT): Multidisciplinary teams providing comprehensive services
- Integrated dual diagnosis treatment: Addressing mental health and substance use simultaneously
- Critical Time Intervention: Time-limited support during transitions from institutions
- Peer support services: Engagement from people with lived experience
System-Level Improvements
- Coordinated entry systems: Streamlining access to housing and services
- Cross-system data sharing: Identifying people at risk before housing loss
- Medicaid expansion: Increasing access to behavioral health services
- Flexible funding models: Allowing for personalized approaches to complex needs
Success Story: New York's Supportive Housing
New York State's supportive housing initiative for people with serious mental illness has demonstrated that with appropriate housing and services, even those with the most complex needs can maintain stable housing. Studies show approximately 85% housing retention rates after two years, along with reduced hospitalizations, incarceration, and emergency service use.
Prevention Opportunities
Several points of intervention could prevent this pathway to homelessness:
Early Intervention
- Identifying and addressing mental health and substance use issues before they affect housing stability
- School-based mental health services to reach young people early
- Primary care integration to identify issues during routine healthcare
Transition Points
- Improved discharge planning from psychiatric hospitals
- Better coordination between foster care and adult mental health systems
- Support during transitions from military service to civilian life
Crisis Response
- Mobile crisis teams that can respond to mental health emergencies
- Respite centers as alternatives to hospitalization or incarceration
- Eviction prevention specifically targeting people with behavioral health needs
Policy Implications
Addressing this pathway requires policy changes at multiple levels:
Housing Policy
- Expanding the supply of permanent supportive housing
- Increasing affordable housing options for people living on disability income
- Strengthening fair housing protections for people with mental health conditions
Healthcare Policy
- Expanding insurance coverage for mental health and substance use treatment
- Enforcing mental health parity laws
- Increasing funding for community-based behavioral health services
Income Support
- Increasing SSI/SSDI benefit levels to match housing costs
- Streamlining disability benefit application processes
- Creating subsidized employment opportunities for people with mental health conditions
Conclusion
Mental health conditions and substance use disorders can contribute to pathways into homelessness, particularly when treatment systems fail to provide adequate, accessible care and when housing supports are insufficient. However, it's crucial to understand that these health conditions alone rarely cause homelessness—they become risk factors primarily in the context of poverty, housing unaffordability, and inadequate social safety nets.
The relationship between mental health, substance use, and homelessness is bidirectional, with homelessness often exacerbating or even causing these health conditions. This complex relationship requires integrated approaches that address both housing and health needs simultaneously.
By improving mental health and substance use treatment systems, expanding housing options with appropriate supports, and strengthening prevention efforts, we can significantly reduce this pathway into homelessness and better support those who are currently experiencing both homelessness and behavioral health challenges.
Key Takeaway
Mental health and substance use issues become pathways to homelessness primarily when treatment systems fail and affordable, supportive housing is unavailable. The most effective solutions combine immediate access to housing with flexible, voluntary support services that address individual needs and preferences.
References & Further Reading
- Substance Abuse and Mental Health Services Administration (SAMHSA). "Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States." SAMHSA, 2023. https://www.samhsa.gov/homelessness-programs-resources
- National Institute of Mental Health. "Mental Illness." NIMH, 2024. https://www.nimh.nih.gov/health/statistics/mental-illness
- 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, 5(12), 2008. https://doi.org/10.1371/journal.pmed.0050225
- Torrey, E. F. "Out of the Shadows: Confronting America's Mental Illness Crisis." John Wiley & Sons, 1997. https://www.treatmentadvocacycenter.org/
- Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. "A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use Disorders." Psychiatric Rehabilitation Journal, 27(4), 2004. https://doi.org/10.2975/27.2004.360.374
- Tsemberis, S. "Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction." Hazelden Publishing, 2010. https://www.pathwayshousingfirst.org/
- U.S. Department of Housing and Urban Development. "The 2023 Annual Homeless Assessment Report (AHAR) to Congress." HUD, 2023. https://www.huduser.gov/portal/sites/default/files/pdf/2023-AHAR-Part-1.pdf
- National Alliance on Mental Illness (NAMI). "Mental Health By the Numbers." NAMI, 2024. https://www.nami.org/mhstats
- Coldwell, C. M. & Bender, W. S. "The Effectiveness of Assertive Community Treatment for Homeless Populations with Severe Mental Illness." American Journal of Psychiatry, 164(3), 2007. https://doi.org/10.1176/ajp.2007.164.3.393
- New York State Office of Mental Health. "New York/New York Housing Study: 10-Year Follow-Up." NYS OMH, 2012. https://omh.ny.gov/omhweb/special-projects/housing-study/