Financial Strain Predicts Future Risk of Homelessness and Partly Explains the Effect of Mental Illness

To what extent does financial strain mediate the relationship between severe mental illness and homelessness?

Financial strains like debt or unemployment are significant risk factors for becoming homeless, and even help to explain increased risk of homelessness associated with severe mental illness, reports a study in a supplement to the April issue of Medical Care. The journal is published in the Lippincott portfolio by Wolters Kluwer.

The findings “suggest that adding financial well-being as a focus of homelessness prevention efforts seems promising, both at the individual and community level,” according to the new research, led by Eric Elbogen, PhD, of the US Department of Veterans Affairs (VA) National Center on Homelessness and Duke University School of Medicine. The study appears as part of a special issue on “Multimorbidity and social drivers of homelessness and health,” produced in partnership between the VA National Center on Homelessness and the American Public Health Association Caucus on Homelessness.

Financial strain is a mediator of the link between homelessness and mental illness

Using data on nearly 35,000 participants in a nationally representative longitudinal survey, Dr. Elbogen and colleagues analyzed financial strain as a predictor of homelessness, on its own and in combination with mental illness. Responses to a 2001-02 survey were analyzed to identify factors associated with homelessness at a follow-up survey in 2004-05.

All types of financial strain analyzed – financial crises and debt, lower income, and unemployment – were associated with an increased risk of future homelessness. As expected, severe mental illness – psychotic, bipolar, or depressive disorder – was directly related to an increased risk of homelessness.

In addition, there was a significant “mediating effect” of financial strain, which explained 39 percent of the link between homelessness and mental illness. Homelessness risk was lowest for participants with none of the four types of financial strain, whether or not they had severe mental illness.

“Conversely, participants with all four financial strain variables had significantly higher risk of homelessness,” Dr. Elbogen and coauthors write. The risk of becoming homeless increased with each additional type of financial strain, independent of mental illness.

The findings offer a “fresh perspective” on homelessness prevention efforts, the researchers write. “[I]nterventions could be proactively targeted at improving an individual’s financial literacy and well-being such that they could prevent situations that may contribute to future homelessness.”

The finding that financial strain accounts for part of the impact of severe mental illness “suggests that addressing mental illness without consideration of financial strain may not lead to optimal reduction in homelessness risk,” Dr. Elbogen and colleagues add. The study supports efforts to help homeless individuals grow financially through employment, increased financial knowledge, and money management skills – as offered in effective interventions such as Housing First and VA homeless programs.

The special supplement to Medical Care focuses “on the intersection of homelessness, medical illnesses, and related social factors,” according to an introductory guest editorial by Jack Tsai, PhD, of the VA National Center on Homelessness and University of Texas Health Science Center at Houston and colleagues. A key focus is on the rising rates of multimorbidity – having multiple medical, mental health, and substance use disorders – amid the ongoing obesity crisis in an aging population.

The supplement includes nine original papers examining special populations such as homeless youth, older adults, and veterans, along with medical and behavioral health conditions such as tuberculosis, HIV, and opioid use disorder. It also presents two editorials commenting on the history of homelessness and its association with suicide. Dr. Tsai and colleagues write: “This special issue illustrates the complex realities of homelessness but also the progress that has been made and the continued efforts and gaps in knowledge that need work.”

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