Smoking & Struggling: Nicotine Dependence & Co-Morbid Psychiatric Illnesses

Addressing the Addiction

The 2021 National Survey on Drug Use and Health found that among individuals aged 12 and older in the United States, approximately 22.0% report using tobacco or nicotine vaping products in the last 30 days. Further, the 2022 Future Monitoring Survey found that among young people, approximately 8.7% of 8th graders, 15.1% of 10th graders, and 24.8% of 12th graders report using any form of nicotine in the past 30 days.[1] 

While the smoking rates among adults without chronic conditions are significantly reduced over years, the rates remain high among adults with psychiatric disorders.[2] Nicotine dependence especially affects individuals with underlying mental illnesses or cognitive impairments, at a rate of approximately 41% - twice the rate of which the CDC reports for the general population. Many nicotine-dependent individuals have comorbid psychiatric disorders, such as attention-deficit hyperactivity disorder (ADHD), anxiety disorders, and depression.[3]

Nicotine Dependence & Comorbid Psychiatric Disorders 

Smoking is the leading and most preventable cause of death in the United States, which is disproportionately affecting those with psychiatric disorders. By determining the prevalence of nicotine dependence and comorbid psychiatric disorders, smoking cessation efforts can be more focused upon those affected individuals.[4]

Miller (2005) conducted a representative sample study of U.S. adults, to investigate the connection between nicotine dependence and psychiatric disorders. A face-to-face interview conducted according to the DSM-IV interview schedule assessed the dependence on nicotine and the presence of a wide range of psychiatric disorders based on DSM-IV criteria. One of the criteria was whether they used nicotine to alleviate withdrawal symptoms of nicotine. This could be assessed based on four factors:[5]

1. Using nicotine upon waking

2. Using nicotine despite being restricted from its use (e.g., banned in certain locations, activities, events)

3. Using nicotine to avoid withdrawal symptoms

4. Waking up in the middle of the night to use nicotine

The study concluded that a significant correlation exists between individuals with a nicotine dependence and certain Axis I (e.g., alcohol and drug use disorders, major depression, dysthymia, mania, hypomania, panic disorder with and without agoraphobia, social phobia, specific phobia, and generalized anxiety disorder) and Axis II disorders (e.g., avoidant, dependent, obsessive-compulsive, histrionic, paranoid, schizoid, and antisocial PDs).[6] There was an especially strong association to disorders involving alcohol and other drug use, as well as mood disorders such as major depression, specific phobia, antisocial, and paranoid personality disorders.[7] 

Nicotine smoking has also been found that put individuals at an increased risk for suicide, biopolar disorder, and a dose-response relationship has been found between smoking and schizophrenia. In a two-sample Mendelian randomization study conducted by Yuan et. al (2020), the odds ratios of smoking initiation was higher for all seven psychiatric disorders included in the study than for no psychiatric disorder at all. The disorders and odds ratios include 1.96 for suicide attempts, 1.69 for post-traumatic stress disorder, 1.54 for schizophrenia, 1.41 for bipolar disorder, 1.38 for major depressive disorder, 1.20 for insomnia, and 1.17 for anxiety.[8]

The symptoms of ADHD are notably similar to withdrawal symptoms of nicotine. For example, such symptoms include deficits in sustained attention, response inhibition, and working memory. Pomerleau et. al (1995) found in their study that individuals with ADHD are at more risk for smoking due to the similarities in these symptoms, and the quit ratio for smokers with ADHD was 29%, while the quit ratio for smokers with no mental illness was a significantly higher percent of 48.5%. Other studies have also reached similar results, with Lambert and Hartsough (1998) finding tobacco dependence to be 40% in individuals with ADHD, compared to 19% for individuals without ADHD.[9] 

The reason why nicotine dependence affects patients with psychiatric disorders disproportionately higher is because people may attempt to self-medicate to alleviate symptoms of their mental disorders with nicotine. For some, nicotine abstinence may actually worsen symptoms of mental disorders.[10] Moreover, about 20 years ago, major tobacco US manufacturers recognized that a large proportion of their customer population was individuals with underlying psychiatric disorders. Knowing this, they began to craft advertisements and marketing of their nicotine products to target consumers with different psychological needs, such as using nicotine to manage mood, anxiety, stress, anger, social dependence, and insecurity.[11] 

Why is Quitting So Hard? 

Smoking cessation for individuals with psychiatric disorders is significantly more difficult than for healthy individuals for a variety of reasons. For one, smoking increases metabolism against antipsychotic medications. For example, smokers with schizophrenia would then have a lower ratio of serum concentration to dose of antipsychotics. Genetic differences influence which individuals will develop a nicotine addiction upon initial use of the drug. In particular, individuals with a fast metabolism may experience quicker nicotine withdrawal symptoms after being exposed to it, increasing the risk of nicotine dependency. The cessation process also involves addressing the fundamental deficit in cognitive processing that nicotine temporarily resolves. For example, in patients with schizophrenia, this deficit may be the psychotic symptoms.[12] 

Some individuals with a mental health illness may believe that the initial worsened feelings of anxiety and depression, withdrawal symptoms, upon cessation indicate that quitting nicotine will worsen their mental health. However, multiple researchers, such as Wu et. al (2023), have shown that long-term cessation of smoking among people with and without psychiatric disorders improved mental health outcomes. The incorrect psychological perception that smoking relieves stress prevents many people from trying to stop smoking. This distress is simply the cause of nicotine withdrawal, which would eventually end in long-term cessation.[13]

Smokers with a mental illness are also significantly more likely to develop nicotine withdrawal syndrome, where the symptoms of withdrawal are more severe and distressful. This heavy burden of withdrawal also makes it more difficult for a psychiatrically ill patient to quit. This makes nicotine withdrawal an important target for intervention for smokers with a mental illness.[14]

Starting the Journey to Stop Smoking 

Patients with a psychiatric illness and comorbid nicotine dependence are dying 25 years younger than the general population, from smoking-related illnesses such as heart and lung disease.[15] Understanding why these patients smoke, becoming dependent on nicotine, and what we can do to encourage smoking cessation would help prevent these premature mortalities.

Psychosocial support and medication are two types of treatment that have been published by the United States Public Health Service Guidelines in 2000 for general medical patients. However, these treatment types may not be completely suitable or applicable to psychiatric patients as well. Psychosocial support involves cognitive-behavior therapy (CBT) strategies to target identifying smoking cues, breaking the link between smoking and these cues, and learning alternative coping mechanisms. A formal program with other people trying to quit smoking may also contribute to the social aspect of support. Medications for nicotine replacement include bupropion, nortriptyline, clonidine, and varenicline. Identifying what a patient has already tried during their attempts to quit nicotine, as well as their mental and physical reactions to it, can help to determine what the next method of quitting can entail.[16]

If one is trying to quit, it is important to recognize that the cessation process will require constant effort. Overcoming withdrawal symptoms (e.g., feelings of irritability, anger, and depression) can be done by staying active, connected with people, and busy. Anxiety and depression levels are significantly reduced within the first few months of cessation, which means these withdrawal symptoms will decrease automatically, as well.[17] The Centers for Disease Control and Prevention (CDC) (2022) explains withdrawal symptoms that one may experience, and ways to manage them, including:[18] 

• Urges/Cravings

• Medications to quit 

• Avoiding triggers and cues to smoke (people one smokes with, places one smokes, activities one frequently does while smoking)

• Remind oneself why one is quitting

• Irritability/Anger

• Deep breaths

• Meditation

• Therapy

• Restlessness

• Physical activity

• Reducing caffeine intake

• Difficulty Concentrating

• Limiting activities with strong concentration for a short period of time

• Recognizing that this is an effect of nicotine withdrawal

• Trouble Sleeping

• Reducing caffeine, especially near bedtime

• Taking off nicotine patches at least an hour before sleeping

• Reducing electronic device usage

• Adding physical activity during the daytime

• Building a sleep schedule

• Excessive Hunger/Weight Gain

• Snacking smart

• Physical activity

• Mindfulness/focusing on eating while eating

• Anxiety or Depression Symptoms

• Physical activity

• Scheduling and organization

• Social interactions

• Rewarding yourself

• Speaking to a healthcare provider

If one is experiencing nicotine dependence and comorbid psychiatric illnesses, or having severe difficulty with quitting nicotine due to withdrawal symptoms, it is important to reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) or healthcare provider for guidance and support. 

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 U.S. Department of Health and Human Services. (2023, January 23). What is the scope of tobacco, nicotine, and e-cigarette use in the United States?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-scope-tobacco-use-its-cost-to-society  

2 U.S. Department of Health and Human Services. (2023b, February 24). Do people with mental illness and substance use disorders use tobacco more often?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often 

3 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). Nicotine Addiction and Psychiatric Disorders. International review of neurobiology, 124, 171–208. https://doi.org/10.1016/bs.irn.2015.08.004 

4 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). Nicotine Dependence and Psychiatric Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(11):1107–1115. doi:10.1001/archpsyc.61.11.1107 

5 Ibid. 

6 Ibid. 

7 Ibid. 

8 Yuan, S., Yao, H. & Larsson, S.C. (2020). Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study. Sci Rep 10, 13807 https://doi.org/10.1038/s41598-020-70458-4 

9 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). 

10 Ibid. 

11 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). 

12 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). Smoking cessation in patients with psychiatric disorders. Primary care companion to the Journal of clinical psychiatry, 10(1), 52–58. https://doi.org/10.4088/pcc.v10n0109 

13 Wu A.D., Gao M., Aveyard P., Taylor G. (2023). Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders. JAMA Network Open. 6(5):e2316111. doi:10.1001/jamanetworkopen.2023.16111

14 Smith, P. H., Homish, G. G., Giovino, G. A., & Kozlowski, L. T. (2014). Cigarette smoking and mental illness: a study of nicotine withdrawal. American journal of public health, 104(2), e127–e133. https://doi.org/10.2105/AJPH.2013.301502 

15 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). 

16 Centers for Disease Control and Prevention. (2023, February 10). People with mental health conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/groups/people-with-mental-health-conditions.html   

17 Ibid.

18 Centers for Disease Control and Prevention. (2022, December 12). 7 common withdrawal symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/7-common-withdrawal-symptoms/index.html 

Examining Cross-Cultural Differences in Mental Health Diagnoses

Does Location Matter?   

Why do certain psychiatric conditions share universal diagnosis criteria and treatment while others vary widely, dependent on location and culture? These discrepancies can be attributed to the lack of a gold standard for validating these conditions as well as the lack of biological markers, leading to different clinical interpretations and inconsistency across studies.[1]

Consistency across cultural studies can allow a more general understanding of conditions and how culture affects symptoms’ manifestations and diagnoses differently. By creating a clearer understanding of mental health conditions worldwide, better/more effective treatments and patient outcomes can arise. 

Should Diagnosis be Universal or Relative?   

Within the debate of why these differences occur, two main arguments exist. The first focuses on universality across cultures. The “universalistic viewpoint” emphasizes that all conditions occur equally and have a core set of symptoms - what varies is the manifestations and determination of pathology versus normalcy. “Ethnotypic consistency” was coined by Weisz et al., in 1997 to describe the idea that psychopathology is the same across locations and cultures, but varies in how symptoms are displayed.[2]  

The opposing viewpoint of universality places a larger emphasis on culture. The “relativistic viewpoint” stresses that culture shapes a person’s development and psychopathology. Symptoms and conditions can be unique and particular to specific cultures, as well as affect the magnitude and intensity of the condition.[3] 

From these two viewpoints, a combined conclusion can be established: certain disorders are seen as “universally occurring” due to their neural pathology, while others are shaped by social contexts and cultural norms.[4] 

Examining Cross-Cultural Differences 

One of the most well-researched conditions cross-culturally is attention-deficit/hyperactivity disorder (ADHD). From 1997 to 2016, attention deficit disorders in the United States has fluctuated from 6.1% to 10.2%, with debate ensuing whether the fluctuation arose from over-diagnosis, under-diagnosis and/or diagnostic disparities.[5] When comparing global prevalence, vast differences were found between North America, Africa and the Middle East. However, those differences were not found between North America, Europe, Oceania, Asia or South America. Canino and Alegria (2008) note that these discrepancies were attributed to the differences in instruments, methods, and how these disorders are defined within the different cultural studies compared.[6] 

Professor Mashai Ikeda began to research Bipolar Disorder (BD) after finding most conclusions on major psychiatric disorders were made using European samples. In 2022, Ikeda specifically looked at the genes of patients with BD type I (manic and depressive states) and BD type II (mild mania and depression) between European populations and East Asian populations.[7] He found East Asian populations containing genes of BD I were more correlated with major depression while European populations with BD I were more correlated with schizophrenia, however, no differences were found between the samples when examining BD type II. These differences were attributed to how the disorder is diagnosed in each country; East Asian psychiatrists hold that bipolar disorder is a mood disorder while European psychiatrists tend to diagnose patients with delusion and other psychotic symptoms.[8] These vast differences in definitions can later lead to issues with clinical trials, especially for drug therapy. 

Even the threshold that needed to be met to be considered pathological differs culturally. For example, Hong Kong’s rates of reported hyperactivity are double those of the United States.[9] Additionally, Chinese and Thai cultures place a high value on hiding aggression and overt behaviors, which lowers the threshold of hyperactive behaviors and raises the likelihood that parents would report it. Chinese and Indonesian clinicians also gave higher scores for hyperactive behavior problems when compared to scores given by Japanese and American clinicians.[10] A study conducted by Bird (2002) examined Italy, New Zealand, China, Germany, Brazil and Puerto Rico and found that hyperactive disorders were found in all cultures, but the prevalence and threshold of what was considered pathological is what differed. Therefore, while these conditions happen universally, the way each culture views the symptoms varies widely.[11]

These cultural distinctions of appropriateness not only occur cross-continentally but also within different communities. According to Andrade (2017), African Americans are more likely than White Americans to keep personal distress private and seek spiritual support versus seeking professional mental health treatment.[12] Further, in the United States, most minority groups are less likely than White Americans to seek mental health treatments or delay seeking help until their symptoms are severe. Many of these issues are tied to the discrimination and mistreatment minorities face when seeking help; in fact, 43% of African Americans and 28% of Latinos have felt they were mistreated in clinical settings due to their background.[13] There is also a lack of resources for non-English speakers to gain access to mental health services. These cultural factors tied with affordability and insurance coverage also create a very difficult situation for many people in certain populations to get mental health assistance at all. 

Mental health resources vary widely across the globe, depending on location. Nielsen, et al., (2022) found major differences among countries in the Far East, Middle East, and Southeast Europe, as most countries reported the need for more child psychiatrists and mental health professionals. The researchers note that 10% to 20% of adolescents experience a mental health disorder before they turn 14 years old.[14] Thus, the lack of resources in these countries poses a great risk to the population, as early intervention is key to recovery and well-being.

Future Steps: Integrating Culture and Diagnosis 

These locational and cultural challenges pose a clear threat to the reliability and validity of cross-cultural research; as we discover more about how these factors affect diagnosis and symptoms, it is essential to create instruments keeping these differences in mind. Historically, research has been based on Western diagnosis systems and definitions, but when using those definitions with other populations, concepts can become unclear.[15] Conceptual equivalence ensures the concept is identified uniformly according to the populations being studied.[16] Therefore, these disparities must be emphasized when conducting research. If not, misclassifications and incorrect conclusions about populations can be made. 

Harris (2023) stresses that with the growing importance culture plays on manifestations and diagnosis, it is important clinicians and mental healthcare professionals assess how a person’s background affects their condition. As well, adjust their assessment based on the person’s attitude towards mental health and how they express and cope with their mental health. Different populations may also have stigmas on seeking help or undergoing certain treatments, professionals must be aware of and protect those preferences.[17] 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has also embraced these strategies and highlights the impact of race and culture on disorders. Clarifications and disclaimers have been added to provide further information when specific communities had higher rates of certain disorders.[18] These considerations are fundamental in improving the disparities in diagnosis found across cultures as it allows psychiatry residents and fellows to see the effects race and culture can have on mental health and diagnosis.  

If you or someone you know is struggling with their mental health, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology & Psychiatry, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Abdelnour, E. (2022, October 1). ADHD diagnostic trends: Increased recognition or overdiagnosis? PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/#:~:text=The%20past%20couple%20of%20decades,the%20causes%20for%20this%20trend 

6 Canino & Alegría (2008)

7 Saito, T., Ikeda, M., Terao, C., Ashizawa, T., Miyata, M., Tanaka, S., Kanazawa, T., Kato, T., Kishi, T., & Iwata, N. (2022). Differential genetic correlations across major psychiatric disorders between Eastern and Western countries. Psychiatry and Clinical Neurosciences, 77(2), 118–119. https://doi.org/10.1111/pcn.13498 

8 Ibid. 

9  Ho, T.P., Leung, P.W., Luk, E.S., Taylor, E., BaconShone, J., & Mak, F.L. (1996). Establishing the constructs of childhood behavioral disturbances in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, 417–4314

10 Canino & Alegría (2008)

11 Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of ADHD. In P.S. Jensen & J. Cooper (Eds.), Attention deficit hyperactivity disorder: State of the science; best practices (pp. 12-1–12-36). Kingston, NJ: Civic Research Institute. 

12 Andrade, S. (2017). Cultural Influences on Mental Health | The Public Health Advocate. The Public Health Advocate. 

https://pha.berkeley.edu/2017/04/16/cultural-influences-on-mental-health/

13 Ibid. 

14 Nielsen, M. S., Clausen, C. E., Hirota, T., Kumperscak, H., Guerrero, A., Kaneko, H., & Skokauskas, N. (2022). A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe. Asia-Pacific Psychiatry, 14(2), 1–9. 

https://doi.org/10.1111/appy.12490

15 Canino & Alegría (2008)

16 Ibid. 

17 Harris, J. (2023, January 9). Cultural competency in mental Health Care: Why it matters. NAMI - Dominate Amazing Capabilities. https://nami-dac.org/cultural-competency-in-mental-health-care-why-it-matters/

18 Moran, M. (2022). Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR. Psychiatric News, 57(3).  https://doi.org/10.1176/appi.pn.2022.03.3.20

Uncovering the Connection: Mental Illness & the Homeless Crisis

To be Homeless in America

A person or family are defined as homeless when they lack a fixed, regular, and adequate nighttime residence.[1] In addition to the extreme poverty they face, the homeless are often in a struggle to be met with sympathy from the general population. In a 2019 poll of Americans taken by the CATO Institute, 42% responded that poverty is a result of a “lack of personal responsibility”.[2] While existing societal stigmas have caused many Americans to blame the homeless for their condition, several other factors must be considered.[3]

Monetary issues, in part, contribute to this mounting crisis. Three years into the pandemic, the steadily increasing costs of living and limited access to affordable housing are compounding issues for the average American.[4] But as the conversation surrounding homelessness steers towards pointing the blame at the economy, it is important not to lose sight of a factor that makes someone more vulnerable to losing their home: mental illness.[5] Public health research has long come to the resounding conclusion that homelessness and mental illness have a complex, two-way relationship that compounds challenges for those who are afflicted.[6] With the added pressure of another recession looming, mental health and homelessness have an exacerbating relationship: mental illness greatens the chances of becoming homeless, and trying to survive while homelessness takes a toll on a person’s mental health.

The Mental Illness to Homeless Pipeline

In America, approximately 4% of the general population of adults have a severe mental illness (e.g., schizophrenia, bipolar disorder, or major depressive disorder).[7] In contrast, it is estimated that 45% of the homeless population experience a form of mental illness,[8] with 25% of this population suffering from severe mental illness.[9] Unfortunately, as researchers lack sufficient access to the homeless population, the actual number of homeless people living with any form of a mental illness is potentially much higher than these annual estimates.[10]

Since the last Census in 2020, rising housing costs combined with continuous inflation for basic goods and services have left an estimated 2,000 Americans newly homeless,[11] with thousands more fearing they will soon lose their homes. In June 2022, the inflation rate hit a 41-year high of 9.1%,[12] leaving the average family strained to pay for gas, energy bills, and groceries.[13]

For those diagnosed with a mental health condition, even more challenges arise against their efforts to keep a home. Research conducted by Luciano and Merea (2010) divided over 77,000 participants into groups of “none, mild, moderate, and serious mental illness” and found that employment rates decreased with increasing mental illness.[14] Further, within the group diagnosed with “serious mental illness”, nearly 40% made an annual salary of less than $10,000”,[15] which is roughly half of the annual minimum needed for a two-bedroom apartment, according to the National Low Income Housing Coalition.[16]

While anti-discrimination laws offer protection for workers who disclose their mental illness diagnosis, many of the symptoms behind mental disorders complicate a person’s ability to maintain continuous employment. The average work week is 40 hours over the span of five days, and requires employees to show up on time, remain productive, and limit their sick leave to the numbers prescribed by their organization. But those with a mental illness are more likely to call-in sick, take medical leave, and under-perform at work.[17] As a result, individuals with a mental illness are two to three times more likely to be unemployed, with their employment rate at 15 percentage points lower than for those without mental health problems.[18]

Struggles with employment are especially relevant for people with schizophrenia, who fare poorer than any other disadvantaged group in the labor market. Individuals with this condition experience a 70-90% unemployment rate, which is roughly 30 times higher than the general population.[19] Unemployed more than any other group with disabilities, those with schizophrenia are estimated to make up 40% of the homeless population.[20] 

Lacking the ability to maintain employment, Americans with mental illnesses have a higher likelihood of unpaid medical bills and missed rent/mortgage payments.[21] Eventually, cumulating costs increase their potential of losing a place to live. 

Navigating Homelessness with a Mental Illness

It is even more difficult to overcome mental health challenges once a person becomes homeless. Lacking necessities (e.g., food, water, and hygiene) often leads to the development of worry, fear, and sleeplessness, which can then compound into mental illnesses (e.g., anxiety, depression, and substance abuse disorder) in those who may not have even had them prior to losing their home. For those that already had a diagnosis prior to losing their home, these conditions only further exacerbate their illness, and resources like medication, therapy, and hospitalization are often difficult to obtain without medical insurance. Facing relentless pressure to have basic necessities as well as gain treatment, many homeless people can barely cover the short-term costs of food, medicine, and soap,[22] and are unable to build any savings that could be used to contribute to paying rent.

Housing Discrimination

Of course, once a person becomes homeless, the natural question is: “How do they get back into a home?” Unfortunately, the compounding factors of poor mental health and lack of a steady income introduce a large barrier to owning or renting a home. When a person applies to rent a property, they are often expected to submit proof of at least six months of employment, consent to having their credit score checked, and provide information for a background check. Not only does a homeless person often have no proof of current employment, but their chances of having a low credit score from prior financial difficulties are more likely than not.[23] If they surpass these points in a renter’s application, many renters are then expected to provide a downpayment or 1.5 months’ rent for their first month. Even if an individual is eligible to rent or own a house from a financial standpoint, they may be unable to pass a background check. This predicament lands many in motels, which are non-permanent shelter, and often amount to more than the median $1,715 dollars spent monthly on rent.[24] Unable to afford motels for an extended period of time, many individuals become vulnerable to returning to living on the streets.

Adding to their difficulties, the concepts of homelessness, incarceration, and poor mental health are often inseparable. Severe mental illness is more prevalent among the homeless population and is associated with increased risk of involvement with the criminal justice system.[25] In fact, over 25% of people experiencing homelessness report being arrested for activities that are a direct result of their homelessness, such as loitering and sleeping or lying down in public spaces.[26] As aforementioned, these arrests can add to the vicious cycle facing homeless populations, as a criminal record often impacts future employment and housing opportunities. 

Not all is lost

Despite these alarming numbers, specific demographics have shown improvements in the homeless crisis in recent years, with even the most at-risk subpopulations experiencing a steady decrease in homelessness:

• While 20% of veterans are diagnosed with PTSD in any given year, their rate of homelessness has steadily decreased 55% since 2010.[27]

• Black Americans comprise only 13% of the U.S. population, yet make up 40% of the homeless population. However, between 2020 and 2021, the number of Black or African American people staying in shelters decreased by 12%.[28]

• While the number of homeless families increased between the 2020 Census and 2022, the overall number of homeless independent adults dropped.[29]

• The number of people under 25 experiencing homelessness has decreased by 12%, with youth homelessness down 6%.[30]

Further, the Federal Government continues to emplace financial interventions to support Americans with mental illness. According to a Continuing Disability Review from the Social Security Administration in 2014, mental illness is now the primary diagnosis for one-in-three persons under the age of 50 who receive disabled worker benefits.[31] As the number of disability beneficiaries with mental illness grows steadily, policy makers have an increased interest in monitoring employment rates by mental health status,[32] a sign of progress that will directly aid the homeless population.

The implications? Why does it matter

Much of the advocacy for homeless rights supports increasing the visibility of this crisis and placing additional responsibility on the general population. Since 1991, when the United Nations declared housing to be a fundamental right,[33] American society has made strides in its perception and support of the homeless population. However, mental illness is a significant hurdle to overcome, and this is often only one of a homeless person’s marginalized identities. Too often, women, people of color, and members of the LGBTQ+ community are overrepresented in the annual numbers of people without permanent housing.[34] The multiple layers of discrimination these marginalized communities combat on a daily basis also cause them to face higher barriers to reintegrate into society.

Ways We Can Help

While government intervention is key to continuing to improve the homelessness crisis, there are several ways people can continue to help:

1. Practice Kindness & Respect: While much of the responsibility to fix discrimination against the homeless falls on policy changes, it is still within every individuals’ control to manage the ways they personally engage with homeless people. Even in small interactions with a homeless person, it is damaging to treat them as though they are invisible, or try to judge them for their state. Instead, simply saying “good morning” and treating them as though they are a normal human being have the potential to improve someone’s day. No one wants to be judged for their worst day, and the homeless are often in a unique position where they are experiencing hardship on a daily basis.

2. Advocate Against Homelessness Discrimination: Employers are not only responsible for knowing anti-discrimination laws, but further, they must practice them in a manner that supports employees with mental illnesses and prior criminal records. It is illegal in every state to deny someone employment because of a prior felony, but employers often find work-arounds to make employment more difficult for this demographic. The “Ban the Box” campaign, which has already been implemented in 150 cities across 30 states, removed questions about criminal history from Federal job applications and pushed background checks to later in the hiring process.[35] With this change, an individual has the opportunity to be judged for other qualifications instead of being discounted over one aspect of their past. This initiative and others like it are key to combating the incarceration-to-homeless pipeline.

3. Decriminalize Homelessness: Walking around major cities, it is often easy to find excessively slanted benches, spiked window sills, and raised grate covers, all of which all intended to keep the homeless from sheltering in public spaces. Other communities have taken measures even further, adopting laws that criminalize people for behaviors that are side effects of their survival. According to the National Homelessness Law Center, 48 states have at least one law restricting behaviors of people experiencing homelessness (e.g., loitering, trespassing, or sleeping in public spaces) and these types of laws continue to gain traction across the country.[36] Members of a community can counteract these laws through protest, by voting, and by encouraging local business owners to enact more homeless-friendly provisions.

For more programs and resources on how to help the homeless, click here.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

Citations:

1 General definition of a homeless individual, 42 U.S.C § 11302 (1994). 

https://www.law.cornell.edu/uscode/text/42/11302#:~:text=(1),(2).

2 Ekins, E. What Americans Think About Poverty, Wealth, and Work. CATO Institute Website. https://www.cato.org/publications/survey-reports/what-americans-think-about-poverty-wealth-work. Updated 2019. Accessed February 15, 2023.

3 Ibid.

4 Homelessness: The Problem. The National Low Income Housing Coalition Website.  https://nlihc.org/explore-issues/why-we-care/problem. Updated 2023. Accessed February 12, 2023.

5 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

6 About Mental Health. Center for Disease Control and Prevention Website.  

https://www.cdc.gov/mentalhealth/learn/index.htm. Updated June 2021. Accessed February 11, 2023.

7 Mental Health by the Numbers. National Alliance on Mental Illness Website. https://nami.org/mhstats?gclid=CjwKCAiA_6yfBhBNEiwAkmXy50NgnpQVgRjIdYOunA1ZbReAHYOORBq_P_wvqkK7uH9AXWh-Y2rOHRoCcmwQAvD_BwE. Updated June 2022. Accessed February 12, 2023.

8 Ibid.

9 Ibid.

10 Ibid.

11 U.S. Department of Housing and Urban Development. (2022). Annual Homelessness Assessment Report. https://www.hud.gov/press/press_releases_media_advisories/HUD_No_22_253. HUD Public Affairs.

12 Carter, C. With inflation at a 41-year high, USF economics professor explains what to expect. WUSF Public Media Website. 

https://wusfnews.wusf.usf.edu/economy-business/2022-07-14/inflation-41-year-high-usf-economics-professor-explains-what-to-expect. Updated July 2022. Accessed February 12, 2023.

13 Ibid.

14 Luciano A, Meara E. Employment Status of People with Mental Illness: National Survey Data from 2009 and 2010. American Psychological Association Publishing, 2014;65(10):1-9. https://doi.org/10.1176/appi.ps.201300335.

15 Lloyd, A. Average Rent is 32% of the typical Americans’ pay; that’s more than financial experts recommend budgeting for housing. Business Insider Website.

https://www.businessinsider.in/policy/economy/news/average-rent-is-32-of-the-typical-americans-pay-thats-more-than-financial-experts-recommend-budgeting-for-housing/articleshow/90428300.cms. Updated March 2022. Accessed February 14, 2023.

16 National Low Income Housing Coalition (2022). Out of Reach: The High Cost of Living. https://nlihc.org/oor

17 How your Mental Health may be Impacting your Career. PBS Website.

https://www.pbs.org/newshour/health/how-mental-health-impacts-us-workers. Updated 2013. Accessed February 13, 2023.

18 Ibid.

19 Greenstein, L. Can Stigma Prevent Employment? National Alliance on Mental Illness Website.

https://www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment. Updated 2017. Accessed February 10, 2023.

20 Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:370.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880407/.

21 Colato EG,  Enard KE, Orban BL, Wiltshire JC.  Problems paying medical bills and mental health symptoms post-Affordable Care Act. 2022;7(2):274-286. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327393/

22 Fleury MJ, Grenier G, Sabetti J, et al. Met and unmet needs of homeless individuals at different stages of housing reintegration: A mixed-method investigation. PLOS One. 2021;16(1). https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245088. Accessed February 15, 2023.

23 Bharat N, Cicatello J, Guo E, Vallabhaneni V.  University of Michigan School of Public Health Website. https://sph.umich.edu/pursuit/2020posts/homelessness-and-job-security-challenges-and-interventions.html. Updated 2019. Accessed February 14, 2023.

24 Joint Center for Housing Studies of Harvard University. (2022). America’s Rental Housing. https://www.jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_Americas_Rental_Housing_2022.pdf. 

25 Greenberg GA, Rosenheck RA. Jail Incarceration, Homelessness, and Mental Health: A National Study. Psychiatric Services. 2008;59(2):135-143.

https://doi.org/10.1176/ps.2008.59.2.170

26 Gillison, D. Veteran Mental Health: Not All Wounds are Visible. National Alliance on Mental Illness Website. https://www.nami.org/Blogs/From-the-CEO/November-2021/Veteran-Mental-Health-Not-All-Wounds-are-Visible. Updated November 2021. Accessed February 10, 2023.

27 U.S. Department of Housing and Urban Development (2022)

28 Ibid.

29 Ibid.

30 Ibid.

31 Social Security Administration. (2013). Annual Statistical Report on the Social Security Disability Insurance Program. https://www.ssa.gov/policy/docs/statcomps/di_asr/2013/di_asr13.pdf.

32 Luciano & Meara (2014)

33 United Nations Higher Commissioner for Human Rights. (2009). The Right to Adequate Housing. (UN Publication FS 21-1). https://www.ohchr.org/sites/default/files/Documents/Publications/FS21_rev_1_Housing_en.pdf.

34 Oliva, A. Ending Homelessness: Addressing Local Challenges in Housing the Most Vulnerable. Center on Budget and Policy Priorities Website. 

https://www.cbpp.org/research/housing/ending-homelessness-addressing-local-challenges-in-housing-the-most-vulnerable. Updated 2022. Accessed February 12, 2023. 

35 Avery B, Lu H. Ban the Box: U.S. Cities, Counties, and States Adopt Fair Hiring Policies. National Employment Law Project Website. https://www.nelp.org/publication/ban-the-box-fair-chance-hiring-state-and-local-guide/. Updated 2021. Accessed February 12, 2023. 

36 National Homelessness Law Center. (2021). Housing not Handcuffs 2021: State Law Supplement. https://homelesslaw.org/wp-content/uploads/2021/11/2021-HNH-State-Crim-Supplement.pdf.