Schizophrenia: Cross-Cultural Comparisons of Case Management & Research Progress

A Global Enigma

While our understanding of the human brain is constantly advancing, one of the least understood psychological disorders with the most ubiquitous global impact, is schizophrenia. Schizophrenia is a chronic mental illness characterized by symptoms generally falling into three categories:[1,2] 

• Psychotic Symptoms: Hallucinations, delusions, disorganized speech and behaviors

• Negative Symptoms: Withdrawal from aspects of life, difficulty functioning normally, affective flattening, lack of motivations

• Cognitive Impairment: Problems in attention, concentration and memory. 

The prevalence of the disease is approximately 1% worldwide and accounts for a large healthcare burden. It is highly heritable (e.g., the likelihood of the disorder to aggregate among family members), estimated at around 80%.[3] Further, Degnan et al. (2018) note that the incidence rate of schizophrenia in ethnic minority populations are triple that of major White populations.[4] 

In itself, the definition and categorization throughout the history of schizophrenia has differentiated across countries. Schizophrenia was first described by Emil Kraepelin (1899), a German psychiatrist, as “attentional impairments”.[5] Eugen Bleuler (1911) later famously coined it as a disorder which originates from the splitting of different psychic functions leading to loss of unity within the personality (hence the name “schizophrenia”) from the Greek roots “split-mind.”[6] Our foundational understanding of the disease is still limited, and this article aims to review some current cross-cultural perspectives on the research and management of the disease.

The diverse faces of psychosis in schizophrenia  

Recent research has consolidated the literature on the effects of cultural and social perspectives on the framing of schizophrenic/psychotic symptoms. While psychosis is present globally as a symptom for schizophrenia, the actual content of the psychotic symptom is culturally determined.[7] For example, research conducted in India, Nigeria and Trinidad in 2016  concluded that “disruptive behaviors, wandering and decline in functioning” are more commonly thought of as psychosis rather than the “distorted perceptions and beliefs” emphasized in Western understanding of the condition.[8] 

Additionally, the interpretations of psychiatrists determine what behaviors constitute psychosis; this, too, will vary based on one’s training, education, upbringing and life experiences, which differ across cultures.[9] In a case study in 2008, a NHS psychiatric nurse in a London hospital recounted his conflict for a Nigerian patient diagnosed with schizophrenia under his care. While in Nigeria, the patient’s “psychotic symptom” of religious delusions would have been considered gifted, the patient was coerced into taking medication in the UK.[10] Therefore, it is important to consider cultural backgrounds as a crucial factor in determining the symptoms of the disease. 

Cross-national context and culturally-adapted interventions of schizophrenia

Schizophrenia has been identified as a globally-prioritized mental health problem with the magnitude of its impact on individuals’ health, economic and social hardships, increased mortality rates and human rights violation (e.g., involuntary hospitalization or imprisonment with inadequate mental health care).[11,12] Recommendations from the World Health Organization (WHO) guidelines and the Disease Control Priorities (DCP3)  have shown that there are two kinds of intervention for schizophrenia that have strong enough evidence to deem them significant: antipsychotic drugs and psychosocial treatments.[13] However, one important limitation is that there is little evidence supporting these interventions in low and middle income countries (LMIC), and few of them have been actually implemented in high income countries.[14]

Psychosocial Interventions:

The psychosocial treatments of schizophrenia with strongest empirical support are: social skills training; family psychoeducation; cognitive behavioral therapy (CBT) and cognitive rehabilitation.[15,16] 

In 2012, Lora et al. noted that among 50 LMICs, around 69% of those diagnosed with schizophrenic disorders do not have access to specialized care despite evidence that psychosocial interventions alone can alleviate symptoms of the disorder, and not all patients may require treatment with antipsychotics.[17,18] In 2018, Degnan et al. published a review on adaptations of Western psychosocial interventions to specific ethnic groups or subculture studying these adaptations in 13 different countries.[19] It was found that all cultural adaptations included language, a majority adapted to concepts and illness models, cultural norms and practices, and family. Noticeably, there were modifications to include spiritual/religious activities, adjustments to communication styles and family dynamics. The analysis demonstrated significant outcomes in support of adapted interventions, however only two studies out of 43 compared the effectiveness of adapted and non-adapted interventions, and neither found significant differences in outcomes.[20] Overall, while the study indicates positive results for culturally-adapted psychosocial interventions, the limited studies providing support for adapted over non-adapted treatments is not enough evidence of a significant increase in effectiveness.

Antipsychotic Interventions: 

While psychosocial interventions have been increasingly researched and recognized as effective care for schizophrenia, antipsychotics have long been the popular measure of intervention for medical professionals.[21] Common antipsychotic agents are classified as first-generation (chlorpromazine, haloperidol) or second-generation (clozapine), which work by blocking dopamine receptors.[22] According to Wood et al. (2003), first-generation drugs are more-likely to induce parkinsonian side effects and second-generation drugs are thought to have enhanced therapeutic efficacy.[23] However, research by Agid et al. (2006) questions if the side effects of first-generation schizophrenia drugs may actually be from unintentionally overdosing patients while searching for optimal drug efficacy (hence, inadvertently causing more-pronounced side effects).[24] 

Recent research on culturally-adapted antipsychotics and alternative drug treatments for schizophrenia has been scarce. However, a study done by Chong et al. (2004) on differences in antipsychotics usage in East Asian countries revealed that prescription patterns of antipsychotic drugs vary greatly between countries.[25] This can be explained by the differences in respective healthcare policies, preferred treatment modality, availability and cost of the drugs.[26]

For example, Japan has a long history of national health insurance and a preference for treating patients with mental health issues in psychiatric hospitals over community care. Therefore, a higher prevalence of antipsychotics is prescribed due to the longer hospitalization period for schizophrenia in the country.[27] Meanwhile, Xiang et al. (2017) also found that while community-based services are increasingly encouraged, a large number of patients in China end up receiving hospital-based services.[28] Additionally, as clozapine is the most effective and affordable antipsychotic medication in China, over one-third of schizophrenia patients have been prescribed the drug.[29] This is not the case for all countries in the surrounding regions, as the cost of second-generation antipsychotic is considerably higher, thus is often restricted and difficult to prescribe.[30] However, as first-generation antipsychotics for schizophrenia are known as “major tranquilizers” with more serious side effects, this may create a disparity in treatment of the disorder in different countries.[31] 

Alternative treatments may also prove valuable. In 2017, a study conducted by Deng et al. on Wendan decoction (WDD), a traditional Chinese medicine for schizophrenia, discovered that WDD demonstrated some short-term positive effects on its own. Further, when WDD was used alongside an antipsychotic, positive outcomes were observed with fewer adverse effects.[32] 

Future directions: beyond the “one-size-fits-all” treatment framework

While there is still more research to be done, this brings the question to whether popular antipsychotics are the ultimate pharmacological treatment for schizophrenia, or if there are alternative options we need to take into consideration. Specialists have long called for the facilitation of mental health care by traditional practitioners due to lack of resources in LMICs; research has echoed the sentiment that traditional healers are generally more accessible and affordable, and patients benefit from sharing cultural beliefs and world views with them.[33] 

Traditional healers have often been more open to collaborating with primary health care than vice versa.[34] Watt et al. (2017) studied this issue qualitatively with populations in Ghana, Kenya and Nigeria. They found that many patients and caregivers still distrust non-medical treatments; despite some medical practitioners advocating for their validity, traditional care is often met with ridicule and doubt. The study further found that there appear to be suggestions to “convert” non-medical healers to a medical paradigm, and that rivalry and perceived superiority seem to be the underlying cause of this attitude.[35] 

However, it is also important to note that patients who implore both methods of care seem to reap more benefits, overall.[36,37] Watt et al. note that non-medical healers also desire to be recognized in their validity and not be exoticized simply due to their non-Western practices and beliefs.[38] Many studies have supported that labeling these practices as “witchcraft” or “inferior” is failing to understand indigenous knowledge and meaningful perspectives, and thus a missed opportunity to improve population health.[39,40]

Social and cultural perspectives continue to inform the characteristics and future directions of both the research and treatment of schizophrenia. Yet, as we have seen, the current landscape of what we know about the disorder in a cross-cultural context is lacking. As we expand on this field of research in a broader context, it is important to note the potentials of alternative medicine, culturally-adapted measures and how they can benefit the accessibility of health care for ethnic minorities, non-Western or low/middle-income patients. Acknowledgement and deeper insight into culturally-appropriate diagnosis and care for patients with schizophrenia is crucial to shift the evolution of global mental health into a truly global discipline. 

If you or someone you know are experiencing any signs of schizophrenia, it’s best to speak with a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss your concerns and determine the underlying cause of symptoms.

Contributed by: Mai Tran

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

References

1 Rahman, T., & Lauriello, J. (2016). Schizophrenia: An Overview. Focus (American Psychiatric Publishing), 14(3), 300–307. https://doi.org/10.1176/appi.focus.20160006

2 NHS. (2023, April 13). Symptoms - Schizophrenia. NHS. https://www.nhs.uk/mental-health/conditions/schizophrenia/symptoms/ 

3 McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360  

4 Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., Husain, N., Rathod, S., & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714–727. https://doi.org/10.1017/S0033291717002264

5 Kraeplin, E. (1950). Dementia praecox and paraphrenia (J. Zinkin, Trans.).

6 Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press. 

7 Shalhoub, H. (2012). Decoding schizophrenia across cultures: Clinical, epidemiological and aetiological issues (Doctoral dissertation, School of Social Sciences Theses).

8 Cohen, Alex; Padmavati, Ramachandran; Hibben, Maia; Oyewusi, Samuel; John, Sujit; Esan, Oluyomi; Patel, Vikram; Weiss, Helen; Murray, Robin; Hutchinson, Gerard; Gureje, Oye; Thara, Rangaswamy; Morgan, Craig (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project. BMC Psychiatry, 16(1), 388–. doi:10.1186/s12888-016-1090-4

9 Shalhoub (2012)

10 Ibid.

11 Wigand, M. E., Orzechowski, M., Nowak, M., Becker, T., & Steger, F. (2021). Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights. The International Journal of Social Psychiatry, 67(2), 168–174. https://doi.org/10.1177/0020764020942797

12 Patel V. (2016). Universal Health Coverage for Schizophrenia: A Global Mental Health Priority. Schizophrenia Bulletin, 42(4), 885–890. https://doi.org/10.1093/schbul/sbv107

13 Ibid. 

14 Ibid.

15 Alan. S. Bellack (2001) Psychosocial treatment in schizophrenia, Dialogues in Clinical Neuroscience, 3:2, 136-137, DOI: 10.31887/DCNS.2001.3.2/asbellack

16 Cooper, R. E., Laxhman, N., Crellin, N., Moncrieff, J., & Priebe, S. (2020). Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review. Schizophrenia Research, 225, 15–30. https://doi.org/10.1016/j.schres.2019.05.020

17 Ibid.

18 Lora, Antonio; Kohn, Robert; Levav, Itzhak; McBain, Ryan; Morris, Jodi; Saxena, Shekhar (2012). Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. doi:10.2471/BLT.11.089284  

19 Degnan et al. (2018)

20 Ibid. 

21 Guo, Xiaofeng; Zhai, Jinguo; Liu, Zhening; Fang, Maosheng; Wang, Bo; Wang, Chuanyue; Hu, Bin; Sun, Xueli; Lv, Luxian; Lu, Zheng; Ma, Cui; He, Xiaolin; Guo, Tiansheng; Xie, Shiping; Wu, Renrong; Xue, Zhimin; Chen, Jindong; Twamley, Elizabeth W.; Jin, Hua; Zhao, Jingping (2010). Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Archives of General Psychiatry, 67(9), 895–. doi:10.1001/archgenpsychiatry.2010.105 

22 Wood, Alastair J.J.; Freedman, Robert (2003). Schizophrenia. New England Journal of Medicine, 349(18), 1738–1749. doi:10.1056/NEJMra035458  

23 Ibid. 

24 Agid, O., Seeman, P., & Kapur, S. (2006). The “delayed onset” of antipsychotic action—An idea whose time has come and gone. Journal of Psychiatry & Neuroscience, 31(2), 93–100.

25 Chong, M. Y., Tan, C. H., Fujii, S., Yang, S. Y., Ungvari, G. S., Si, T., Chung, E. K., Sim, K., Tsang, H. Y., & Shinfuku, N. (2004). Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences, 58(1), 61–67. https://doi.org/10.1111/j.1440-1819.2004.01194.x

26 Ibid.

27 Ibid.

28 Xiang, Y. T., Kato, T. A., Kishimoto, T., Ungvari, G. S., Chiu, H. F. K., Si, T. M., Yang, S. Y., Fujii, S., Ng, C. H., & Shinfuku, N. (2017). Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009). Asia-Pacific Psychiatry: official journal of the Pacific Rim College of Psychiatrists, 9(4), 10.1111/appy.12277. https://doi.org/10.1111/appy.12277

29 Ibid.

30 Chong et al. (2004)

31 Ibid.

32 Deng H, Xu J. Wendan decoction (Traditional Chinese medicine) for schizophrenia. Cochrane Database Syst Rev. 2017 Jun 28;6(6):CD012217. doi: 10.1002/14651858.CD012217.pub2. PMID: 28657646; PMCID: PMC6481906.

33 van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342

34 Ibid.

35 Ibid.

36 Abbo C. (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global health action, 4, 10.3402/gha.v4i0.7117. https://doi.org/10.3402/gha.v4i0.7117

37 Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154–170. https://doi.org/10.1016/S2215-0366(15)00515-5

38 Watt et al. (2017)

39 Konadu, K. (2008) Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology. African Studies Quarterly, Vol. 10 (2&3).

40 Shaw, I., & Middleton, H. (2013). Approaches to “mental health” in low-income countries: A case study of Uganda. Mental Health Review Journal, 18, 204–213. doi:10.1108/MHRJ-07-2013-0025

To Diagnose or Not to Diagnose: The Debate on Personality Disorders in Adolescence

The Intersectionality of PD in Adolescence 

The presentation of a personality disorder in adolescence is complicated by the ongoing debate of whether personality disorders should be diagnosed. Some licensed health professionals are hesitant to provide a diagnosis due to the belief that adolescence is a period of changing personality,[1] thus, it is not appropriate to judge if a personality is disordered. However, other health professionals argue for the benefits of early detection and treatment, leading to better health outcomes.[2] The impacts of the home environment, genetics and consequences of a diagnosis further complicate this debate.

Effects of Home Environment 

Childhood maltreatment (e.g., neglect, physical abuse) substantially increases the risk of developing a personality disorder.[3] The Minnesota Project by Sroufe et al. (2005) followed a group of high-risk children into adulthood and found that insecure attachment during childhood is strongly associated with the later development of personality disorders in adolescence.[4] Later studies on Borderline Personality Disorders (BPD) further supported the association of adverse childhood experiences as a risk factor for personality disorders. Marchetti et al. (2022) found that a history of childhood maltreatment was associated with higher levels of BPD in adolescents (average age 16).[5] Furthermore, studies by Xiao et al. (2023) found that adolescents with BPD had higher rates of all the assessed childhood traumas when compared to adolescents with non-disordered personalities; this was especially true for emotional neglect (the most commonly seen childhood trauma).[6]

Effects of Biological Factors

Adolescence is a time of biological change, including those that regulate one’s personality. Throughout adolescence, the brain continues to develop in term of myelination and the formation of synaptic networks; thus, the neural basis for many psychological regulatory systems are still in development.[7] Furthermore, the frontal, temporal and occipital lobes of the brain (which are responsible for response inhibition, emotion regulation, planning and organization) are still developing during adolescence, which may account for the increased impulsivity sometimes seen during this period.[8] The increased levels of sex hormones adolescents are exposed to during puberty also affect mood regulation.[9] Therefore, the developmental changes of adolescence can bring forth impulsivity and mood changes, similar to the changes brought by a personality disorder. 

However, studies by Xiao et al. (2023) have found that there are also biological differences in adolescents with personality disorders compared to non-disordered peers.[10] They found that adolescents with Borderline Personality Disorder showed increased Amplitude Low-Frequency Fluctuations in the limbic system (a measure of spontaneous neuronal activity related to the mood swings associated with BPD).[11] Thus, biological factors can also account for differences in the mood swings of adolescents with disordered personalities compared to non-disordered adolescents.

Arguments in favor of a diagnosis

The argument in favor of a diagnosis appeals to the benefits of early diagnosis, specifically: better health outcomes. Paris et al. (2013) report that conditions such as antisocial personality disorders begin in childhood, and as a result of the early onset, psychopathology is more likely to continue.[12] An analysis of personality trait dimensions also supports the early establishment of personality. Studies by Shiner et al. (2009) suggest a continuity from child to adult personality based on findings that certain personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) in childhood predicted later behaviors.[13] Klimstra et al. (2009) distinguish that personality traits change considerably at the ages of 10-15 years old and then stabilize at the ages of 16-21 years.[14] However, according to Cicchetti et al. (2009), since personality disorders (PD) do not begin in adulthood, early investigation is necessary to develop a lifespan model for treatment.[15] Schmeck (2022) further supports the need for early intervention in personality disorders, arguing that early diagnosis rids the stigma associated with PD and lessens the possibility of long-lasting impairments and disability by facilitating the transition into adulthood.[16] 

These benefits of early diagnosis may have been considered by the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the most recent version of the guide to diagnosing mental disorders has changed its age requirements for diagnosing PD. While earlier versions of the DSM did not allow someone under 18 to be diagnosed, the DSM-5 (the most recent version) allows the diagnosis of a personality disorder in someone under 18 if symptoms are present for at least one year.[17] 

Arguments against diagnosis

A study by Laurenssen et al. (2013) found that 57.8% of psychologists working with adolescents acknowledged the existence of personality disorders in this age group; however, only 8.7% of them actually made formal PD diagnoses in the adolescents.[18] The majority of psychologists are reluctant to diagnose adolescents based on the idea that personality is fluid and still developing.[19] Dijk et al. (2021) argue that while personality traits (e.g., openness, conscientiousness, extroversion, agreeableness, neuroticism) are structurally similar between adolescents and adults, there are developmental differences; for example, adolescents appear to be less conscientious.[20] Some psychologists also argue that an early diagnosis is stigmatizing since personality pathology can often be viewed as being unmodifiable.[21,22] Furthermore, according to Adshead et al. (2012), a misdiagnosis of a personality disorder in adolescence can focus attention away from interventions to improve the caregiving environment, particularly if neglect or abuse are present.[23] Perhaps taking the drawbacks of diagnosis into account, the American Psychiatric Association webpage, as of now, states that diagnosis of personality disorders is only applicable to individuals 18 and older (It is important to note that the American Psychiatric Association oversees the DSM-5).[24]

Treatment of PD in adolescence

Personality disorders vary in the ways they impact an individual’s thoughts and ways of expressing themselves, however, they align in their need for treatment to go away.[25] In adults certain psychotherapies (e.g., Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Group Therapy, Psychoanalytic) have shown to be effective for treating personality disorder.[26] If an adolescent is diagnosed with a personality disorder, their treatment plans may differ slightly from adults. Adolescent treatment plans are complex due to a current need for more evidence if adult interventions also work for adolescents.[27] Furthermore, these treatment plans are unique as they often incorporate the adolescent’s school and parents.[28]

If you believe you or your child may have a personality disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Maria Karla Bermudez

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

References

1 Adshead, G., Brodrick, P., Preston, J., & Deshpande, M. (2012). Personality disorder in adolescence. Advances in Psychiatric Treatment, 18(2), 109-118. doi:10.1192/apt.bp.110.008623

2 Cicchetti, D., & Crick, N. R. (2009). Precursors and diverse pathways to personality disorder in children and adolescents. Development and Psychopathology, 21(3), 683-685. doi:https://doi.org/10.1017/S0954579409000388

3 Adshead et al. (2012)

4 Sroufe, A, Egeland, B, Carlson, E et al (2005) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. Guilford Press

5 Marchetti, D., Musso, P., Verrocchio, M., Manna, G., Kopala-Sibley, D., De Berardis, D., . . . Falgares, G. (2022). Childhood maltreatment, personality vulnerability profiles, and borderline personality disorder symptoms in adolescents. Development and Psychopathology, 34(3), 1163-1176. doi:10.1017/S0954579420002151

6 Xiao, Q., Yi, X., Fu, Y., Jiang, F., Zhang, Z., Huang, Q., Han, Z., & Chen, B. T. (2023). Altered brain activity and childhood trauma in Chinese adolescents with borderline personality disorder. Journal of affective disorders, 323, 435–443. https://doi.org/10.1016/j.jad.2022.12.003

7 Adshead et al. (2012)

8 Ibid. 

9 Ibid. 

10 Xiao et al. (2023)

11 Ibid. 

12 Paris, Joel. “Personality disorders begin in adolescence.” Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l'Academie canadienne de psychiatrie de l'enfant et de l'adolescent vol. 22,3 (2013): 195-6. doi:10.1007/s00787-013-0389-7

13 Shiner, R (2009) The development of personality disorders: perspectives from normal development. Development and Psychopathology 4: 715–34

14 Klimstra, TA, Hale, WW, Raaijmoken, QA (2009) Maturation of personality in adolescence. Journal of Personality, Society & Psychology 96: 898–912

15 Cicchetti et al. (2009)

16 Schmeck, K. (2022, March 17). Debate: Should CAMHS professionals be diagnosing ... - wiley online library. ACAMH. https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12553

17 Personality disorders: Diagnosis. CAMH. (n.d.). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/personality-disorders/personality-disorders---diagnosis#:~:text=According%20to%20DSM%2D5%2C%20features,for%20at%20least%20one%20year.

18 Laurenssen, E. M., Hutsebaut, J., Feenstra, D. J., Van Busschbach, J. J., & Luyten, P. (2013). Diagnosis of personality disorders in adolescents: a study among psychologists. Child and adolescent psychiatry and mental health, 7(1), 3. https://doi.org/10.1186/1753-2000-7-3

19 Paris (2013)

20 van Dijk, I., Krueger, R. F., & Laceulle, O. M. (2021). DSM-5 alternative personality disorder model traits as extreme variants of five-factor model traits in adolescents. Personality disorders, 12(1), 59–69. https://doi.org/10.1037/per0000409

21 Cicchetti et al. (2009)

22 Adshead et al. (2012)

23 Ibid. 

24 What are personality disorders?. Psychiatry.org - What are Personality Disorders? (2022, September). https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders#:~:text=Diagnosis%20of%20a%20personality%20disorder,their%20personalities%20are%20still%20developing.

25 Ibid.

26 Ibid.

27 Adshead et al. (2012)

28 Ibid.

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.