Relationship of psychosocial adversity to depressive symptoms and self-harm in young homeless people.

An increased incidence of psychiatric disorders has been reported in homeless young people. These disorders are often related to their childhood experience of trauma, although less is known about how secondary traumatic experiences while being homeless affect psychopathology. The aim of this study was to establish the relationship between life adversities - living on the street, physical and sexual abuse (during both childhood and young adult life) and substance misuse - and depressive symptoms and self-harm among homeless young people.

The number of homeless people worldwide has grown steadily in recent years. Accurate statistics are difficult to gather; however, UNICEF estimates there are approximately 100 million street children worldwide, with that number constantly growing (see Kanth, 2004). Interventions and service provision for homeless adolescents and young adults with psychiatric disorders remain a challenge to mental health services because of the complexities surrounding the assessment of this population. The situation can be worsened by stigma associated with mental illness. The difficulty for them to ask for help partly remains with them and partly within the service structure.

Exposure to any type of abuse (physical, sexual or emotional) in early life can increase the likelihood of young people running away from the family home and being accommodated in care. This in turn makes them more vulnerable to poor psychological adjustment, depression, substance misuse and suicidal behaviour (Kimberly et al, 2000; Tyler, 2006). It is well established that adverse life experiences during childhood, particularly those involving family breakdown, in conjunction with inadequate substitute care and resulting stressors and rejections, make young people more vulnerable to depression and other forms of psychopathology (Herman et al, 1994).

In summary, previous research has shown the multitude and complexity of mental health problems among young homeless people and their relationship with various adverse social factors. There is limited understanding of the impact of such adverse factors from young people’s earlier upbringing, the secondary effects of being homeless and the nature of the relationship between adverse experiences and mental health problems. The rationale for this study was to explore the nature of these relationships rather than to suggest any causal association between the adversities and mental disorders.

Method

The study was conducted in a network of shelters for homeless young persons called Foyers. It currently has 132 shelters (Foyers) across the UK that provide accommodation and preparation for homeless people aged 16–25 years. These are interlinked under the Foyer Federation’s international accreditation scheme. Out of these 132, 18 shelters from four UK regions (the South West, West Midlands, East Midlands and North East) were chosen to be provided with access to a pilot in-house designated mental health service. Over 1 year, 150 young homeless people were referred to this mental health service and they constituted the sample for this study. Ethical approval for the study was obtained from the multicentre National Health Service research ethics committee. Informed written consent was obtained and none of the participants refused to participate in the study. More than half of the referrals (62.4%) were made by staff at the shelters. Young people’s mean age was 19.0 years (range 16–25 years); 53.3% were male and 46.7% female. Most of them (86.7%) were White British; 4.0% were mixed race, 1.3% Black Caribbean, 1.3% Black African, 2.0% Black British and 4.7% from other ethnic groups.

The mental health service systematically collected data on behalf of the research team at the point of first assessment for each young person referred. The young people were rated for their depression and self-harm according to the Health of the Nation Outcome Scales (HoNOS), a standardised and well established assessment and outcome measure specifically developed for use by mental health practitioners (Wing et al, 1998). The HoNOS was scored following interviews with the young people in the study sample. The instrument assesses a range of mental health needs. One of the 12 items is depressed mood. Each HoNOS item is rated on a five-point severity scale (Wing et al, 2000): 0, no problem; 1, minor problem requiring no action; 2, mild problem but definitely present; 3, moderately severe problem; 4, severe to very severe problem. Accordingly, we considered 0 and 1 on the severity scale of depression as being of no clinical significance, and a score of 2–4 as requiring a clinical assessment and possible treatment. A service checklist was also completed on young people’s history, risk behaviours and service contacts.

We initially analysed the descriptive statistics of the adverse life events and mental health problems among participants. Based on the aim of this study, we selected the following life adversities: history of sleeping on the streets, taking illicit drugs, physical abuse and sexual abuse (both as a child and as a young adult), and reported bullying during childhood. Chi-square tests were used to explore the relationship between these childhood adversities and the mental health variables of current depression and suicide attempts or self-harm. The latter two variables were distinguished by the reported intent.

Results

A substantial proportion (28.7%) of the sample had ‘attempted suicide’ at some point during their lives. More than half (56.6%) scored highly on the depressed mood item of the HoNOS. The frequencies of different life adversities were: physical abuse as a child 36.7%, as an adult 21.3%; sexual abuse as a child 16.7%, as an adult 12.0%; sleeping on the street 25.3%; taking drugs 72%; and being bullied as a child 47.3%. These are high incidence rates of traumas both as children and as young adults.

A history of sleeping on the streets was associated with attempting suicide (P = 0.003) but not with current depressed mood. No association was found between suicide attempts and drug misuse. Nevertheless, substance misuse was associated with both depressed mood (P = 0.035) and self-harm (P =0.014).

Bullying was not associated with any mental health problems.

Having been abused as both a child and an adult was significantly associated with high scores for depressed mood (P =0.019 and P = 0.007 respectively). In addition, physical abuse as an adult was associated with a history of suicide attempts (P = 0.002) (Table 1). Sexual abuse as both a child and as an adult was also strongly associated with attempted suicide (P =0.020 and P = 0.025 respectively) (Table 2).

Table 1

Association between physical abuse and psychiatric variables

Tested associations with physical abuse as a child/adult	χ2	d.f.	P
Physical abuse as a child
Attempted suicide	2.733	1	0.098
Self-harm (HoNOS)	7.231	4	NS
Depressed mood (HoNOS)	11.850	4	0.019
Physical abuse as an adult
Attempted suicide	9.722	1	0.002
Self-harm (HoNOS)	6.238	4	NS
Depressed mood (HoNOS)	14.112	4	0.007

Table 2

Association between sexual abuse and psychiatric variables

Tested associations with sexual abuse as a child/adult	χ2	d.f.	P
Sexual abuse as a child
Attempted suicide	5.440	1	0.020
Self-harm (HoNOS)	8.920	4	0.063
Depressed mood	3.147	4	NS
Sexual abuse as an adult
Attempted suicide	5.036	1	0.025
Self-harm (HoNOS)	3.628	4	NS
Depressed mood	5.161	4	NS

Discussion

The rates of depression and other psychiatric disorders are significantly elevated among the homeless population (West, 1999). Our study revealed high levels of mental health needs among a group of young homeless people. The underlying mechanisms are complex, and a number of vulnerability factors appear to be involved. Abusive experiences during earlier and later life were significantly associated with depressed mood and suicide attempts. In another UK study, two-fifths of people who had fled physical violence at their parental home had depression or anxiety, in comparison with less than one-fifth of those who became homeless for other reasons (Nassor & Brugger, 2000).

Despite a body of evidence on the high prevalence of psychiatric disorders among homeless youth, less is known about its long-term course and the impact of early and subsequent risk factors (Nassor & Brugger, 2000). In this study, we have found a number of significant associations between life adversities experienced by homeless young adults and psychiatric presentations.

Homeless youths present challenges to both psychiatric and other services. There is a need for better interventions and prevention. There is a compelling need for researchers and policy-makers to make efforts to work collaboratively to improve policy, informed by research findings (Kidd & Davidson, 2006). However, this joint endeavour to address sociopolitical issues to influence mental health outcomes for these youths could be made acrimonious by the current economic and political situation.

There are a number of limitations in this study that need to be acknowledged. A retrospective study can be subject to recall bias. The lack of geographical stability, the priority of meeting their basic needs, and legal and ethical complexities have constrained previous research with homeless young people, hence a strength of this study was to obtain a reasonably large sample. This should not deter us from attempting longitudinal research in this area to replicate and substantiate these findings, as well as to shed further light on the interaction between risk factors and mental health. Other limitations of this study are the potential for bias through the use of a clinician-rated tool (the HoNOS), rather than independent diagnostic interviews or self-rated measures.

The needs of this often forgotten group cannot be met by any single agency (Craig & Hodson, 2000; Taylor et al, 2006). Hence there is a well-documented gap in transitional generic psychiatric services for older adolescents/young adults, with problems being multiplied for this vulnerable group. Despite the need for new services, a better skill base and transitional arrangements, the current economic climate worldwide means that the need of this politically weaker section of society is easily moved to the bottom of the priority list of any policy-makers, especially when the resources of the public services are stretched to their limit.