April 2024 – Maria Yang, MD

Tomorrow (April 22) the United States Supreme Court will hear oral arguments in the case City of Grants Pass, Oregon, v. Gloria Johnson. This article, 5 things to know about the Grants Pass homelessness case before the US Supreme Court, summarizes the issue well: “The repercussions could have national implications for how cities can regulate homelessness.” In short, if the Supreme Court sides with the City of Grants Pass, it could essentially be a crime to be homeless. (Note: “Homelessness” here refers strictly to street homelessness. The federal definition includes other populations that are not as visible, such as people living in shelters, people about to be evicted, etc.)

This brings to mind other information:

California Statewide Study of People Experiencing Homelessness. This came out in June of 2023. It’s one of the few recent surveys that examines mental health conditions and substance use among people experiencing homelessness. Over 3,000 people in various parts of California answered surveys and over 300 people participated in detailed interviews. They didn’t administer technical interviews to determine whether people met diagnostic criteria for psychiatric conditions. They instead asked people if they had ever experienced certain symptoms (e.g., hallucinations, anxiety, depression) or engaged in certain behaviors (e.g., used any substance three or more times a week) in the past or at the time of the interview. More than half of the people who responded said that they either had a mental health condition in the past or were experiencing one now. More than half reported that they had used substances in the past; about one-third reported that they were currently using any substance at least three times a week. (Note that “substance” here does not include alcohol or tobacco.)

JAMA Psychiatry: Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness. I have yet to read this paper. It’s a review and analysis of past research related to this topic (a research study of past research studies, if you will). It looks like they looked at specific diagnoses, with a call out of 44% of people experiencing homelessness experiencing any substance use disorder. Other highlights included in the abstract include prevalence rates for antisocial personality disorder (26%) (one of my most popular posts—from 2013!—is about this condition, for whatever reason… and I’ve been wondering about this one again), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).

Open drug scenes: responses of five European cities. This paper is from 2014, though it holds lessons that we in the US can and should learn from. The information within disappoints everyone, which means it is probably a reasonable map to use.

Open drug scenes are gatherings of drug users who publicly consume and deal drugs.

To be clear, as evidenced by data shared above and from anecdotes from those of us who do this work, not everyone who is homeless uses drugs. Not everyone who uses drugs is homeless, either. Much of the current discourse about homelessness is related to drug use, though, which is why I bring up this paper.

The five cities described in the paper vary in size (Zurich, Switzerland, at around 415,000 people to Lisbon, Portugal, at 2.7 million people), though they each use similar strategies to reduce and eliminate open drug scenes:

drug dependence is a health problem
drug use behavior is a public nuisance problem
need for low threshold health services, outreach social work, and effective policing
appropriate combinations of harm reduction and restrictive measures

Law enforcement is needed to address the public nuisance problem. Robust health and social services that include harm reduction are needed to address the health problem. (At least two of the cities legalized heroin so people can use drugs safely in monitored settings, with hopes that they will one day use less and perhaps stop. Recall that this paper came out before the destructive wave of fentanyl overcame us.) Most cities have yet to find the “appropriate combinations” to reduce open drug scenes. (Just to reiterate, these strategies did not eliminate homelessness, only open drug scenes.)

Textbook Talk: Dr. Van Yu on Housing First and the Role of Psychiatry in Supported Housing. One significant way to eliminate homelessness is to ensure that people have places to live. Lemme tell ya: It is hard to effectively treat someone’s mental health or substance use disorder if they don’t have a stable place to live. If the person can’t or won’t come to you, that means you have to go to them. If you can’t find them (because they don’t have a place to live so they move around a lot), it’s hard to make a connection to help them. Even if they want to participate in treatment, it’s challenging to Do All the Things when you don’t know where you are going to sleep. Can you imagine what you’d do or how you’d feel if you didn’t know where you were going to sleep tonight? Seeing a health care professional likely won’t be your priority. Working in a Housing First or other public setting also changes the way you think about health care: Your interventions don’t just affect one person; they affect a whole community. Conversely, the community influences your interventions as a health care professional. We naturally become systems thinkers. (Full disclosure: Dr. Yu was once my boss. I learned and continue to learn a lot from him.)

I will follow the City of Grants Pass, Oregon, v. Gloria Johnson case with interest. The problem of homelessness is complex because people experiencing homelessness each have distinct challenges. They are not a monolith. I believe that there are government officials who are sympathetic to their circumstances. I still wonder, though, what problem are they trying to solve? Is it that they don’t want people to live outside? Or that they don’t want to see people living outside?

Let’s take a look at the last figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. The authors call this the Transdomain Model of Health:

I like this model. (Do note, though, that the map is not the territory.) It reminds us of the interdependencies between and within ourselves. If our community isn’t doing well, that will affect our individual mental health. To intentionally use a trivial example (because there are WAY too many heavy things happening these days), consider a city’s baseball team. A not-so-fictional team called the Tridents has had some embarrassing games; hits are uncommon, fielding errors abound, and pitchers are giving up a lot of runs. Grumpy viewers write corrosive comments about the Tridents in the city’s newspaper. Suckers like me read the comments and feel a disjointed sense of “us”. Maybe some of these grumpy viewers are in foul moods for other reasons and they direct their ire at the Tridents because that’s easier to talk about than their alcohol or gambling problems. They would go to Cell Phone Carrier Stadium to grumble at the Tridents directly, but they are dealing with illnesses that limit their abilities to navigate social spaces. Most of us don’t feel psychologically fine when we are physically unwell.

Contrast this Transdomain Model of Health with this recent Psychiatric News article, Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health.

The authors define “lifestyle psychiatry” as seeking

to cultivate well-being and support individuals in preventing and managing psychiatric disorders and optimizing their brain health.

(Editorial comment: I feel some vexation about “lifestyle psychiatry” because I don’t think “lifestyle psychiatry” should be a specialty with its own textbook. Every psychiatrist should practice “lifestyle psychiatry”.) While the authors concede that “patients may have cost or access barriers to traditional care” and conclude the article with a proclamation that lifestyle psychiatry is “a vital component in improving the health and well-being of people around the world”, the final sentence gives away the underlying sentiment of bootstrapping: supporting “individuals in taking ownership of their mental health and well-being” (emphasis mine).

The “social health” component from the Transdomain Model of Health is missing from “lifestyle psychiatry”, even though addressing social health will make it much easier for people to succeed in the “lifestyle psychiatry domains”:

It’s much easier to get physical exercise when there are generous green spaces, plenty of intact sidewalks, and public safety isn’t a concern. Healthy diets and nutrition are easier to achieve when fresh food is available and affordable. It’s easier to be mindful and take yoga classes when you don’t have to work two jobs to make rent. People sleep better when there’s no noise pollution; what if the affordable housing wasn’t only close to airports, trains, and freeways? Neighborhoods with “third spaces” make social relationships more likely to bloom.

To be fair, the lifestyle psychiatry authors do write of “consultation and leadership to governments, corporations, and health care systems” and informing “public education programs and community planners to support the creation of healthy communities [and] employers in creating healthy workplaces”. Their definitions, though, ultimately focus on individuals and do-it-yourself interventions with some consultation with your local lifestyle psychiatrist. (And, to be clear, I’m not saying that systems are the only issue. People do still need to make their own choices, but we can shift systems so it’s not as hard for people to make healthier choices. Life is already hard enough.)

Seattle was not anywhere near the path of totality for the total solar eclipse today. Over lunch I watched part of NASA’s live broadcast. And what a mush ball I am: I cried into my meal as I watched the skies turn to black, heard the crowds cheer and gasp, and saw the dancing corona of the Sun.

I’m not so naive to believe that being in community solves everything. However, I do believe that being in community–contributing to social health–can powerfully change the way we view and feel about ourselves, others, and the world around us. Millions of people witnessed a total solar eclipse in person or in two-dimensions today. I’m pretty sure I wasn’t the only one who cried while watching the broadcast. Three things had to be in place for this celestial event to occur: The Sun, the Moon, and the Earth. To witness this stellar occasion, we all had to be on the same planet. Maybe this is naive: I’d like to think that the shared experience of a total solar eclipse boosted our planetary social health. And, as a result, we individually experienced higher mental health today.