Mental Illness - Homeless Veterans
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Homeless Veterans


Mental Illness


MISSION-Vet HUD-VASH Implementation Study

Up to 80% of homeless Veterans suffer from mental health and/or substance use disorders. The path into and out of homelessness is often complicated by untreated or under treated mental health and substance use disorders. Even after housing has been obtained, the presence of these disorders can further isolate homeless Veterans, resulting in greater rates of emergency room visits and hospitalizations. Thus, integrating mental health and substance use disorder treatment with community-based permanent housing is important in sustaining housing placements for formerly homeless Veterans. The Center studies mental illness, substance abuse, and co-occurring disorders among homeless Veterans in order to develop Veteran-centric models of care to sustain permanent housing in the community.

Evidence-based approaches have been developed to assist with co-occurring mental health, substance abuse and related issues among the homeless population. However, passive dissemination strategies alone are insufficient to obtain adoption and strong implementation of evidence-based treatments. This project is testing the use of an implementation model-Getting To Outcomes (GTO)-designed to assist in the delivery of an evidence-based intervention for Veterans with co-occurring mental health and substance use disorders (MISSION-Vet) in the HUD-VASH program. To facilitate the adoption and sound implementation of MISSION-Vet within HUD-VASH, GTO is being used to strengthen the capacity of practitioners to carry out the evidence-based MISSION-Vet treatment protocol with high fidelity.

In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by sub-teams of HUD-VASH case managers to receive either MISSION-Vet Implementation as Usual (IU - standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, & Maintenance (RE-AIM) model.

Contact: David Smelson, PsyD /

Other Published Articles and Research Briefs related to Mental Illness, Substance Abuse, & Co-Occurring Disorders:

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Disparities in Housing Status among Veterans with Medical, Cognitive, Mental, and Behavioral Health Conditions

Montgomery, A. E., Dichter, M. E., Thomasson, A. M., Roberts, C. B., & Byrne, T. H.
Psychiatric Services, 66(3), 317– 320; doi: 10.1176/
March 2015
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Objective: The study explored disparities in housing status among Veterans with general medical, cognitive, and behavioral health conditions.

Methods: Multinomial mixed-effects models estimated the relationship between medical, cognitive, and behavioral health comorbidities and housing instability among Veterans enrolled in the Veterans Health Administration (VHA) (N=1,582,125) who responded to the Homelessness Screening Clinical Reminder for homelessness and risk during a three-month period.

Results: Veterans were two or more times as likely to screen positive for homelessness or risk if they had a diagnosis of a cognitive or behavioral health conditions in the study. Findings related to general medical conditions were inconsistent.

Conclusions: The study found disparities in housing instability among VHA outpatients with cognitive and behavioral health conditions, suggesting the need to identify Veterans with these conditions experiencing housing instability and the need to develop appropriate interventions to mitigate homelessness or risk.

Contact:  Ann Elizabeth Montgomery, PhD /

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Housing Instability and Mental Distress among U.S. Veterans

Bossarte, R.M., Blosnich, J.R., Piegari, R.I., Hill, L.I. & Kane, V.
American Journal of Public Health, Published online ahead of print October 22, 2013: e1–e3. doi:10.2105/AJPH.2013.301277
22 October 2013
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Evidence has suggested increased risk for homelessness and suicide among US Veterans, but little is known about the associations between housing instability and psychological distress (including suicidal ideation). We examined frequent mental distress (FMD) and suicidal ideation among a probability-based sample of 1767 Nebraska Veterans who participated in the 2010 Behavioral Risk Factor Surveillance Survey who had and had not experienced housing instability in the past 12 months. Veterans experiencing housing instability had increased odds of FMD and suicidal ideation.

Contact: Robert Bossarte /

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Requiring Sobriety at Program Entry: Impact on Outcomes in Supported Transitional Housing for Homeless Veterans

Schinka, J.A., Casey, R.J., Kasprow, W, Rosenheck, R.A.
Psychiatr Serv. 62(11):1325-1330. doi: 10.1176/
November 2011
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OBJECTIVE:  An important distinction in models of housing for the homeless is whether programs that require abstinence prior to program admission produce better outcomes than unrestricted programs. Data from a large transitional housing program were used to compare client characteristics of and outcomes from programs requiring abstinence at admission and programs not requiring abstinence.

METHODS: The U.S. Department of Veterans Affairs (VA) Northeast Program Evaluation Center provided records of individuals who were admitted into, and discharged from, the VA Grant and Per Diem program in 2003-2005. Records contained information from intake interviews, program discharge information, and descriptions of provider characteristics. Analyses were based on 3,188 Veteran records, 1,250 from programs requiring sobriety at admission and 1,938 from programs without a sobriety requirement. Group differences were examined with t tests and chi square analyses; predictors of program outcome were determined with logistic regression.

RESULTS: Individuals using drugs or alcohol at program admission had more problematic histories, as indicated by several general health and mental health variables, and shorter program stays. There were significant differences between groups in the frequency of program completion, recidivism for homelessness, and employment on program discharge, but effect sizes for these analyses were uniformly small and of questionable importance. Regression analyses did not find meaningful support for the importance of sobriety on program entry on any of the outcome measures.

CONCLUSIONS: The results add evidence to the small body of literature supporting the position that sobriety on program entry is not a critical variable in determining outcomes for individuals in transitional housing programs.

Contact: John Schinka, PhD /

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Rethinking Homelessness Prevention among Persons with Serious Mental Illness

Montgomery, A. E., Metraux, S., & Culhane, D. P.
Social Issues and Policy Review 7(1), 58–82. doi: 10.1111/j.1751-2409.2012.01043.x
January 2013
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During recent years, the need to consider effective and innovative ways to prevent and end homelessness among individuals with serious mental illness has been abetted by an increased and more sophisticated understanding of the composition of the homeless population, the emergence of evidence-based practices to address homelessness, and the passage of the Patient Protection and Affordable Care Act. This article summarizes the evolving understanding of the role that serious mental illness plays in homelessness as well as the interventions that are effective at preventing and ending homelessness among persons with serious mental illness. This summary contextualizes a discussion of the practice and policy agenda to address homelessness among people with serious mental illness using a new prevention framework and considering the opportunities inherent in increased affordable health care coverage for very low-income individuals with serious mental illness.

Contact:  Ann Elizabeth Montgomery, PhD /

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Screening for Homelessness among Individuals Initiating Medication-Assisted Treatment for Opioid Disorder in the VHA.

Bachhuber, M., Roberts, C. B., Metraux, S., & Montgomery, A. E.
Journal of Opioid Management, 11(6), 459–462; doi: 10.5055/jom.2015.0298
Nov-Dec 2015
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Objective: To determine the prevalence of homelessness and risk for homelessness among Veterans with opioid use disorder initiating treatment.

Methods: Setting - Addiction treatment programs operated by the U.S. Department of Veterans Affairs (VA). Participants - All Veterans initiating treatment with methadone or buprenorphine for opioid use disorder between October 1, 2013 and September 30, 2014 (N=2,699) who were administered the VA's national Homelessness Screening. Main Outcome Measures - Self-reported homelessness or imminent risk of homelessness.

Results: The prevalence of homelessness was 10.2 percent and 5.3 percent were at risk for homelessness. Compared to male Veterans, women Veterans were less likely to report homelessness (8.9 percent vs 10.3 percent) but more likely to be at risk (11.8 percent vs 4.9 percent). By age group, Veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and Veterans aged 45-54 and 55-64 years most frequently reported risk for homelessness (6.5 and 6.8 percent, respectively).

Conclusions: The prevalence of homelessness in this population is approximately 10 times that of the general Veteran population accessing care at VA. Screening identified a substantial number of Veterans who could benefit from VA housing assistance and had not received it recently. Programs to address Veteran homelessness should engage with Veterans seeking addiction treatment. Integration of homelessness services into addiction treatment settings may, in turn, improve outcomes.

Contact:  Ann Elizabeth Montgomery, PhD /

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Self-Stigma, Self-Esteem, and Co-Occurring Disorders

Rodrigues, S., Serper, M., Novak, S., Corrigan, P., Hobart, M., Ziedonis, D., Smelson, D.
Journal of Dual Diagnosis 9(2), 129-133. doi: 10.1080/15504263.2013.777988
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Objective: The current study sought to examine the relationships among mental health/substance use severity, self-esteem, and components of self-stigma among individuals with co-occurring schizophrenia-spectrum and substance use disorders. Stereotype concurrence, or the internalization of negative preconceptions associated with membership in a stigmatized group, was hypothesized as a mediator.

Methods: Forty-nine subjects with co-occurring schizophrenia-spectrum and substance use disorders completed self-stigma, mental health, substance use, and self-esteem assessments. A multiple regression was employed to identify direct effects. Bootstrap mediator analyses were used to identify indirect effects through the hypothesized mediator: stereotype concurrence.

Results: Aside from poly-substance dependence (49%), most subjects had a diagnosed co-occurring alcohol use disorder (43%). Dysphoria and alcohol severity were negatively related to self-esteem. Stereotype concurrence mediated the relationship between autistic preoccupation and self-esteem.

Conclusions: Self-stigma was related to decreased self-esteem in individuals with a diagnosed co-occurring schizophrenia spectrum and substance use disorder, which is consistent with previous findings that have linked self-stigma to decreased self-esteem in individuals with either disorder alone. Decreased self-esteem has been linked to treatment noncompliance and relapses, impeding recovery, while improvements in self-esteem have been shown to be an important consequence of stigma reduction. Treatment implications are discussed.

Contact: Stephanie Rodrigues /

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Unemployment and Co-Occurring Disorders among Homeless Veterans

O'Connor, K., Kline, A., Sawh, L., Rodrigues, S. Fisher, W., Kane, V., Kuhn, J., Ellison, M., Smelson, D. Journal of Dual Diagnosis, 9(2), 134-138. doi: 10.1080/15504263.2013.778804
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Objective: To examine employment patterns from 2005 to 2008 among homeless Veterans with co-occurring mental health and substance use disorders relative to national trends in Veteran and non-Veteran populations.

Methods: Unemployment rates for homeless Veterans (N = 328) with co-occurring disorders were compared to national Veteran and non-Veteran unemployment rates using Current Population Survey data.

Results: From 2005-2008, unemployment among the homeless Veteran sample with co-occurring disorders increased from 47% to 66%. While unemployment decreased for Current Population Survey comparison groups from 2006-2007, homeless Veterans with co-occurring disorders experienced a 35.62% increase in unemployment.

Conclusions: Homeless Veterans with co-occurring disorders were disproportionately affected by the 2007 recession. This increase in unemployment, relative to comparison group data, indicates the need for more comprehensive and integrated vocational supports aimed at obtaining competitive employment upon program discharge. Future research should monitor the impact of economic fluctuations on placement and employment sustainability for homeless Veterans with co-occurring disorders.

Contact: David Smelson, PsyD /

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A Wraparound Treatment Engagement Intervention for Homeless Veterans with Co-Occurring Disorders

Smelson, D., Kline, A., Kuhn, J., Rodrigues, S., O'Connor, K., Fisher, W., Sawh, L., Kane, V.
Psychological Services
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This article reports the results of a low intensity wraparound intervention, Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION), to augment Treatment as Usual (TAU) and engage and retain homeless Veterans with a co-occurring disorder (COD) in care. Using a quasi-experimental design, 333 homeless Veterans were enrolled, 218 who received MISSION along with TAU and 115 who received TAU alone. Group assignment was based on MISSION treatment slot availability at time of enrollment. Compared to TAU alone, individuals receiving MISSION demonstrated greater outpatient session attendance within the 30 days prior to the 12-month follow up assessment and a larger decline from baseline in the number of psychiatric hospitalization nights. Individuals in the MISSION and TAU-only groups both showed statistically significant improvements in substance use and related problems at 12 months, with those in MISSION less likely to drink to intoxication and experience serious tension or anxiety. While this study confirmed that compared to TAU alone, MISSION along with TAU is effective in augmenting usual care and engaging and retaining homeless Veterans in treatment, some caution is warranted as this study did not involve random assignment. These results, however, are similar to a recent study involving a briefer version of the intervention which included random assignment. Based on these findings, MISSION is being further studied in the joint Department of Housing and Urban Development (HUD) – Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program, which offers rapid housing placement and case management to aid in housing maintenance.

Contact: David Smelson, PsyD /

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