Homelessness and health : analysis of mortality and morbidity from a gender perspective

In this thesis, results from epidemiological cohort studies of morbidity and mortality among homeless men and women are presented. Comparisons were made with the general population concerning hospital care for somatic diseases, injury and mental disorders, and concerning mortality. The thesis contains also the results from a five-year follow-up study of 82 homeless men with mental problems.

Results from Paper I shows that the mortality among the 82 homeless men was higher than expected (SMR 4.7). Surprisingly, among men with severe psychiatric disorders, such as schizophrenia, none had died at the follow-up. Among the survivors, 75% were still homeless, and the mental health problems combined with substance use problems had increased.

Paper II, shows that among 1 364 homeless men and 340 homeless women, the relative risk of being hospitalised for physical diseases was double that of men and women in the general population. When age was considered, younger homeless women had the highest risk compared to homeless men (RR 1.6). The highest prevalence was found in the diagnosis group injury/poisoning (22% men, and 20% women). The highest risk was found for skin diseases (RR 36.9) and concerned homeless women.

Paper III shows that among 1 364 homeless men and 340 homeless women, the relative risk of having mental disorders, including alcohol and drugs, was 13-21 times higher that of the general population. The homeless women ran a higher risk compared with homeless men (RR 1.2), where younger homeless women had the highest risk (RR 2.2). Alcohol use disorders were equally common among homeless men and women, but women had more drug use disorders (RR 1.3). Women had a higher risk of schizophrenia (RR 2.8), and personality disorders (RR 2.7). When adjustment was made for substance use disorders, no increased risk for mental disorder was found in the homeless group.

Paper IV reports a relative risk of 3.1 for death among 1 758 homeless men compared with men in the population, and a relative risk of 2.5 for 527 homeless women compared to women in the population. No difference in mortality was found between homeless men and women. The mortality among men was principally related to alcohol, and among women to drug abuse. For homeless men with long homelessness and mental problems including substance misuse, the life and housing situation had not improved at the 5-year follow-up, and substance misuse problems and mental problems had increased among them.

There was no connection between mortality and mental illness. Among homeless men and women the risk of having diseases that requires hospitalisation was very high, compared with the general population. Younger homeless women were particularly at risk. There were a number of gender specific somatic and psychiatric diagnoses that are important to take into account when planning services for homeless people. The excess risk for mental illness found among the homeless was entirely related to alcohol and drug misuse, as was their excess mortality.

List of scientific papers

I. Beijer U, Andréasson A, Agren G, Fugelstad A (2007). Mortality, mental disorders and addiction: a 5-year follow-up of 82 homeless men in Stockholm. Nord J Psychiatry. 61(5): 363-8
https://pubmed.ncbi.nlm.nih.gov/17990198

II. Beijer U, Andréasson S (2009). Physical diseases among homeless people: gender differences and comparisons with the general population. Scand J Public Health. 37(1): 93-100
https://pubmed.ncbi.nlm.nih.gov/19141558

III. Beijer U, Andreasson S (2009). Gender, hospitalisation, and mental disorders among homeless people compared with the general population - a cohort study. [Submitted]

IV. Beijer U, Andréasson S, Ågren G, Fugelstad A (2009). Mortality and causes of death patterns among homeless men and women in Stockholm. [Manuscript]