The Prevalence of Mental Illness in Homeless People in Germany
A systematic review and meta-analysis
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Background: The number of homeless people in Germany is increasing. Studies from multiple countries have shown that most homeless people suffer from mental illnesses that require treatment. Accurate figures on the prevalence of mental illness among the homeless in Germany can help improve care structures for this vulnerable group.
Methods: We carried out a systematic review and meta-analysis on the prevalence of mental illness among homeless people in Germany.
Results: 11 pertinent studies published from 1995 to 2013 were identified. The overall study population consisted of 1220 homeless people. The pooled prevalence of axis I disorders was 77.4%, with a 95% confidence interval [95% CI] of [71.3; 82.9]. Substance-related disorders were the most common type of disorder, with a pooled prevalence of 60.9% [53.1; 68.5]. The most common among these was alcoholism, with a prevalence of 55.4% [49.2; 61.5]. There was marked heterogeneity across studies.
Conclusion: In Germany, the rate of mental illness requiring treatment is higher among the homeless than in the general population. The development and implementation of suitable care models for this marginalized and vulnerable group is essential if their elevated morbidity and mortality are to be reduced.
The correlation between mental illness and homelessness has been the subject of both sociopolitical discussion and psychiatric research since the early 20th century (1). International studies conducted in the last 20 years have found lifetime prevalence rates for mental illness of between 60% and 93.3% among the homeless (2–6). For instance, one-month prevalence rates of between 8.1% and 58.5% have been found for alcohol dependency and between 2.8% and 42.3% for psychotic illnesses (7). These are associated with increased mortality due to, for example, suicide (8, 9) and substance abuse (10), an increased risk of serious somatic illness, particularly infectious diseases (11, 12), and increased rates of criminality (13–15) and violence (16).
The extent to which figures from a meta-analysis on the prevalence of mental illness among homeless people in Western countries are comparable to the situation in Germany is limited. The meta-analysis found that the most common disorders were alcohol dependency at 8.1 to 58.5%, drug dependency at 4.5 to 54.2%, and psychotic illnesses at 2.8 to 42.3% (7). These figures must be interpreted in the context of factors relating to the cultures, societies, and medical care in the countries in which the research was conducted, as societal and social phenomena such as homelessness, poverty, and marginalization are dependent on countries‘ social orders.
In Germany there is no single, nationwide set of figures on homeless people. However, estimates by the German National Coalition of Service Providers for the Homeless (Bundesarbeitsgemeinschaft Wohnungslosenhilfe) indicate that homelessness in Germany has increased substantially: in 2014 there were approximately 335 000 people in the country without a home of their own, representing an estimated 18% increase compared to 2012 (17). The German National Coalition of Service Providers for the Homeless expects an additional 200 000 increase to around 536 000 homeless people in Germany by 2018 (17), partly due to migration and refugee movements.
Reliable figures on the distribution of mental disorders among homeless people may provide political players, public bodies, and psychiatric facilities a basis for improvement of the urgently needed support options for this vulnerable group. The risk of an undersupply of medical care for homeless people with mental illness is high: Europe-wide, fewer than one-third receive treatment (18).
This article aims to provide an overview of German studies that have already been conducted on the prevalence of mental illness among the homeless in Germany, by means of a systematic search of the literature and a meta-analysis.
A systematic search of the literature for studies on the prevalence of mental illness among the homeless in Germany was performed via digital search platforms, using the search terms „homeless“ (or „homeless persons“) and „German“ (or „Germany“ or „Hamburg,“ „Berlin, “ „Munich“) (Figure 1). Next, the bibliographies of major publications were searched and individual authors were contacted. The search of the literature was performed by a physician, aided by a librarian. Studies were evaluated by a physician.
The following study inclusion criteria were used:
- A definition of homelessness was stated; standardized diagnosis was conducted using ICD or DSM
- Psychiatric diagnosis was performed via clinical examination based on validated diagnostic tools
- With the exception of personality disorders, precise one-month prevalence rates were stated
- Data was collected in Germany
There were various definitions of homelessness: from persons living directly on the streets only to other definitions that included those living in shelters for the homeless. Five studies used a time-based criterion, ranging from 30 days to 3 months.
Prevalence rates were calculated using a double arcsine transformation via MetaXL 5.3, which stabilizes variance (19). A random-effects model was used. The heterogeneity of the included studies was estimated using Cochran‘s Q and I2 and represented using 95% confidence intervals. Heterogeneity was further explored using subgroup analyses based on categorical variables (time data collected [beginning before or after 2000], study size [less or more than 100], sex [male or female], participation rate [less or more than 80%]). This procedure was based on the MOOSE (Meta-analysis of Observational Studies in Epidemiology) criteria (20).
We found 11 studies published between 1995 and 2013 (Table 1) (2, 11, 12, 21–40, e1). Data was collected between 1989 and 2012. The total population of all the studies was 1220 homeless people, 131 (10.7%) of whom were women. Six studies investigated male-only samples (11, 12, 21, 26, 28–30, 32–35, 38–40), 2 female-only (22, 31, 37), and 3 studies investigated samples of both sexes (with women accounting for between 13.7 and 20.7% of individuals) (2, 23–25, 27, 36, e1). The mean ages of the investigated homeless people ranged from 29 to 48.1 years. Five studies were conducted in Munich (n = 804) (2, 11, 27, 29, 31–39, e1), two in Tübingen (n = 108) (22, 30), and one each in Berlin (n = 72) (28, 40), Münster (n = 52) (26), Mannheim (n = 102) (23–25), and Dortmund (n = 82) (12, 21). For the longitudinal study conducted in Munich, analysis took account of when data was first collected (27, 36). All data was collected in large cities (population >100 000), with the exception of Tübingen. Table 1 provides an overview of sampling strategies, definitions of homelessness, participation rates, and measuring tools used.
The pooled prevalence of mental illness was 77.5%, 95% confidence interval [95% CI] [72.4; 82.3] (11 studies). The corresponding figure for Axis I disorders was 77.4% [71.3; 82.9] (8 studies) (2, 11, 22, 30, 31, 36, 39, 40). In decreasing order, pooled prevalence rates were as follows: the most common disorders were substance-related disorders at 60.9% [53,1; 68,5] in 6 studies (22, 25, 31, 33, 36, 39), with 55.4% [49.2; 61.5] in 8 studies (21, 22, 25, 31, 32, 36, 38, 40) for alcohol dependency and 13,9% [7.2; 22.2] in 6 studies (21, 22, 31, 33, 39, 40) for drug dependency. The second-most common disorders were anxiety disorders, with a pooled prevalence of 17.6% [12.9; 22.8] in 6 studies (22, 31, 33, 36, 39), followed by affective disorders at 15.2% [9.8; 21.5] in 8 studies (21, 22, 24, 30, 31, 33, 39, 40), with major depression at 11.6% [4.4; 21.3] in 5 studies (22, 31, 33, 36, 39), and psychotic illnesses at 8.3% [5.4; 11.8] in 10 studies (21, 22, 24, 26, 30, 31, 33, 36, 39, 40). The pooled prevalence of cognitive impairment was 11.7% [6.0; 18.9] in 7 studies (21, 22, 31, 33, 36, 39, 40); that of personality disorders was 29.1% [5.6; 59.5] in 3 studies (2, 21, 24) (summarized in eTable 2 and Figures 2 to 4, eFigures 1 to 7).
Overall heterogeneity was high (I2 ranged from 58.66% to 96.84%, Q from 12.09 to 63.36). Subgroup analysis shed further light on individual factors (eTable 2).
This systematic review and meta-analysis of mental illness among the homeless in Germany included 11 studies, covering 1220 individuals. We found a prevalence of alcohol dependency 1.5 times higher than in other Western countries (including the USA, the United Kingdom, and Australia) (55.4% [49.2; 61.5] versus 37.9% [27.8; 48.0]) (7). Prevalence rates of psychotic illnesses and drug dependency were lower than in other Western countries (Table 2).
The German National Health Interview and Examination Survey for Adults (DEGS1, Studie zur Gesundheit Erwachsener in Deutschland), conducted between 2008 and 2011 in a sample representative of the population, found a one-month prevalence rate of DSM-IV disorders of 19.8% (e4). Our data on the homeless thus yielded a mental illness rate 3.8 times higher than in the general population. This includes all disorder spectra (Table 2). The prevalence of substance-related disorders was 21 times higher than in the general population (2.9%) (e4), and that of alcohol dependency was 22 times higher. In the general population the rate of alcohol dependency and alcohol abuse combined was 2.5% (e4).
There are 3 possible models that might explain the substantially higher rates of alcohol dependency:
- The fact that the support system is partly based on abstinence makes it harder for those particularly at risk to access: numerous international studies on the housing-first concept (e5) show that low-threshold accommodation and support that accepts alcohol consumption enable homeless people to be taken off the streets.
- The availability and price regulation of addictive drugs, which in Germany depends on comparatively low alcohol prices, may be an additional factor. In contrast, the rates of dependency on other substances such as crack or other stimulants are significantly higher in North America than among German homeless people (e6). Alcohol, meanwhile, is comparatively expensive there, and its use among the homeless is less widespread (e6).
- The consumption of psychotropic substances is a major coping strategy among those who are marginalized and have few other resources to solve their problems and very little access to the support system (e7).
The extent to which mental illness or substance abuse and homelessness are interrelated is a subject of ongoing discussion. It seems uncontroversial that each affects the other. A recently published meta-analysis of US veterans suggests that mental illness and substance abuse are the most consistent risk factors for becoming homeless (e8). Both substance abuse and homelessness can be associated with increased mortality: Tsai et al. report alcohol-associated mortality between 3 and 5 times higher, and drug-associated mortality between 8 and 17 times higher, among the homeless than in the general population (e9). Canadian data also shows that mental illness and substance abuse are associated with becoming homeless at an early age (e10).
This research yielded a pooled prevalence of 11.7% [6.0; 18.9] for significant cognitive deficits. Limited cognitive function, for example due to traumatic brain injury, is widespread among the homeless (e11). Tsai et al. also identified cognitive deficits as an important risk factor for homelessness (e9). Thus both severe substance abuse and traumatic brain injury increase the probability of cognitive deficits (e6).
Subgroup analysis revealed interesting findings for individual subgroups of homeless individuals. One important factor is sex. Only 131 (10.7%) of the total of 1220 homeless people were female. Our subgroup analyses found particularly high prevalence rates in studies involving only female homeless people for all Axis I disorders (83.3% [56.9; 100.0] versus 76.6% [68.7; 83.7]), psychotic illnesses (23.1% [5.0; 47.7] versus 7.6% [5.8; 9.7]), and drug dependency (24.6% [17.4; 32.6] versus 10.1% [4.8; 16.9]). This means that females are a particularly at-risk group. Although there was only one study in female homeless people that examined affective disorders, this also showed a higher prevalence rate, 46.9%, than in male homeless people only (14.6% [9.4; 20.6]). There were lower prevalence rates among homeless women compared to men for substance-related disorders and alcohol dependency. Homeless women are a subgroup that may be confronted with particular difficulties: estimated numbers of unreported homeless women are particularly high, as women are less likely to live directly on the streets and more likely to live in the homes of acquaintances, so their homelessness is more likely to go undetected, and they often do not use the available support system (e12, e13). As a result, homeless women are more frequently confronted with difficulties such as dependency on others and lack of safeguards (e12, e13). Because study sampling focused mainly on homeless people on the streets or in homeless shelters, homeless women have not yet been sufficiently researched.
In studies with participation rates above 80% only, the prevalence of Axis I disorders was 84.0% [74.7; 91.6] (versus 73.3% [68.5; 77.9] for studies with participation rates below 80%). There was a similar trend for psychotic illnesses (prevalence 9.8% [4.9; 16.0] for participation rates above 80% versus 8.6% [3.5; 10.5] for participation rates below 80%). Fazel et al. found a comparable correlation between high participation rates and high prevalences of depressive disorders and personality disorders (7, e14). The explanation for this correlation may be a refusal to participate in studies by individuals with more severe symptoms (7, e14). The correlation between lower prevalence rates and low participation rates suggests that homeless people should be investigated particularly thoroughly, e.g. via repeat questionnaires or data collection from other, additional sources (7).
Subgroup analyses for time of data collection (2000 onwards) highlight the lack of recent studies. The pooled prevalence of Axis I disorders in studies conducted after 2000 was lower than in older studies (73.3% [68.5; 77.9] versus 80.6% [71.1; 88.5]). However, the prevalence of psychotic illnesses was slightly higher in studies conducted after 2000 (8.6% [3.9; 14.7] versus 8.2% [4.9; 12.2]). This supports the idea put forward by some authors that psychotic illnesses have increased over time among homeless people due to factors such as dehospitalization (e15, e16).
Pooled prevalence rates were almost all lower in studies with sample size above 100 participants only than in studies with smaller case numbers. This was true of Axis I disorders, psychotic illnesses, affective disorders, alcohol and drug dependency, anxiety disorders, and cognitive disorders. It therefore seems advisable to interpret studies with lower case numbers cautiously in general, as they may indicate falsely high prevalence rates.
This research raises several questions which might be addressed in future studies on homelessness in Germany:
- Studies on this subject do not have a uniform definition of homelessness. Some studies have investigated only people living on the streets; others have also included those living in homeless shelters. We consider it appropriate for future work to be guided by the definition laid down by the European Commission, which includes all people with no fixed address (e17).
- Studies have not included enough homeless women: the majority have investigated all-male populations, which makes it difficult to take sufficient account of the needs of homeless women. Only 10.7% of the total of 1220 homeless people were female.
- Non-German-speaking homeless people, and therefore refugees and those with a background of migration, remain underresearched.
- In addition, sample sizes are often small, and the data collection tools used vary. This makes comparison difficult. Personality disorders were examined in only 3 studies (2, 12, 21, 24, 25).
One limitation of our analysis is the fact that multiple studies were conducted in Munich. It is therefore possible that individual participants may have been included in studies more than once. (Study intervals were between 4 and 14 years.) In addition, all the studies were conducted in towns and cities, where the risk of mental illness is generally higher than in rural areas (e18).
Social marginalization and homelessness are a highly charged, growing problem among those with mental issues. There is an urgent need for social, political, and psychiatric bodies to develop care models for this at-risk group. International studies have found assertive community treatment (ACT) programs that provide an intensive level of care directly on the streets or in homeless shelters, and intensive case management (ICM) programs, particularly beneficial in caring for homeless people with mental illness (e5, e19). Critical factors in care are strategies involving reach-out programs and a continuous active contact, as tailored and low-threshold support are especially important for this particularly at-risk group. An example of the use of such low-threshold support that involves visiting individuals is the „Mainz Model,“ which operates according to the principle, „if the patient doesn‘t come to the doctor, the doctor must go to the patient“ (e20). This approach can also be used to prevent homelessness: models in Mannheim and Freiburg have shown that early referral of individuals at risk of becoming homeless for specialized psychiatric treatment led to improved quality of life and social support (e21). The mortality and need for urgent care of homeless people is increased not only by mental illness, examined here, but also by somatic illness. Both comprise an important subject for research and care (11). Access to treatment is a particularly severe problem.
A recently published EU study of access to the support system for socially marginalized groups identified the following factors as particularly requiring improvements in care:
- Work visiting homeless people in communities
- Support aimed at preventing emergencies, in order to reduce the burden on acute hospital care
- Improvements in interfacing problems
- More intensive community relations (e22)
In this context, it seems particularly important to evaluate international experiences as bases for further work and to discuss care models and the extent to which they can be transferred to other settings.
We would like to express particular gratitude to Prof. Seena Fazel, University of Oxford, UK, for his support in performing the meta-analysis.
We would like to thank Gabriele Menzel of the Charité Library for her help in performing the systematic search of the literature.
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 27 March 2017, revised version accepted on
5 July 2017.
Translated from the original German by Caroline Shimakawa-Devitt, M.A.
Dr. med. Stefanie Schreiter
Department of Psychiatry and Psychotherapy
Charité – Universitätsmedizin Berlin
Charité Campus Mitte
10117 Berlin, Germany
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Psychiatric Clinic of the Ludwig-Maximilians-Universität München: Prof. Dr. med. Leucht
Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, University of Zürich: Prof. Dr. med. Rössler
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