The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.
The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.
Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.