Experts offer insight on mental health hospitalization for those facing homelessness

Key takeaways:

• New York City has implemented a policy for hospitalizing people facing homelessness for severe mental illness.
• Experts provide criticism and alternative evidence-based solutions.

On Nov. 29, 2022, New York City Mayor Eric Adams announced a directive clarifying that authorities can bring people experiencing homelessness and severe mental illness to a hospital for care, according to a city press release.

The directive specifies that the threshold for involuntary admission for care is “when their mental illness prevents them from meeting their own basic needs,” rather than an “‘overt act’ demonstrating that the person is violent, suicidal or engaging in outrageously dangerous behavior likely to result in imminent harm,” according to the release.

Other parts of the directive outline requirements for hospitals and clinicians in admitting and discharging psychiatric patients; increases in the number of psychiatric inpatient beds; creation of a tele-consultation line between on-duty police officers and clinicians; and provision of comprehensive training to clinicians, first responders and outreach workers.

However, mental health experts dispute how effective this plan will be.

“Contemporary thinking emphasizes mental health crisis teams instead of expanding the duties of police, and mental health crisis facilities instead of additional inpatient units in psychiatric centers,” Michael F. Hogan, PhD, an adjunct professor of psychiatry at Case Western Reserve University School of Medicine in Cleveland, wrote in a recent JAMA Psychiatry Viewpoint. “Developing this array of services, already in place in Arizona and other locations, would be a preferable strategy.”

In the viewpoint, Hogan acknowledges that while people with acute mental illness may benefit from inpatient treatment, involuntary inpatient treatment may be traumatic and intrusive.

“We cannot prejudge whether proposed efforts in New York will be operated with kindness or force,” Hogan wrote. “But we must acknowledge that the history of police encounters with people with mental illness offers little solace.”

In a separate JAMA Psychiatry Viewpoint, Nick Kerman, PhD, a project scientist at the Centre for Addiction and Mental Health in Toronto, and colleagues wrote that the policies being implemented “will magnify treatment inequities and human rights violations rather than address them.

“Many people with mental illness experiencing homelessness already have tenuous relationships and engagement with mental health services due to experiences of stigma and discrimination when accessing supports,” they wrote. “We believe that coercive involuntary hospitalization in the absence of imminent risk will further erode this population’s self-determination in seeking health care and service engagement and heightens power imbalances between people experiencing homelessness and service providers, including first responders.”

To provide appropriate support for people with severe mental illness who are experiencing homelessness, Hogan and Kerman and colleagues emphasized the importance of implementing solutions that focus on stable housing options.

“The approach is logical; how can anyone with a serious illness let alone a serious psychiatric disorder possibly thrive and participate in treatment if they are homeless?” Hogan wrote. “The evidence suggests that a commitment to secure, safe and affordable housing for anyone hospitalized under the plan is essential — whether in existing housing or if needed through the development of new units.”

Kerman and colleagues specifically suggested investing in and expanding programs such as Housing First, “which provides a rent supplement with ongoing intensive supports, [and] is effective at stably housing most people with serious mental illness experiencing chronic homelessness.”

In sum, the viewpoints convey the message that the New York City policy is “well-intended but incomplete,” according to Hogan, and that ensuring access to stable housing and continuous mental health care are integral to improving the lives of people with serious mental illness who are experiencing homelessness.

References:

• Hogan MF. JAMA Psychiatry. 2023;doi:10.1001/jamapsychiatry.2023.0038.
• Kerman N, et al. JAMA Psychiatry. 2023;doi:10.1001/jamapsychiatry.2023.0537.
• Mayor Adams announces plan to provide care for individuals suffering from untreated severe mental illness across NYC. https://www.nyc.gov/office-of-the-mayor/news/870-22/mayor-adams-plan-provide-care-individuals-suffering-untreated-severe-mental#/0. Published Nov. 29, 2022. Accessed April 21, 2023.