The Impact of Gender on the Relationship
Between Mental Health and Homelessness
Brieanna Ngui
Macaulay Honors College
Seminar III
Science and Technology in New York
Professor Oppenheimer
Abstract
Although the United States is one of the world’s leading political and economic powers, we have yet to evade problems that plague even the poorest of countries. Homelessness is pervasive throughout the country. It is especially prevalent in areas of highly concentrated populations, such as our leading cities. In the hopes of creating policies to prevent homelessness or to create programs to help our country’s homeless population get back on their feet, we must examine the trends and circumstances that created such a pervasive homeless population.
In thus examining these trends and circumstances, several clear trends emerge. One of them being that a high percentage of the homeless population also presents symptoms of mental illness. In one study, this percentage is as high as one third of the homeless population was presenting symptoms of mental illness.
This paper will examine the correlation between homelessness and mental health while also taking into account issues of gender. Because homelessness and mental health is such an immense topic, and also due to the fact that this semester’s seminar was focused on public health in New York City, this paper will focus on statistics and studies based on the homeless population in New York City as a sample population for the homeless in our country. Claims will be supported by articles, academic journals and statistics
The Impact of Gender on the Relationship Between Mental Health and Homelessness
“What we have found in this country, and maybe we’re more aware of it now, is the one problem we’ve always had, even in the best of times, and that is the people who are sleeping on the grates, the homeless, you might say, by choice.” -Ronald Reagan
In Ronald Reagan’s quote, excerpted from an interview with David Hartman on ABC News in regard to the 1984 Presidential Election, he clearly addresses homelessness as a problem that we have always had from the worst of times to “the best of times”. Furthermore, Reagan also expresses that one of the only differences is that we are “more aware of it now.”
Although the United States is one of the world’s leading political and economic powers, we clearly have yet to evade problems that plague even the poorest of countries. Homelessness is pervasive throughout our country. It has become especially prevalent in areas of highly concentrated populations, such as our leading cities. However, in order to address this immense issue of homelessness, including both preventing homelessness in the first place and creating programs to help our homeless get back on their feet, we must first ask several questions. The first of them being whom exactly does the homeless population consist of? How does this breakdown demographically? And more specifically to my paper, what impact does mental health have on our homeless population? And finally, what role does gender play in our homeless population, and even more precisely in our homeless population afflicted with mental health issues?
In examining the homeless population as a whole, the first conclusion that we must come to is that homelessness does not discriminate. According to the US Census Bureau, the current resident population of the United States is 314,988,740. Out of this resident population, there an estimated 643,067 homeless individuals on any given night in the United States, according to an article from U.S. News based on the report, “State of Homeless in America 2012” that was originally issued by the National Alliance to End Homelessness. In New York City alone, there were a total of 48, 694 homeless individuals living in shelters, this number does not even account for the homeless individuals in the streets unable or unwilling to seek a shelter.
While a 0.2% homeless population may not seem that problematic, percentage wise, it averages out to about 21 individuals in every 10,000 that live on the streets on a daily basis. These 21 individuals out of every 10,000 could really be anybody. They include men, women, and children, sometimes even entire families. Furthermore, they include the mentally ill, the physically disable, veterans, victims of HIV/AIDS and victims of domestic violence. In these statistics provided by the 2006 US Conference of Mayors as made available by the National Coalition for the Homeless, it is also evident that not a single race or ethnicity was immune from the possibility of becoming homeless.
Within these demographics one of the most concerning statistics is the discrepancy between the male and female homeless population. As reported in the 2010 Annual Homeless Assessment Report to Congress, there are very stark gender differences in the sheltered homeless population. It is reported that 68% percent of homeless individuals who reside in homeless shelters are male as opposed to the 32% of females who reside in these shelters. These discrepancies become even more apparent when you compare the male to female gender ratios of the unsheltered homeless population. In 2003, the NYC Department of Homeless Services conducted a survey with the objective of obtaining a “point in time estimate of the unsheltered homeless population in Manhattan.” (Homeless Outreach Population Survey 2003. NYC Department of Homeless Services) According to their collected data, approximately 90.6% of unsheltered homeless individuals who were living in the subway system were male, while only 8% were female, leaving the remaining 1.4% as unreported or unidentifiable. Similarly, among the unsheltered homeless individuals who were living on the streets, or other public places excluding the subway, roughly 80.5% of the homeless individuals were male as opposed to only 14% whom were the unsheltered homeless females. With such marked and pronounced differences between male and female homeless ratios, other factors have to be examined in order to come up with reasons for not only these discrepancies, but also homelessness itself.
Based on the demographic breakdown provided by the 2006 US Conference of Mayors, “an average of 26% of homeless people are considered mentally ill.” (How Many People Experience Homelessness? National Coalition for the Homeless, July 2009) Worse so, according to the 2005 US Conference of Mayors, “approximately 16% of the single adult homeless population suffers from some form severe and persistent mental illness.” In another study that comes from the article, Homelessness: Programs and the People They Serve from the Urban Institute of Washington D.C., the statistics are even more dismaying. It states that the homeless population experiences mental health conditions at a prevalence rate of about 30%. Even more shocking is the approximated 26.2% rate of all the sheltered homeless that have a severe mental illness, according to the same study. Homelessness: Programs and the People They Serve further elaborates on the pervasive prevalence rates by stating that over 60% of those who are chronically homeless have or will experience mental health problems.
But what exactly do these mental illnesses consist of? According to the DSM-IV-TR (Diagnostic and Statistical Manual; 4th Edition, text revision) mental illness includes include less commonly diagnosed disorders such as schizophrenia, somatoform disorders and personality disorders. This umbrella term of mental illness opens to include common diagnoses such as anxiety disorders, mood disorders, eating disorders and even sleeping disorders. Even more surprisingly, substance-related disorders such as alcohol, nicotine and other drug addictions also fall under the category of mental illness. However, if one were to account for every homeless individual that has fallen to an addiction such as drinking or smoking these statistics would be extremely skewed. For these purposes, “severe and persistent mental illness” often includes diagnosis such as schizophrenia and major depressive disorder, while “mental illness” continues to include the majority of the mental disorders with the exclusion of common substance abuse.
In fact it was the prevalence of these mental illnesses that were explored in a research article published in PLOS: Medicine, an online medical journal. “The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis” written by Seena Fazel, Vivek Khosla, Helen Doll, and John Geedes is described as a secondary analysis where they searched “for surveys of the prevalence of major depression, psychotic illness, alcohol and drug dependence, and personality disorder that were based on [actual] interviews…[with] samples of… homeless people.” Not surprisingly they found that the most common mental disorders were alcohol dependence and drug dependence. However, they also found high prevalence in disorders such as major depressive disorder and psychotic illnesses.
For example, their research was able to identify 19 different surveys that reported major depression as a diagnosis in some homeless subjects in order to come up with a prevalence rate of 11%. While this prevalence rate among homeless individuals is less than the lifetime prevalence rate of 17% among the general population, it is almost double the 6.5% prevalence rate among adults in 2008. The lifetime prevalence rate simply means that 17% of all adults will experience depression at some point in their lifetime. However, the average prevalence rate is the rate of people with the disorder at that time. Since homeless subjects had an average prevalence rate of 11% that means at least one in ten homeless individuals can be diagnosed with major depressive disorder at any given time.
Major depressive disorder can be a highly debilitating disorder as it not only has cognitive and mood effects, but it often comes with both behavioral changes and physical symptoms. It is always characterized by either a persistent sad mood or a loss of interest in activities that one once found enjoyable. In addition, it is usually accompanied by changes in appetite resulting in weight loss or weight gain and drastic changes in sleep patterns. Other physical trademark symptoms involve psychomotor retardation or agitation, difficulty concentrating, and fatigue or loss of energy. Since major depressive disorder can have both internal and external factors and stressors in its onset, it is often a disorder that an individual can feel like they can handle on their own. However, the physical symptoms that accompany depression can have a definite impact on one’s life and without professional treatment and in some cases medication it can get progressively worse.
Similar to the homelessness epidemic, there are very noticeable discrepancies in the demographics of the population of those affected with depression. However, these discrepancies are not related to ethnicity, education, income or marital status. Like homelessness, the discrepancies are most apparent in the gender ratio. However, unlike homelessness rates of depression are two times higher in women than in men as compared to that almost exact opposite statistics for homelessness.
Many researchers have tried to theorize why women seem to experience higher rates of depression when compared to men. In a research article “Why Women Are More Susceptible to Depression: An Explanation for Gender Differences” written by Christina M. Mule from Rochester Institute of Technology, Mule focuses on “biological differences (hormones), age prevalence of depression differences, sex/gender role identity differences, depression rate and recurrence differences, and comorbidity differences” as possible explanations. Mule also goes on to claim that the “sex/gender role identity differences” explanation is probably the most likely option in explaining why women are more susceptible to depression.
The sex/gender role identity theory is based largely in typical gender stereotypes and expectations. “… Women are usually socialized to be emotionally expressive, nurturing, and to direct their achievement through affiliation with others, men are usually socialized to be emotionally inhibited, assertive, and independent” (Kimberling & Ouimette, 2002) Furthermore, the stereotypes regarding men and women’s roles in relationships and in the households have not changed as much as we would like to think so. Even if working a full time job and committing as many hours a week to their career as men, most women still face the expectation to raise the children (if any) and keep the house. These expectations not only come from external sources but from within. As Mule points out, “women who are employed [often] feel dissatisfaction with the amount of time they are allotted for their children and spouse.” On the other hand, women who do not work, or have many experiences outside of their life as a wife and/or mother, can often be left “feeling as if they were servant to their husbands, [and] not companions.” (Why Women Are More Susceptible to Depression: An Explanation for Gender Differences. Mule 2004) As a result, women are not only dissatisfied with their roles and responsibilities, but they are often dissatisfied in their accomplishments if they believe they have not adequately divided their time among all of their responsibilities including their family and their work. This internal dissatisfaction along with the external stressors would definitely be enough to lead to the onset of major depressive disorder in many women.
Aside from the fact that women tend to experience different types of stressors than men may do which may contribute to the difference in susceptibility to depression. There are also studies that show that men may experience depression differently and as a result respond in various ways. According to the National Institute of Mental Health, men are more likely to feel symptoms of irritability and fatigue along with difficulties in sleeping than women typically do. NIMH also mentions that, “ many men do not recognize, acknowledge, or seek help for their depression.” It’s usually speculated that this is because “they may be reluctant to talk about how they are feeling.” The National Alliance on Mental Illness also notes that in addition “men may feel more shame about their depression, and ‘try to tough it out.’” Furthermore, men are more likely to “tend to assume full responsibility for their grief and suppress emotions that they think can be taken as a sign of weakness. Studies have shown that this suppression can… lead to complications such as escalating anger, aggressiveness and substance abuse.” In turn, the common reaction of many men in experiencing symptoms of depression include denial and suppression, these reactions not only do nothing to improve the symptoms of depression, but also can worsen the situation.
Another mental illness that the research article published in PLOS: Medicine explored was psychotic illnesses and their prevalence rates in the homeless community. As previously mentioned, “The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Analysis” as published in PLOS: Medical, was a research article based on secondary research of first hand surveys and interviews with homeless individuals to determine average prevalence rates. This study found a total of 28 surveys that included homeless individuals with psychotic symptoms and illnesses. They found an average prevalence rate of 12.7% among these homeless individuals. The article “Lifetime Prevalence of Psychotic and Bipolar I Disorders in a General Population” which appears in the JAMA Network for Medical Journals, aimed to “provide reliable estimates of the lifetime prevalence of specific psychotic disorders.” Their results concluded that the lifetime prevalence of all psychotic disorders was 3.06%, which less than ¼ of the average prevalence rates among the homeless.
Of all the mental disorders, psychotic disorders are particularly debilitating because they can significantly hinder a person’s ability to function. As evident from the name of these category of disorders, the main hallmark for these “disorders is psychosis, or delusions and hallucinations.” (All Psych Online. Psychiatric Disorders) Delusions are false beliefs such as they belief that people are trying to hurt you when there is no evidence of such. In contrast, hallucinations are perceptual distortions that occur when the senses start sensing things that aren’t really there.
One of the most common psychotic disorders is schizophrenia. While there was no data available as to how many of the psychotic homeless population have schizophrenia as opposed to other psychotic diseases, the average lifetime prevalence rate for the general population is 0.87%. While such a small percentage may seem insignificant, 0.87% is almost a third of the prevalence rate for the lifetime prevalence rate of all psychotic disorders. This means that on average, out of 100 people (not necessarily homeless) 3 people may be diagnosed with a psychotic disorder. Out of that three, one of them most likely has schizophrenia. While the other two may have any of the remaining psychotic disorders such as, brief psychotic disorder, delusional disorder, schizoaffective disorder, schizophreniform, and shared psychotic disorder.
Schizophrenia is a neurological disorder in which the individual experiences declining function, and which prior to the declining function, they were completely normal. As the schizophrenic individual declines in function, they enter an “active phase.” With medical treatment or sometimes with just the passing of time, the individual comes “up” from their active phase, unfortunately they are never able to reach the level of functioning that they were operating at prior to the onset of schizophrenia. We now understand that schizophrenia is a biological illness with a severe imbalance in neurotransmitters. In fact, it’s a highly genetic disorder that features actual structural brain differences in those who are pre-disposed to schizophrenia along with structural brain changes that occur as an individual declines into the “active phase.”
Schizophrenia itself is broken down into sub-types of the disorder. It is based on their symptoms in the active phase in which the individual is diagnosed as having either Type I schizophrenia or Type II schizophrenia. In the diagnostic criteria, a person must have at least two of the following five symptoms: hallucinations, delusions, disorganized speech, disorganized behavior, flat affect or any other negative symptoms of the like. Type I schizophrenia is often known as the disorganized type of schizophrenia. It is characterized by the more frequent expression of symptoms such as flat affect and disorganized speech/ behavior. It is also interesting to note that you can see much more structural abnormalities in the brains of those with Type I schizophrenia. In contrast, Type II schizophrenia is usually referred to as the paranoid type schizophrenia. It is usually based more in the symptoms of delusions. And while there are some brain abnormalities, it is clear that an extremely severe imbalance of neurotransmitters (specifically dopamine) is one the causes since it tends to respond better to medication.
Like most other mental illnesses, schizophrenia can also manifest itself differently depending on the individual especially when it comes to factors such as gender. According to Ohio State University’s Wexner Medical Center, schizophrenia affects both men and women equally. However, schizophrenic symptoms tend to manifest themselves earlier in life than they do in women. “In most cases, schizophrenia appears in men during their late teens or early 20s. In women, schizophrenia often first appears during their 20s or early 30s.” In a recent study by the Central Institute of Mental Health in Germany, the researchers attributed “the delayed onset of schizophrenia in women to be protective effects of estrogen, one of the main hormones responsible for secondary sex characteristics…in women. Several studies have demonstrated experimentally that estrogen has an antipsychotic effect.” Furthermore, because women have higher levels of estrogen than men do, it may seem to not only delay the onset of schizophrenia but also decrease the severity of the symptoms. Unfortunately, there is also evidence of a spike in the onset of schizophrenia in women usually between 45 and 50. In accordance to the estrogen theory, this would be attributed to the decreased estrogen levels. As a result, a woman who may have been predisposed to schizophrenia and did not experience an onset of the disease during her 20s may manifest the symptoms after menopause, that were only delayed by the levels of estrogen.
The average age on onset is not the only difference that occurs between genders. Males are more often diagnosed with Type I schizophrenia, while women tend to be diagnosed with type II schizophrenia. One psychiatrist in particular, Godfrey Pearlson focused on these differences. Since more women tend to be diagnosed with type II schizophrenia, they often experience more archetypal symptoms of schizophrenia such as delusions. In an article by Pearlson published by John Hopkins Medical School in 2000, Pearlson goes on to say that, “those symptoms [of hallucinations and delusions] are often easier to treat than the broader, subtler deficits [such as those that accompany type I schizophrenia]. As a result, women schizophrenics are more likely to marry, [to] hold a job and live relatively normal lives [after they come out of their active phase]. But schizophrenic men often have symptoms that persist, and they tend to have more personal troubles such as being unemployed or homeless.”
It is evident that men and women have very similar prevalence rates when it comes to most mental illnesses. However, as the data has shown men represent almost two thirds of the entire population of homeless individuals. What can account for this huge discrepancy?
Because of societal norms and constraints it is often considered unusual for men to seek out psychiatric treatment when they are experiencing symptoms of mental illness. Even more so, it is often considered abnormal when men express emotions and feelings such as depression and other negative affects. In contrast, it is not considered unusual for a woman to seek psychiatric or even professional advice regarding emotional or mental health issues. It could be this very reason that could lead to such a discrepancy in the homeless population especially in regards to those with mental health problems.
If a woman is experiencing mental health issues, it is highly likely that she will seek professional advice and in turn receive treatment. Therefore it extremely unlikely that her mental health issues will become so severe as to intervene with her everyday life and lead her into a situation in which she may become homeless as result, such as losing her job from severe depression.
Unfortunately this is not the same for men. If a man is experiencing mental health issues, he is more likely to try and deal with those issues on his own, as oppose to seeking out and receiving professional health. In fact even those who may seek out professional care, may not get the diagnosis they deserve. According to the Men and Depression Fact Sheet provided by the National Alliance on Mental Illness, “male depression may not be as widely recognized as female depression.” Concurrently, for a lot of mental health issues, the lack of professional advice and treatment will only lead to an increase in the severity if the symptoms. As symptoms possibly become more severe, the chances of an individual finding him or her self in a situation that may lead to homelessness increases substantially.
However understanding the differences in mental health that can lead to homelessness is not enough to combat homelessness. One thing that can contribute to helping the situation in a bigger sense; would be more awareness of mental health issues, especially in terms of mental illness and men. If stigmas regarding mental illness and men didn’t exist, it would increase the amount of men who sought out professional help. Also for those individuals that are diagnosed with severe forms of psychotic illness, a better support system for helping them manage their illness needs to be created. Those with families should be made aware the imperativeness of possibly staying with their family so others can monitor their mental state.
However, when it comes to the mentally ill who are already homeless, measures need to be taken so that they are taken off the streets and placed in long-term shelters. While, the government’s current fiscal budget may not allow for this, ideally there should be a task force designated to bringing in homeless individuals off the streets. There should also be a system for allowing people to “call in” homeless individuals they notice acting erratically or mentally unstable. The task force should pay special attention to making sure that those who may be identified as mentally ill are also brought in so they may receive treatment of some sort. Once they are in long-term shelters, managers of these facilities need to make sure that they have access to psychiatric help.
References
“APA Diagnostic Classification DSM-IV-TR.” Behave-Net. N.p., 2000. Web. 28 September. 2012. <http://behavenet.com/apa-diagnostic-classification-dsm-iv-tr>.
“Basic Facts About Homelessness:Â New York City Data and Charts.” Basic Facts About Homelessness:Â New York City Data and Charts. NYC Department of Homeless Services, Oct. 2012. Web. 28 October. 2012. <http://www.coalitionforthehomeless.org/pages/basic-facts-about-homelessness-new-york-city-data-and-charts>.
Canuso, CM, and G. Pandina. “Gender and Schizophrenia.” National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 28 October. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/18227787>.
“Current Statistics on the Prevalence and Characteristics of People Experiencing Homelessness in the United States.” SAMHSA. Substance Abuse and Mental Health Services Administration, July 2011. Web. 28 Dec. 2012. <http://www.nrchmi.samhsa.gov/ResourceFiles/hrc_factsheet.pdf>.
Eng, James. “Homeless Numbers Down, but Risks Rise.” U.S. News. NBC News, 18 Jan. 2012. Web. 28 September. 2012. <http://usnews.nbcnews.com/_news/2012/01/18/10177017-homeless-numbers-down-but-risks-rise?lite>.
Fazel, Seena, Vivek Khosla, Helen Doll, and John Geddes. “The Prevalence of Mental Disorders among the Homeless in Western Countries: Systematic Review and Meta-Regression Analysis.” PLOS Medicine. Ed. John McGrath. University of Queensland, 2 Dec. 2008. Web. 28 October. 2012. <http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0050225>.
Hafner, H. “Gender differences in schizophrenia“. Psychoneuroendocrinology. vol 28 pp. 17-54 (2003) www.sciencedirect.com
Hartman, David, and Ronald Raegan. “Interview With David Hartman of ABC News on the 1984 Presidential Election.” Interview With David Hartman of ABC News on the 1984 Presidential Election. University of Texas, n.d. Web. 1 Decmber. 2012. <http://www.reagan.utexas.edu/archives/speeches/1984/13084c.htm>.
“Homeless Outreach Population Survey Results.” NYC Department of Homeless Services. NYC Department of Homeless Services, 27 Mar. 2003. Web. 28 November. 2012. <http://www.nyc.gov/html/dhs/downloads/pdf/hopsresults.pdf>.
“How Many People Experience Homelessness?” National Coalition for the Homeless. National Coalition for the Homeless, July 2009. Web. 28 October. 2012.
“Hunger and Homelessness Survey.” US Mayors. The United States Conference of Mayors, Dec. 2008. Web. 28 October. 2012. <http://usmayors.org/pressreleases/documents/hungerhomelessnessreport_121208.pdf>.
Lloyd, Kami. “HOMELESSNESS AND MENTAL HEALTH.” HOMELESSNESS AND MENTAL HEALTH. CAL Psych, 28 Mar. 2003. Web. 28 September. 2012.
“Major Depressive Disorder Among Adults.” NIMH RSS. National Institute of Mental Health, 2008. Web. 28 November. 2012. <http://www.nimh.nih.gov/statistics/1mdd_adult.shtml>.
“Men and Depression- Fact Sheet.” National Alliance on Mental Illness. Ed. Ken Duckworth, MD. N.p., Oct. 2009. Web. 28 September. 2012. <http://www.nami.org/Template.cfm?Section=Depression>.
“Men and Depression.” NIMH RSS. US Department of Health and Human Services, n.d. Web. 28 September. 2012. <http://www.nimh.nih.gov/health/publications/men-and-depression/complete-index.shtml>.
“Mental Illness and Homelessness.” National Coalition for the Homeless. National Coalition for the Homeless, July 2009. Web. 28 September. 2012.
Mule, Christina M. “Why Women Are More Susceptible to Depression: An Explanation for Gender Differences.” Why Women Are More Susceptible to Depression. Rochester Institute of Technology, Mar. 2004. Web. 28 November. 2012. <http://www.personalityresearch.org/papers/mule.html>.
Opler, LA, L. White, CL Caton, B. Dominguez, S. Hirshfield, and PE Shrout. “Gender Differences in the Relationship of Homelessness to Symptom Severity, Substance Abuse, and Neuroleptic Noncompliance in Schizophrenia.” National Center for Biotechnology Information. U.S. National Library of Medicine, July 2001. Web. 10 September. 2012.
Peralala, Jonna, MD. “Lifetime Prevalence of Psychotic and Bipolar I Disorders in the General Population.” Archives of General Psychiatry. American Medical Association, Jan. 2007. Web. 28 September. 2012. <http://archpsyc.jamanetwork.com/article.aspx?articleid=209973>.
“Psychotic Disorders.” ALLPSYCH Online. N.p., 29 Nov. 2011. Web. 12 November. 2012. <http://allpsych.com/disorders/psychotic/index.html>.
Ramsay, Rosalind, Sarah Welch, and Elizabeth Youard. “Needs of Women Patients with Mental Illness.” Advances Is Psychiatric Treatment. The Royal College of Psychiatrists, 2001. Web. 14 September. 2012. <http://apt.rcpsych.org/content/7/2/85.full>.
“Schizophrenia.” Schizophrenia. Ohio State University; Wexner Medical Center, n.d. Web. 11 October. 2012. <http://medicalcenter.osu.edu/patientcare/healthcare_services/mental_health/mental_health_about/schizophrenia/Pages/index.aspx>.
“U.S. POPClock Projection.” US & World Population Clock. US Census Bureau, n.d. Web. 28 September. 2012. <http://www.census.gov/population/www/popclockus.html>.
“Who Is Homeless?” National Coalition for the Homeless. National Coalition for the Homeless, July 2009. Web. 10 September. 2012.
“Why Are People Homeless?” National Coalition for the Homeless. National Coalition for the Homeless, July 2009. Web. 10 September 2012.
“Why Schizophrenia Hits Men Harder.” Schizophrenia and Men and Women. John Hopkins Medical School, 2000. Web. 28 September. 2012. <http://www.schizophrenia.com/research/szmen2000.htm>.
