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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part III-New Approaches: Innovations to Address Homelessness & Health

Chapter 11. An Examination of the Delivery of Psychiatric Services within a Shelter-Based Management of Alcohol Program for Homeless Adults

Susan Farrell, Beth Wood, Heather King-Andrews, Donna Lougheed, Wendy Muckle, Lynn Burnett et Jeffrey Turnbull

Texte intégral

Introduction

1Approximately one in five Canadians will have a dual disorder (mental illness and substance use disorder, commonly termed 'concurrent disorder' in Canada) in their lifetime (camh 2001). Yet there is a paucity of research on the delivery of, or measurement of the impact of, efficacious concurrent treatment (Drake et al. 1998; Mercier and Beaucage 1997; RachBeisel, Scott and Dixon 1999). Rates of concurrent disorders among the homeless population in Ottawa are estimated at 60 to 70 percent of the population (Farrell 2003; Farrell et al. 2000), in comparison to incidence estimates of 18 percent in the housed population (camh 2001). Persons with concurrent disorders are one of the fastest growing groups of the homeless population as the rates of substance use and the detection of mental illness are increasing (Barreira et al. 2000; Mayes and Handley 2005; Nuttbrock et al. 1998; Rosenblum et al. 2002). This population represents an extensive cost to the health care system due to their frequent need for acute health care and their demonstrated difficulty accessing and remaining attached to existing models of service delivery (Burnam et al. 1995; Tsemberis, Gulcur and Nakae 2004).

2Treatment programs for homeless persons with substance abuse problems have been found to be effective for those whose goal is abstaining from substance use (Hwang et al. 2005). However, it remains a challenge to work with persons who wish to address but not stop their substance use. Harm reduction is the focus of treatment used most often for those who do not wish to stop substance use (Baer, Peterson and Wells 2004). Harm reduction is an umbrella term for the variety of practices used to reduce the negative consequences of substance use and promote improved quality of life while incorporating a spectrum of strategies from safer use to managed use to abstinence (Harm Reduction Coalition 2003). Marlatt and Witkiewitz (2010) note that the primary goal of harm reduction is to minimize the harmful effects of behaviours related to substance use. These may include health risks, psychosocial risks or criminal involvement. As noted by Pauly and colleagues (2007), the adoption of a harm reduction philosophy has been primarily within street outreach, inner-city health care centres, needle exchange programs and, more recently, supervised injection sites. This chapter focuses on harm reduction within an emergency shelter, particularly on persons who have a concurrent disorder of alcohol dependence and mental illness.

3Harm reduction programs with a housing focus such as Housing First have been implemented to assist homeless individuals with psychiatric illness and substance abuse problems to attain a residence (Gulcur et al. 2003; Tsemberis, Gulcur and Nakae 2004; Tsemberis et al. 2003). Some housing programs had aids to sustain housing, such as substance abuse and/or mental health treatments (Bebout 1999; Blankertz and Cnaan 1994). Other harm reduction programs that have been developed and implemented for homeless individuals have been mental health and substance abuse treatments (Tsemberis et al. 2003).

4Despite literature on the key principles of harm reduction being pragmatism, humanistic values, focus on harms, balancing costs and benefits and hierarchy of goals (Riley et al. 1999), which should be agreed-upon principles within universal health care, harm reduction has been a controversial issue. Harm reduction has been described by its critics as promoting continued substance use (Buchanan et al. 2003). Advocates of harm reduction, by contrast, support it as a model for reducing the detrimental effects of substance abuse rather than promoting abstinence from substances (Davis et al. 2006; Pauly et al. 2007). Harm reduction strategies have been most prominent in initiatives for injection drug users (Wood et al. 2004), although the need for harm reduction strategies for persons with alcohol abuse has been recognized (Health Canada 2001). Interestingly, although there has been some initial opposition to harm reduction practices for alcohol use (Svoboda 2009), this has not been considered as controversial as harm reduction practices and programs for injection drug use (MacPhee 2006/2007; Wood et al. 2003), despite several studies showing evaluation results for safe injection sites including social and health-related improvements and no detrimental effects for users or the community. Although the reasons are not clearly known, a possible explanation for the decreased level of controversy for harm reduction for alcohol is that alcohol use is not illegal, unlike injection drug use. Similar evaluations of the effects of harm reduction for alcohol use programs are less common and none to date have focused on the partnership of harm reduction and psychiatric services to address concurrent disorders (Hass 2001; Podymow et al. 2006).

5Harm reduction for alcohol (or managed alcohol) programs for homeless persons exist within a few emergency shelters in Canadian cities. As noted by Svoboda (2009), a coroner's inquest into the death of three homeless men in Toronto who had uncontrolled heavy alcohol use and mental illness in 1996 led to jury recommendations for a 24-hour-in-shelter harm reduction program to be provided within an emergency shelter. Known as The Annex, and located within Toronto's largest homeless shelter (Seaton House), this managed alcohol program has been found to reduce emergency room and detoxification unit visits, as well as police interactions (Svobodoa 2010). What has not been investigated within the Canadian harm reduction literature is the impact on client characteristics of offering concurrent psychiatric treatment for concurrent disorders within a management of alcohol model program. This is the focus of the present chapter, which examines the Ottawa Inner City Health (oich) Managed Alcohol Program (map), in which individuals who are homeless with substance dependence reside within a shelter in a closed harm reduction program and receive concurrent psychiatric services.

Ottawa Inner City Health—Management of Alcohol Program (MAP)

6Ottawa Inner City was developed in 2001 as a unique model of providing health care to persons who are homeless with complex health needs (Podymow et al. 2006). One of the component programs of Ottawa Inner City Health is the Management of Alcohol Program (map), which is a 25-bed residential harm-reduction program located on a separated unit within an emergency shelter. The program is designed for persons who are homeless and have a long history of alcohol use and limited success with other attempts to control their drinking, plus frequent or prolonged experiences of homelessness, and who are identified as a frequent disruption in the community (as defined by frequent contact with police or disruption to local merchants or residents due to public intoxication). Clients reside in a designated floor of the emergency shelter that is staffed by client care workers and has a medical staff of physicians and nurses available for 24-hour care. Clients are served a regulated amount of wine during the day (one standard serving per hour, 13.6 grams of alcohol) in an attempt to both regulate their alcohol consumption (70% of clients reported daily or weekly binge drinking before admission to map) and as a harm reduction approach to decrease their consumption of non-beverage alcohol (e.g., mouthwash, aftershave, hair spray) (Hass 2001). Both substituting a less dangerous ingested substance and monitoring the intake of the substance contribute to minimizing personal harm and adverse social effects from substance use (Hass 2001). The first small sample outcome study of map ('before and after' design of 17 participants) found a significant decrease in the number of emergency room visits and encounters with police for clients after admission to the program (Podymow et al. 2006). However, the initial study did not account for whether map clients had been diagnosed with mental illness.

7Shortly after the inception of map, program staff recognized that many of the clients had symptoms of concurrent psychiatric illnesses (mainly psychotic and depressive disorders). At that point, psychiatric services (offered by an Advance Practice Nurse, Psychiatry, of the Psychiatric Outreach Team of the Royal Ottawa Health Care Group) were introduced into the program. The Psychiatric Outreach Team is a multidisciplinary team developed to provide specialized mental health services directly to individuals with serious mental illness and/or concurrent disorders who are homeless. The advance practice nurse (apn) role was designed to deliver psychiatric services (under the medical directives of the team psychiatrist) to provide assessment, pharmacological treatment and education to clients and staff about mental illness and concurrent disorders. This was the first known on-site delivery of psychiatric services within a residential management of alcohol program. This unique model of introducing psychiatric services to a management of alcohol program, therefore, requires further investigation and evaluation. Health Canada (2001) identified the need to understand best practices in concurrent disorders for vulnerable, underserved populations such as persons who were homeless, yet noted that this evaluation research was not available in Canada.

8The purpose of the present study was to examine the effects of delivering psychiatric services within a shelter-based management of alcohol program for homeless adults. Given this new area for investigation, outcomes for investigation were selected in consultation with an advisory committee that consisted of program staff, client representatives and community service providers. The effects of delivering concurrent psychiatric services in a map was examined by investigating the effects of program participation on changes over time in psychiatric symptoms, mental status, global functioning, aggression, quality of life and consumption of alcohol and alcohol substitutes for participants in the map.

9Directional hypotheses were assumed for each of the clinical outcomes over time. Specifically, it was hypothesized that: (1) Clients receiving psychiatric services during their residence in the map will have a decrease in the severity of their psychiatric symptoms (as measured by the Brief Psychiatric Rating Scale [bprs]); (2) Clients receiving psychiatric services during their residence in the map will have an increase in their cognitive functioning (as measured by the Mini Mental State Examination [mmse]); (3) Clients receiving psychiatric services during their residence in the map will have an increase in their mental health–related functioning (as measured by the Global Assessment of Functioning [gaf]); (4) Clients receiving psychiatric services during their residence in the map will have a decrease in the frequency of their aggressive behaviour (as measured by the Cohen-Mansfield Agitation Inventory [cmai]); (5) Clients receiving psychiatric services during their residence in the map will have an increase in both their subjective quality of life (client ratings of domains) and providers' perception of their quality of life (as rated by the Wisconsin Quality of Life Index, client and provider forms [w-qli]); (6) Clients receiving psychiatric services during their residence in the map will have a decrease in their consumption of alcohol and alcohol substitutes.

Methods

Participants

10All clients of the Ottawa Inner City Health's map were considered for the project. All participants in this study were already admitted to map when approached for their consent to participate in this study. For the duration of the study, all participants resided within the map in a specialized unit of a homeless shelter. As noted above, inclusion criteria for the study were based on acceptance to the map, in the absence of exclusion criteria, which included a diagnosis of dementia, acquired brain injury or previous head injury—due to the cognitive demands of the measure completion. Only two people were excluded based on these criteria. Four additional people did not consent to participate due to the range of information collected.

Procedure

11The project protocol was developed in collaboration with Ottawa Inner City Health staff and approved by the Royal Ottawa Health Care Group Research Ethics Board. Informed consent for participation was obtained by map staff approaching all clients upon admission with a prepared script describing the project. If interested, participants met with project staff to complete a consent form and discuss the project (to accommodate a range of literacy levels in clients) and then review a written consent form. Participants were informed that participation in the project had no effect on receiving full map services.

12Data collection occurred at admission and at six months following admission to map. map clients are admitted individually as this is not a structured group treatment program. Therefore, given the variation in intake date for each client, a follow-up calendar method was used to determine the required timing for each phase of data collection. All measures were completed within three to five days of the required interval and were always collected before noon to ensure consistency in clients' alcohol consumption at each interval.

13All data were collected by trained staff at admission and follow-up. In addition, an independent reviewer, who is a psychiatrist working with persons who are homeless and have concurrent disorder, saw each participant at both time intervals. The independent review consisted of a psychiatric interview, completion of a mental status exam and rating of global functioning (see Measures section). The independent reviewer conducted the evaluation session using the same procedure mentioned above within the premises of map.

Measures

14Brief Psychiatric Rating Scale-Expanded. The Brief Psychiatric Rating Scale-Expanded (bprs-e) was used (by trained raters) as a measure of psychiatric symptoms (Rhoades and Overall 1988). The bprs-e provides a seven-point Likert-scale rating of the severity of symptoms related to 14 diagnostic categories and 10 clusters of behavioural patterns. The bprs is the most commonly used measure of psychiatric symptoms in evaluation research of persons involved in community-based treatment programs and has been demonstrated to have sufficient sensitivity to detect symptom change within brief intervals in a treatment program. Past research has demonstrated estimates of inter-rater reliability ranging from r = 0.53 to 0.98 (Gabbard et al. 1987; Tarrell and Schultz 1988; Ventura et al. 1993).

15Mini mental state examination. The mini mental state examination (mmse) was used by the independent raters as an objective and short assessment of an individual's cognitive state. It is mostly used as a determinant of cognitive dysfunction at any time, as well as measuring changes in treatment effects (Folstein, Folstein and McHugh 1975; Psychological Assessment Resources 2005). There are two parts to the mmse: (1) assessment of attention, orientation and memory performed orally and (2) assessment of labelling, following orders, composing a sentence and duplicating a polygon. The mmse has also demonstrated strong inter-rater reliability (r = 0.83) as well test–retest reliability (r = 0.98) (Folstein, Folstein and McHugh 1975). In essence, adequate reliability and validity has been confirmed with the mmse among multiple populations with mental health concerns.

16Global assessment of functioning. From the rating scale provided in the dsm-iv-tr, a global assessment of functioning (gaf) score was provided by the independent rater at each time interval. The gaf score is a scale from 0 to 100 that rates an individual's overall psychological, social and occupational functioning and is used to track clinical progress of individuals in global terms (apa 2000). The gaf scale is divided into 10 ranges of functioning and each range has two components: symptom severity and functioning. A single score is derived for functioning in the current time period (a period of five days was used for the current project).

17Cohen-Mansfield Agitation Inventory. The Cohen-Mansfield Agitation Inventory (cmai) was used as a measure of aggressive behaviour and is completed by trained staff raters (Cohen-Mansfield, Marx and Rosenthal 1989). Decreases in aggressive behaviour (both physical and verbal) and related agitation symptoms are often related to improved mental health of clients (Koss et al. 1997). The cmai provides a rating of the severity and frequency of physical aggressive, physical non-aggressive, verbal aggressive and verbal non-aggressive behaviours. The measure is completed by staff who observed the client over the past week. Estimates of inter-rater reliability range from r = 0.88 to 0.92 (Cohen-Mansfield, Marx and Rosenthal 1989; Koss et al. 1997).

18Wisconsin Quality of Life Index, client. The Wisconsin Quality of Life Index (client form) was used as a measure of subjective and other ratings of quality of life (Becker, Diamond and Sainfort 1993). The client form was used (completed in interview format with trained staff raters) to provide ratings of subjective quality of life and satisfaction with physical and psychological health and social relations (Maspero 1998; Sainfort, Becker and Diamond 1996). The measure has been previously used in Canadian studies of quality of life for persons with serious and persistent mental illness (Diaz, Mercier and Caron 2000; Diaz et al. 1999; Diaz and Mercier 1996). The test–retest coefficient of this instrument was noted to be 0.82 and high criterion related validity coefficients were observed between the qli-mh and the Quality of Life Index (0.91), client ratings (0.68) and provider ratings (0.80) (Becker, Diamond and Sainfort 1993).

19Advanced practice nurse practitioner service inventory. This measure was created for the current study to record the frequency and type of activity provided in each contact by the Advance Practice Nurse (Psychiatry) with participants. The inventory included a record of dates and foci for initial and all subsequent intervention.

20Consumption record. The consumption record was created for the study and consists of a daily log of alcohol consumption for each client of the managed alcohol program, including both the type of alcohol consumed (i.e., beverage or non-beverage alcohol) and the location of consumption (i.e., inside or outside of the program). This record is already a part of the daily oichp daily record keeping protocol.

Results

Demographic Characteristics

21The final sample consisted of 80 participants in Time 1 and 63 in Time 2 over a six-month period. Demographic characteristics of the full sample are shown in Table 11-1. There were no significant differences found in demographic characteristics between those who did and did not complete both testing times. The reasons for non-completion were participant leaving the program by his/her own intention (n = 12), being discharged from the program (n = 3) for medical or behavioural issues or no longer wishing to participate in the study (n = 2). Those participants who completed both time intervals were included in the analysis of clinical outcome measures.

22As shown in Table 11-1, the sample was mostly male (88%) with a mean age of 49.73 years (range: 30–70 years). Three quarters of clients (75%) had not completed formal education beyond secondary school, almost all (97%) had past involvement with the legal system and 40 percent had current involvement. The details of legal system involvement were not available. The range of medical conditions reported in the past two years and currently is shown in Table 11-1. However, less than a quarter (24%) reported having been hospitalized or in an emergency department in the past 12 or 24 months. The most common mental health diagnosis among the sample was depression (71%) and 88 percent reported substance use other than alcohol (predominantly marijuana, crack and cocaine).

23Most participants had independent functioning in the areas of personal care, ambulation and communication. However, most (88%) required partial assistance (dispensing support) for daily medication adherence.

Advanced Practice Nurse Practitioner Service Inventory

24Review of the advance practice nurse practitioner service inventory suggests that the most frequently completed clinical activities of the apn were assessment (initial, 100%; monitoring, 95%), medication prescription and monitoring (80%), staff education (75%) and client education (65%). Assessment activities involved psychodiagnostic interviewing and symptom monitoring. Medication interventions were prescription and monitoring of medication effects and side effects. Staff education consisted of formal teaching and informal case discussion about concurrent disorders, the effects of mental illness on behaviour and information on medication interventions. Client education covered the same topics as staff education but was delivered in informal one-to-one sessions delivered in a manner corresponding to the client's cognitive abilities. As shown in the frequency distribution of activities, all clients were seen initially by the advance practice nurse and most remained in follow-up services. The number of interventions provided in the six-month time frame was M = 13 (range = 1–35).

Clinical Outcomes

25Comparison analyses of clinical outcome measures were conducted using parametric and non-parametric tests. Total scores were used for symptom rating scales (bprs-e, cmai, mmse and gaf) and domain scores were used for the quality of life measure, selected on the basis of clinical relevance.

26As shown in Table 11-2, to determine significant change in clinical outcomes over time, a paired-samples t-test was conducted for the cmai, bprs and mmse total scores and the gaf score. Results indicated that there was a significant change in the severity of psychiatric illness symptoms (as measured by the bprs), and in the frequency of aggression observed (as measured by the cmai) between Time 1 and Time 2. There was also a significant improvement reported in the assessed mental status of participants between Time 1 and Time 2, but not in ratings of their global assessment of functioning.

27Quality of life, as rated from the client and staff perspectives, was assessed for changes over time using non-parametric statistics. Statistically significant differences were found for the provider ratings of: (1) psychological health: x2 = 14.8, p < 0.01; (2) physical health: x2 = 6.97, p < 0.05; (3) quality of relations with family: x2 = 60.1, p < 0.001 and (4) quality of life (overall): x2 = 39.5, p < 0.001. Client ratings of perceived quality of life were significant for change over time for physical health: x2 = 23.3, p < 0.001.

Table 11-1. Demographic characteristics of study sample

Table 11-1. Demographic characteristics of study sample

Table 11-1. (Continued)

Table 11-1. (Continued)

28Related to substance use, review of the consumption record at Time 2 stated that there was no longer recorded ingestion of non-alcohol substances by participants. This is a clinically significant change in substance use patterns, but statistically significant change cannot be calculated because reliable estimates of ingestion could not be provided at Time 1 (admission to program), since they were solely based on participant recall. Alcohol consumption at Time 1 was not reliable because it was also based on participant recall. However, the amount of alcohol consumption remained constant between admission and Time 2 as it was regulated within the map protocol, and although it is decreased for some map clients, it was not for this sample.

Discussion

29The purpose of this study was to examine the effects of delivering psychiatric services within a shelter-based management of alcohol program for homeless adults. The effects of delivering concurrent psychiatric services was examined by investigating changes for map participants in their psychiatric symptoms, mental status, global functioning, aggression, quality of life and consumption of alcohol and alcohol substitutes. The hypotheses of the study were that clients of the map who were receiving concurrent psychiatric services would have a decrease in the severity of their psychiatric symptoms, an improvement in mental status, an increase in their mental health-related functioning and a decrease in the frequency of their aggressive behaviour. It was also hypothesized that clients would have an increase in both their own subjective quality of life (client ratings of domains) and in providers' perception of their quality of life, as well as a decrease in consumption of alcohol and alcohol substitutes.

Table 11-2. Changes in clinical outcomes

Time 1

Time 2

Significance
Test

Psychiatric Symptoms
(bprs)

51.29 (17.4)

48.71 (16.3)

t = 5.31*

Mental Status
(mmse)

22.8 (4.6)

25.1 (3.2)

t = 2.20*

Global Assessment of Functioning
(gaf)

36.95 (9.3)

37.29 (7.0)

NS

Aggression
(cmai)

65.71 (16.9)

55.1 (21.1)

t = 3.11*

*p < 0.05

30Results of the study demonstrated mixed support for the hypotheses. There was statistically significant improvement in severity of psychiatric symptoms, mental status and frequency of aggressive behaviour, but not in a global rating of mental health–related functioning.

31The lack of significant change in global functioning may be due to many of the elements of a gaf rating not being changed within participation in the map. The global assessment of functioning (gaf) provides a composite score based on psychological, social and occupational functioning, in addition to symptom severity (apa 2000). Since social and occupational functioning are outside the purview of the map, a composite score of functioning may not be sufficiently sensitive to detect change for map clients. Psychiatric interventions in the map focused on symptom identification, medication treatment and education. These interventions were expected to decrease symptoms, improve mental status (by reduction of interfering symptoms) and decrease behavioural disturbance, but not necessarily change global functioning in some clients. The regulation of alcohol consumption is also expected to have contributed to improved mental status and decreased behavioural disturbance.

32Findings of improved psychiatric symptomatology in this study are consistent with other studies that found a decrease in psychiatric symptoms for homeless individuals with a dual diagnosis (concurrent disorder) as a result of receiving treatment interventions to help them attain sobriety and build work-related and social skills (Drake, Yoveitch and Bebout 1997). Additionally, in another study that compared a Housing First and continuum of care group, it was found that psychiatric symptom improvement was associated with perceived choice and mediated by beliefs of empowerment that was associated with the Housing First model of service (Tsemberis et al. 2003; Tsemeris, Gulcur and Nakae 2004). As noted above, the differences in these approaches, with a focus on building additional skills or improved empowerment, may account for some differences in overall clinical functioning from those observed in the current study, in which clients reside in the shelter and are in earlier stages of engaging in vocational or other types of skill building.

33Changes to ratings of quality of life had mixed results. Service providers rated more positive changes in participants' lives with increases in psychological health, physical health, quality of relations with family and overall quality of life. Conversely, participants rated significant improvement in only their physical health. This may be explained by participants being able to first detect (and report) changes in their physical health, due to changes from the time of admission, when they may have been using non-alcohol substances, to the management of alcohol approach with pre-selected administration of alcohol and other health care needs addressed by map medical staff. Participants' ratings of psychological health, quality of relations with family and overall quality of life did improve over the time interval, but the change was not statistically significant. This may mean that although change had (or was starting to) occur, it was insufficient during the measured time interval to the perception of participants. This may explain the non-significant finding in client and provider ratings in other areas of quality of life such as occupational, social and domestic areas, as these areas may not have changed while in a shelter-based program. Drake, Yovetich and Bebout (1997) found increased ratings of quality of life in the areas of social contact and social relations for homeless clients with a dual diagnosis in an integrated treatment approach (psychiatric and substance use treatment) as compared to a standard treatment group. The focus of that approach, however, had more emphasis on quality of life and assessed participants over a longer time interval. This suggests that with the program being studied, ratings of change in domains of quality of life should be assessed over a longer time interval, such as following residential placement upon successful completion of the map. It may also suggest that domains of quality of life should become a focus of intervention or skill building within the program once participants' initial symptoms are stabilized.

34The incomplete findings related to a decrease in the consumption of alcohol and alcohol substitutes was due to the lack of reliable information at the time of admission to the program, although the reported decrease and ceasing of use of alcohol substitutes represented clinically significant change. Elongation of the length of the follow-up intervals would have allowed for improved examination of consumption patterns within the program.

35There are limitations in this study of the areas of participants' lives measured and the methods used. As noted, not all aspects of quality of life or functioning were addressed within the map. As for study methodology, the duration between time intervals of investigation in this study is a limitation of the study. Some variables under investigation may not have had sufficient time or been sufficiently a focus of service to have undergone significant change during the course of this study. With the finding that 85 percent of services delivered focused on pharmacological treatment, change measured in psychiatric symptoms, aggressive behaviour and mental status may have been detected because of the high number of participants receiving pharmacological and behavioural interventions targeted to these issues. Since all persons in the map were considered for this study, there is the limitation of having no control group against which to compare the clinical outcomes attained by this group. Insufficient detection of change may also be due to the shortened time intervals between ratings, the lack of focus on the domain during intervention or the heightened acuity of initial symptoms, such that the time frame was not sufficient to detect clinically observable change.

36Client attrition from the final sample also limits sample size and the scope of the investigation. For this sample, clinical outcomes were measured for all clients receiving psychiatric services, but due to sample size constraints, the relationship between service intensity and clinical outcomes was not assessed. In a larger sample it would be of value to investigate difference between clients receiving different levels of service intensity and focus. This study also examined clinical outcomes only while clients resided in a shelter-based program. A longer longitudinal measure of their outcomes achieved, or maintained, upon program discharge and transition into housing would be valuable.

37Findings of this study indicate that the introduction of psychiatric services, focused on assessment, pharmacological intervention and education and education to staff and clients can be an important addition to a management of alcohol program, delivered in a concurrent model of service delivery. The extent to which the influence of the characteristics of these clients (their mental health diagnoses, levels of aggressive behaviour, mental status) on the outcomes are not known, but this study suggests that a concurrent model of service delivery (of psychiatric and harm reduction services) for underserved homeless clients, such as these who would not otherwise access traditional models of treatment, should be considered for effective service delivery. The model of management of alcohol within a shelter for homeless persons should also continue to be replicated as a responsive and appropriate service model for persons with substance dependence. It is within this model that concurrent psychiatric services are also well applied to deliver concurrent disorder services for this underserved population. This model of concurrent service delivery should also be replicated for other shelter-based populations to address their mental health issues, substance use and quality of life. The philosophies of many service agencies may present challenges to the further development of concurrent service delivery (since many require abstinence from substances); a broader understanding of need for introducing harm reduction principles while delivering psychiatric services is required. In addition, the use of the concurrent service delivery model that offers harm reduction for other substances should be considered to provide innovative service delivery for the growing rates of concurrent disorder in the homeless population.

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Table des illustrations

Titre Table 11-1. Demographic characteristics of study sample
URL http://books.openedition.org/uop/docannexe/image/809/img-1.jpg
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Titre Table 11-1. (Continued)
URL http://books.openedition.org/uop/docannexe/image/809/img-2.jpg
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Auteurs

Clinical psychologist and the Clinical Director of the Community Mental Health Program of the Royal Ottawa Health Care Group. She provides psychological assessment and consultation services to persons who are homeless and supervises graduate students in this area of research and clinical practice

Works on the Psychiatric Outreach Team of the Community Mental Health Program at the Royal Ottawa Mental Health Centre. She provides assessment, diagnosis and treatment to concurrently disordered clients who are homeless One of the agencies she works with is Ottawa Inner City Health

PhD candidate in the population health program with the Institute of Population Health at the University of Ottawa. Her current research interests consist of the epidemiological, psychological and social determinants of opposition defiance in very young children

Assistant Professor in psychiatry at the University of Ottawa and a former family physician. She has worked in a clinical capacity for over 10 years with homeless and marginally housed adults with mental illness and substance use problems through the Royal Ottawa Health Care Group and has developed an 'underserved populations' clinical rotation for psychiatric residents

Has been the Executive Director of Ottawa Inner City Health since its beginning in February 2001. Her areas of interest are poverty and health, homelessness, hiv/aids, harm reduction and medical education

Care Coordinator at Ottawa Inner City Health. She provides comprehensive care to the homeless population with addictions and health challenges with a particular focus on women's health. She preceptors medical and nursing students and educates frontline staff in the shelters

Co-founder and Medical Director of Ottawa Inner City Health. Dr. Turnbull is currently Chief of Staff at the Ottawa Hospital and past President of the Canadian Medical Association. He is a dedicated medical educator with an interest in poverty and health inequity

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