Intended for healthcare professionals

Clinical Review

ABC of mental health: Mental health on the margins

BMJ 1997; 315 doi: (Published 30 August 1997) Cite this as: BMJ 1997;315:536
  1. Philip Timms,
  2. John Balázs

    Mental illness and homelessness

    People with mental illness have always been marginalised and economically disadvantaged, and deprived inner city areas have excessive rates of severe mental illness. Homelessness is the most marginalised end of the spectrum of poverty, and here are found disproportionate numbers of mentally ill people.

    Pathways to homelessness

    • Unemployment

    • Problem drinking among middle aged men

    • Drug misuse among teenagers

    • Lack of low rent housing

    • Marital break up

    • Clashes with family or friends

    • Leaving local authority care

    • Leaving the armed forces

    • Leaving prison

    • Episode of mental illness

    • Children of homeless families

    Very few people choose to have no home

    Homeless people do not constitute a homogenous population: disparate groups have widely differing needs. The mental health needs of people living in “traditional” homeless lifestyles have elicited particular concern. We focus on the situation in Britain, but similar problems exist in most Western industrialised nations.

    Spectrum of housing needs

    • People living in existing households in very unsatisfactory conditions

    • Households sharing accommodation involuntarily

    • Imminent release from institutional accommodation (prison, local authority)

    • Insecure tenure (holiday letting, tied accommodation, mortgage default)

    • Accommodation for homeless people (hostels, night shelters, bed and breakfast)

    • No shelter (“roofless,” “sleeping out” on streets or in parks or car parks)

    Many homeless people show signs of mental illness

    Size of the problem

    Reliable estimates of the numbers of homeless people are notoriously difficult to come by. The 1991 census concluded that about 3000 people were sleeping out and 20000 were living in hostels for the homeless, but these figures are now recognised to have been underestimates. In addition, 169966 households were registered as statutorily homeless in 1992.

    Although the absolute numbers are small, homeless people place disproportionately large demands on services. Compared with the general population, at least twice as many homeless people have some kind of important mental health problem.

    Nature of the problem

    There are no mental illnesses or emotional problems unique to homeless people. …

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