03/18/2010 05:12 am ET | Updated May 25, 2011

Meds can Reduce Homelessness but the Homeless (and Advocates) Don't Get It.

While Huffington Post has admirably tried to cover homelessness on Impact, little
of the content addresses mental illness. In fact, curing serious mental illness is rarely mentioned in discussions of curing homelessness. 

Part of the reason is political. Some advocates for the homeless believe that housing is a ‘right’ and are devoid of any responsibilities, like taking medicines. Other advocates for the homeless want to present the homeless as being high-functioning well-educated, previously employed individuals who are temporarily down on their luck.  I don’t deny this may be true for the majority of homeless, but these advocates shouldn’t deny there is a giant percentage who don’t fit this mold.

 Unbiased studies suggest that one-third of the homeless have
serious biologically-based mental illnesses. Therefore, homelessness (at least one-third
of it) is a medical issue. And that is good news. Because treatment for mental
illness exist.

Medicines can often control the symptoms of schizophrenia, like delusions, paranoia and
auditory hallucinations. But once the medicines work, individuals stop taking them.
And the psychosis begins again. Maintaining housing under these circumstances
is virtually impossible and homelessness practically inevitable.

Families of the homeless mentally ill know the path to homelessness almost always starts
when someone stops taking medicine. 
Many of these now homeless mentally ill individuals once lived at home
with their parents. But parents have no authority to make their child stay
on the medications that can keep them free of psychosis. The family has become
the "institution" with all of the responsibility but none of the authority. The
tension between the family that wants the child to be well, and the child too
ill to know he or she is sick, leads to child running away.

And the homeless get
another member.

Alternately, when parents are unable to make the child take medication, the child becomes too psychotic, too unruly, often too threatening to live at home and the family has to ask them to leave.

And the homeless get another member.

In other cases, the route to homelessness starts the same, but the ‘institution’ is different. Some seriously mentally ill individuals lucky enough to get into a hospital, day treatment program, group home or an adult home, exercise their
right to go off medicines. Since the hospital, group home, adult home, or day treatment program can no longer treat the individual, and the descent into
psychosis disrupts the institution (much as it did the family), the individual is discharged.

And the homeless get another member.

Lack of treatment for the mentally ill leaving jails and prisons also inflates the
homeless population. (No U.S. County treats more people in a hospital than they
do in jail.) The jails discharge the seriously mentally ill with no requirement
or support to stay on medication.

And the homeless get another member.

Mentally ill individuals are even kicked out of homeless shelters for failure to ‘obey
the rules’ they are too psychotic to understand and too out of control to obey. How’s that for irony?

It’s all so predictable.

Much of this unnecessary homelessness--representing 150,000 to 2000,000 souls--can be prevented with treatment. The treatment most likely to reduce homelessness (and
violence and incarceration) among the seriously mentally ill is called “Assisted
Outpatient Treatment” (AOT). In order to protect patient’s rights, AOT has to be approved by a court. AOT combines a court-order that requires certain mentally ill individuals to stay in treatment (usually on medication) with a court order that requires the county to provide treatment.

The result? Less homelessness, incarceration and violence by the mentally ill. 

When New York started Kendra’s Law, their AOT program for the seriously mentally
ill, they found

  • 74 percent fewer experienced homelessness;
  • 77 percent fewer experienced psychiatric hospitalization
  • 83 percent fewer experienced arrest

 This is not surprising to the mentally
ill, families of the mentally ill or to psychiatrists. Medication compliance is the sine quo non of treatment for the most severely mentally ill. Assisting medication compliance is the single biggest thing we can do to reduce homelessness.

 So why don’t we simply make AOT available to all who could benefit from it, and free up the homeless beds (and jail cells) for others?  Good question. NAMI, the largest consumer/family organization has endorsed AOT, the American
Psychiatric Association
, the largest association of psychiatrists has
recognized the benefits, and law
has embraced it. Mental health consumers who have experienced
it endorse it. So you would think it’s a done deal.

 But AOT does have some opponents who happen to have a disproportionately
important voice primarily due to the funding they receive from government and
the lobbying power that gives them.

 The most significant opposition to AOT comes from government and the ‘providers’ of mental health services they fund. 
The government is not interested in being required to serve anyone, especially those as severely ill. And without a voting bloc like the seriously mentally ill, government would rather use mental health dollars on warm and fuzzy talk therapy for the worried well, than facilitating intense medication compliance regimens for the seriously mentally ill. Schizophrenics need not
apply. The service providers, including certain homeless shelters and mental health providers do not like being mandated to treat any patients, especially the difficult to treat. They would rather treat the totally compliant than the totally psychotic. And who wouldn’t? 

 It’s time for advocates for the homeless
to stop denying the role of untreated mental illness in causing homelessness. It's time to recognize what the cure is. Treatment for the mentally ill may not be a magic pill, but to reduce homelessness, it’s the
closest thing we have. 

To learn more on how to implement AOT legislation in your state, or see that AOT is more widely used, visit the Treatment Advocacy Center.

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