Exploring Mental Health Treatment and Prevention among Homeless Older Adults

Homelessness is an issue of social justice, in the United States, because it leaves people vulnerable, unsafe, and ill, while not having their basic needs for food and shelter met. Although the United States is the wealthiest country in the world, a significant number of its residence, whether citizens or not, have experienced homelessness in their lifetime. Less than 5 years ago, the U.S. Department of Housing and Urban Development (HUD) found that 564,708 people are homeless on any given night. There is a dearth of information available that puts older adults at the forefront or at the center of homelessness epidemic. Moreover, recent HUD reports claim that homelessness has decreased, in the United States, while the National Center on Family Homelessness reported that the number of residents experiencing homelessness is steadily climbing and is expected to hit an historic high, within the next 5 years. Yet, most of the attention given to homelessness as a public health issues, tends to focus on families and children. Few studies have targeted older adults and their primary risk factors experiencing homelessness. Important to note is the fact that consistent data and accurate reporting about homeless older adults are few and far between. This chapter (1) presents a practical definition of homelessness, (2) provides a social work framework for understanding and assessing risk among homeless populations, as well as, (3) emphasizes the importance of cultural competence in health practices for addressing homelessness among older adults as a public health concern.


Introduction
The United States, the population is aging, and increasingly more adults are aging into poverty. At the same time, housing is becoming more unaffordable and the costs of health care are rising, leaving older adults at risk of poverty and homelessness [1]. Healthcare access for older adults is an important public health issue to be addressed globally. In the United States, approximately 10,000 people turn age 65 daily, and as the population ages in general, the prevalence of homeless among older adults remain constant [2]. Based on recent demographic trends, the more than 44,000 older adult population accounted for in 2010 will more than double by the year 2050, to nearly 93,000 [3].
Much is written in the health promotion literature about the social determinants of health for older adults, generally and more specifically, as it relates to disease and health promotion [4]. Moreover, it is well documented that a range of personal, social, economic, and environmental factors contribute to individual and population health [5,6]. Specifically, people with better education, more stable employment, stable housing and living arrangements, and access to preventive health services tend to be healthier across the life course [7,8]. Conversely, poor health care outcomes are often made worse by a lack of access and opportunities to engage in health social and physical environments [9,10].
Worth noting is a surveys of patients' experiences with health care services that revealed how well a country's health system can be observed as meeting the needs of its population. Using data from a 2016 survey conducted in 11 countries-Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States-research found that adults living in the United States (U.S.) reported poor health and well-being and were the most likely to experience accessibility hardships. Furthermore, the U.S. lagged behind other countries in making health care affordable and ranked poorly on providing timely access to medical care. Deficits in patient engagement and chronic care management were reported, in all countries, and at least one in five adults experienced a care coordination issue or problem. In particular, often, such challenges had high levels of acuity for low-income adults. In the Netherlands, performance at the top of the 11-country range on most measures of access, engagement, and coordination was noteworthy as models of best practices [8].
From a psychological and legal perspective, researchers in the United States have argued that access to mental healthcare for diverse public health populations need improvement, if progress is to be made in the areas of addiction and recovery [11]. Sixty percent of people with mental illness do not get the mental healthcare that they need, and up to 90% of those with a substance abuse disorder do not receive services [12]. Some of the hindrances to those who need to receive mental healthcare include the negative stigma surrounding mental illness, cost of care, limited access in rural areas, and lack of transition between services, among other things. These obstacles have an even greater impact on those in the population without insurance, or lacking sufficient mental health coverage, and those who cannot afford to pay out of pocket for these services. Individuals within some minority groups often do not have the same health resources as the majority [13]. Adding these facts to the number of mentally ill people within the homeless population, it appears that those who need the services the most may be unable to obtain it.
The history of homelessness, from a policy standpoint indicates certain patterns of viewing the issue of homelessness, and paints a picture of why the public perception is focused on the individual person and not the structure of our society. Current policies intended to address homelessness can be improved with the incorporation of social work frameworks and perspectives on creating more equitable, social and distributive justice treatments and interventions [14], as well as, affordable healthcare, public and political opinions span the necessary action or inaction of dealing with the social problems at the patient, provider, and policy levels, especially mental health services. Unfortunately, many fail to recognize the need for healthcare for the aging population. According to the World Health Organization [6], 15% of adults aged 60 and over suffer from a mental disorder. There are several mental disorders that older adults may be diagnosed with; including dementia, depression, anxiety disorder, or substance use problems. According to the American Psychiatric Association [15], one in four older adults experience some type of mental disorder. This number is expected to rise over the next several years due to the overall increase among the aging population. Certain characteristics indicate the hypocrisy within mainstream U.S. society's view of the homeless, specifically the homeless that are veterans [16,17]. In spite of the fact that the prevalence of homelessness is paramount and has many contributing factors, less humane approaches are taken to help them gain self-efficacy to be well, emotionally and spiritually. According to National Coalition for the Homeless [18], single individuals comprised 66.7% of all people experiencing homelessness (369,081 people), and about 33.3% are people in families (184,661 adults and children). Based on these data, approximately 7.2% are older adults and according to the National Coalition for the Homeless, some argue the number negatively impacted is too small to give an abundance of attention and resources. This marginalization of older adults should not be tolerated nor condoned. Especially, in the United States (US) which is often viewed as the "land of opportunity" or the "home of the free and the brave." Yet there are many people living in this country that do not have the means for basic human necessities like food and shelter, and older adults are disproportionately impacted [14,42]. The perception of life in the US, in the general public, is far different than the reality of increasingly more people who have little to no "opportunity" and some segments of the population feel they are neither "free nor brave" enough fight to against the inequities and discriminatory practices that oppress them on a daily basis. In struggling to deal with this overwhelming adversity, there is often no attention or time made for the self-care of homeless individuals with substance use disorders (SUD).
From a Social Work perspective, what is understood about the standard of practice is the importance of looking for resources and strategies for assisting marginalized, disenfranchised, poor and underserved individuals, families, groups, communities, and a host of others. The Social Work Code of Ethics [19] speaks to the value of social justice, as well as, social and political action. To advocate for health care reform and especially, for the most effective intervention approaches, so that people can have greater access to mental health and substance abuse intervention is in keeping with the Code for the profession of social work.
Older adults, consistent with the reports on younger and middle-aged adults are impacted by substance use and addiction in ways that are shaped by biological, psychological, and social factors [11]. The social learning theory (SLT) suggests that homelessness, as well as, addiction recovery models are rooted the very opinions and beliefs that are perpetuated and learn from years of social conditioning and exclusion of specific racial and ethnic minority cultural preferences, norms and attitudes toward healthcare. Treatments based on this theory can disrupt patterns of negative thought and patterns of maladaptive behavior.
Racial disparities in treating mental health disorders are widely discussed in the healthcare literature [16,[20][21][22][23]]. Yet, differences in use of recommended strategies to prevent homelessness as a mental health intervention, by race/ethnicity, have not been widely examined. Racial disparity in homelessness among older adults to growing national concern and questions about barriers to service provision, with little attention given to association between health literacy and mental health care; especially trauma-informed care. Once of few studies was conducted to examine the impact of diversity attributes on health care literacy, and this end, statistical data analysis on a nationally representative sample of 15,309 respondents was published [24]. The study revealed a significant difference between ethnic/racial minorities, as well as, between men and women. Most notable were the differences between social, economic, and educational factors that influenced outcomes. This research is especially relevant to the topic of older adults, race/ethnicity and effective prevention and intervention of homelessness. Furthermore, national advocacy reports and federal government sponsored initiatives consistently document the health disparities that racial and ethnic minority persons experience [23,42].
More specifically, racial minority groups, in the U.S., experience disproportionately higher rates of homelessness, than racially White groups. In considering homelessness as a public health problem that requires attention to access and acceptability of healthcare, food, shelter and social support, the clear link for older adults is the strong correlation between mental health and homelessness [11].

Homelessness, mental health and substance use disorders
A practical definition of substance use is one of the most commonly described and identified health risks among people experiencing homelessness [25]. Homelessness is defined as the absence of a permanent home. Individuals and families may live on the streets, in a shelter, a single room occupancy facility, abandoned building or vehicle, or in any other unstable or non-permanent living arrangement (Section 330 of the Public Health Service Act (42U.S.C., 254b)). For more than a decade, studies reporting on the experiences of homeless persons have examined the association between living arrangement and substance use disorder treatment program characteristics, because housing instability is known to impact mental health and SUD prevention and intervention efforts [17,26]. Substance use among older adults, specifically who are homeless, is associated with decreased mobility of physical and mental health capacity [25] and early onset morbidity and mortality [27]. For these reasons, more attention on older adults as a special population of concerns for mental health prevention and intervention is warranted.

Approaches and frameworks
Behavioral modification interventions have been proven to be effective. These approaches are client-centered and provide support for abstinence from substance use. Moreover, such flexible models of care offer a range of modifiable frameworks for addressing attitudes and behaviors related to addiction and recovery [28]. In the field of social work practice, in particular, problem-solving frameworks are often recommended because of the evidence-based, culturally informed, manualized strategic tools that give mental health care provider the options to tailor the intervention to diverse populations and can be implemented in a range of different settings, including clinics, hospital, community-based environments and even in-home services with older adults, specifically [22,29].
Arguably, mental health intervention should take more of a community-based prevention approach versus a medical model, institutional treatment, when tailored to, and for persons living in homeliness [11]. The debate about the degree to which homeless persons will be able to access services to address their problems of substance use disorders, as well as, home and food insecurity, rest squarely on macro-level factors, including policies, legislation, research for evidence-based recommendations and solutions. The World Health Organization (WHO) recognizes mental disorders a public health concern, worldwide and its use of the term "disorder," implies the existence of observable behaviors or symptoms that interfere with normal functioning and that cause distress. Homelessness can exacerbate the symptoms of mental illness, causing an individual to become debilitated, depressed and anxious, all of which can be costly, socially and economically for individuals and families. Prevention of mental disorders and effective interventions, as well as, population-based policies that support and foster health accessibility among all person, are among the ongoing challenges that countries, worldwide must contend with [30]. In the U.S., culturally specific approaches to addressing mental health prevention and intervention among older adults is an important aspect of health care access.

Promising preventive strategies using a cultural competence framework
A cultural competence framework is one that guides healthcare providers' behaviors, attitudes, value and perspective on caring for individuals, families and communities. The culturally competent service provider takes into account an individual's multiple identities, preferences, norms, beliefs, as well as, their social determinants of health. The way in which healthcare providers' social and professional experiences impact their worldview, particularly as it relates to their delivery of care to diverse populations and it influences how and to what degree they are willing to ensure equity and parity in the mental healthcare services they provide. Furthermore, while homelessness is not considered to be a determinant of mental illness, interdisciplinary research and evidence-based theories suggest a strong correlation race culture, homelessness and access to healthcare [12,13,31]. Mental health providers have argued that it is extremely challenging to implement standard intervention strategies with this diverse population. The stigma associated with aging and mental health can make it rather difficult for providers to understand how to facilitate the same approaches with housing secure individuals, as one would implement with older adults living with homelessness. Changing the views and perspectives require a cultural competence lens through which to see and experience prevention and intervention this older adult populations. Based a comprehensive literature review, self-care and mindfulness are useful supporting cognitive behavioral modification interventions with person's managing mental health and substance use disorders [14]. These strategies may well have lasting, positive impacts on health outcomes. Promising preventive strategies for addressing mental health care among older persons that are homeless require a range of varied interventions. Some additional recommended approaches include self-help groups, integration of spiritual/religious beliefs, reminiscence therapy that incorporates the focus of balanced review and reflection of one's past life, and/or interdisciplinary clinical pharmacological treatments, as needed to maintain activities of daily living, physical exercise, and psychosocial health, while in recovery from substance use and homelessness [32]. The adaptation to cultural norms, attitudes and preference can increase accessibility and acceptability [13,17,22].
Cognitive behavioral literacy therapy using books, audiotapes, and video presentations also has been shown to alleviate mild depressive symptoms through promotion of self-help [33]. Such audio and video media for the elderly should take into consider educational level, readability, font size, and use of examples relevant different cultural groups. For example, appropriate content targeting older adults transitioning out of homelessness could involve retirement planning that includes development of positive expectations of a new life phase, a change of environment, developing new interests and stronger social support networks.
Preventive strategies aimed specifically at elders' spiritual/religious beliefs have been shown to be more effective than treatment-as-usual which neglects such beliefs and related practices [34]. These strategies may include religious participation involving prayer, spiritual music consumption, emotional and psychological preparation for an afterlife, a review of one's life journeys, and/or spiritual counseling. Research has shown [35] that involvement in spiritual/religious activities led to decreased depression among some other adults. In the U.S., the 12-Step model of addiction recovery has principles that guide the processes [36] and one of the core components is 'belief in a higher power. ' Reminiscence or life review therapy has yielded mixed results [33]. This potentially preventive approach involves literally reviewing one's life experiences as far back as one can remember and examining each life stage in terms of one's choices and the consequences of those choices for self and others. Given that the consequences of such experiences could be either positive or negative, perhaps it is the attitude toward such consequences that is critical to the effectiveness of this approach for prevention. If one believes that life is an opportunity to learn, then the results of the life review may prove to be positive and instructive for further learning and avoiding the same mistakes, thereby allowing for self-correcting and a sense of perceived control.
Psychodynamic therapy has also been evaluated empirically continue to have popularity as an approach within a managed care environment that reimburses only empirically supported treatments for older adults [33]. With homeless older adults, such interventions have been facilitated in substance abuse recovery program and in other shelter-based program that address mental health conditions, including SUDs [11].
Pharmacotherapy may also be an effective prevention strategy with older adults and there are a number of recommendation for addressing risk and side effects of antidepressant medication when prescribed to older adults, and especially those that are in addiction recovery [37]. One precaution is that approximately 20% of older adults have serious health problems that can be aggravated by antidepressant medications, including increased risk of physical injuries and hypertension disorders [33]. Moreover, research suggests that anti-anxiety and other sedative medications worsen conditions of depression and perhaps anxiety, among older people with substance use disorders [38][39][40][41][42]. Noteworthy is caveat methodological flaws and limitations may contribute to these negative findings in the research. Variations in interventions techniques, provider characteristic and sociocultural diversity of the participants are not clearly explained and such omissions can result in ambiguous and confounding effects.

Summary
As a moral imperative, fundamental in the profession of social work, the core value and belief that every human being deserves a home, food, clothing and access to health care compel us to make this call to action. Older adults should not be excluded from the inalienable rights and dignities, worldwide [19] to have their basic needs met. As the risk of homelessness among older adults increases, this becomes a public health and human right concern for healthcare systems and providers. This call to action for expedient problem-solving to prevent older adults from living in poverty and becoming homeless. Solutions are within our local, regional, national and global reach, such as expanding and strengthening the existing safety net of health care and minimum income supports, such as Temporary Assistance for Needy Families (TANF), Child Support Enforcement, Medicare and Medicaid, as well as, including a livable wage for those whom continue to be employed. An increase in the supply and accessibility of affordable housing for the aging population and low-cost or no-cost community based mental health and substance disorder prevention and intervention services are a few of the recommended solutions [42].