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Can Shelter-Based Interventions Improve Treatment Engagement in Homeless Individuals With Psychiatric and/or Substance Misuse Disorders?: A Randomized Controlled Trial

Bradford, Daniel W. MD, MPH*†; Gaynes, Bradley N. MD, MPH; Kim, Mimi M. PhD; Kaufman, Jay S. PhD§; Weinberger, Morris PhD¶∥

doi: 10.1097/01.mlr.0000170402.35730.ea
Original Article

Background: High proportions of homeless individuals have mental illness and substance use disorders. Few of these individuals engage in consistent treatment, although they are likely to benefit from it. Shelter-based interventions to help this population engage in treatment have not been studied in a rigorous manner.

Objectives: We sought to evaluate the effectiveness of a shelter-based intervention, including intensive outreach by a psychiatric social worker and availability of weekly psychiatrist visits with continuity of care to engage homeless individuals with psychiatric and substance use problems.

Research Design: This was a randomized controlled trial.

Subjects: A total of 102 individuals were referred to a shelter-based psychiatric clinic.

Measures: The primary outcome measure was first appointment attendance at a community mental health center (CMHC). Secondary outcome measures were attendance at second and third CMHC appointments, participation in a substance abuse program, and employment and housing status at shelter exit.

Results: Individuals receiving the intervention were more likely to attend ≥1 CMHC appointment (64.7% versus 37.3%, P = 0.006) and to participate in a substance abuse program (51.4% versus 12.5%, P = 0.0006) than those in the control group. There was a trend towards being more likely to attend 2 CMHC visits (33.3% versus 17.7%, P = 0.083), but no significant differences in attending 3 visits, being employed, or having housing.

Conclusions: Shelter-based interventions hold promise for improving treatment engagement in homeless populations with psychiatric and substance use problems. Further study should address how to foster care beyond an initial CMHC appointment and clarify key program components using a wider range of outcome measures.

From the *Robert Wood Johnson Clinical Scholars Program, Chapel Hill, North Carolina; the †Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina; the ‡Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; the §Department of Epidemiology, University of North Carolina School of Public Health, Chapel Hill, North Carolina; the ¶Department of Health Policy and Administration, University of North Carolina, Chapel Hill, North Carolina; and the ∥Center for Health Services Research, Durham VAMC, Durham, North Carolina.

Dr. Bradford was supported by the Kate B. Reynolds Charitable Trust, The Robert Wood Johnson Clinical Scholars Program, American Psychiatric Institute for Research and Education, and the National Institutes of Mental Health (NIMH T32 MH 19111). Dr. Gaynes was supported in part by an NIMH K23 Career Development Award (MH01951-03). Dr. Weinberger was supported by the Department of Veterans Affairs HSR&D Service through the Career Development Program.

Presented in oral and poster format at the 2003 Young Investigators Colloquium of the American Psychiatric Association, San Francisco, California.

Dr. Bradford is currently affiliated with the Durham VAMC and the Duke University Medical Center, Durham, North Carolina.

Reprints: Dan Bradford, MD, MPH, Durham VA Medical Center, 508 Fulton St., Durham, NC, 27705. E-mail:

© 2005 Lippincott Williams & Wilkins, Inc.