Over 582,000 individuals on a single night in 2022 across the country were struggling with one of the key social determinants of health: homelessness. The Point-in-Time (PIT) census counts sheltered and unsheltered individuals experiencing homelessness on a single night in January. The PIT count is valuable in quantifying homelessness, identifying year-over-year trends, and supporting policy development. Key additional findings from the 2022 Annual Homelessness Assessment Report (AHAR) to Congress (14.8 MB) and Continuum of Care Homeless Populations and Subpopulations Report (178 KB) include:
- 21 percent of individuals experiencing homelessness reported having a serious mental illness, and 16 percent reported having a substance use disorder.
- A 16 percent increase among individuals experiencing chronic homelessness between 2020 and 2022.
- The homeless population comprised 37 percent of individuals who identified as Black and 24 percent identifying as Hispanic.
Homelessness is associated with a higher prevalence of mental and substance use disorders when compared to stably housed individuals. Individuals experiencing homelessness continue to face health disparities, including increased mortality due to suicide (PDF | 192 KB). Homelessness is a complex problem, and the social determinants of health serve as a key factor in addressing and developing comprehensive solutions to prevent and end homelessness. SAMHSA’s 2023-2026 Strategic Plan recognizes the importance of social determinants of health as a lever to achieve its goal of promoting whole-person care, advancing policies and programs, and improving health outcomes to meet the needs of individuals experiencing homelessness.
A prominent risk factor for homelessness is the lack of affordable or stable housing. According to Healthy People 2030, 35 percent of renter households are cost-burdened in the United States, meaning that families spend more than 30 percent of their income on housing costs and utilities. Rental home costs continue to increase while household renter incomes stagnate. Although gentrification is not an area of focus for SAMHSA, it is necessary to acknowledge that gentrification can impact neighborhoods and built environments. Gentrification revitalizes poor urban neighborhoods by developing new businesses and homes to attract potential affluent residents. A central issue with gentrification is the displacement of low-socioeconomic status households and Black and Hispanic incumbent residents in reaction to increased rent.
Additionally, unemployment and underemployment disproportionately impact individuals experiencing homelessness (PDF | 1.1 MB). While many express the desire to work, individuals experiencing homelessness encounter obstacles that make finding and maintaining employment challenging. Without affordable housing and stable employment, families face adversity and expend a significant portion of their income on shelter without having enough funds for necessities, such as food, transportation, and healthcare. Economic instability can create chronic stress for individuals and may lead to illegal drug use and mental health issues, such as anxiety or depression.
Education Access and Quality
Another key social determinant of health is access to quality education. Individuals with lower educational attainment are at greater risk of unemployment and poverty compared to their more educated counterparts. Lack of income due to unemployment is a direct cause of homelessness. Youth with less than a high school diploma or General Educational Development (GED) are especially vulnerable. Compared to youth with at least a high school degree, youth without a high school diploma or GED have a 346 percent higher risk of experiencing homelessness (PDF | 191 KB). Furthermore, the lack of education on mental health is associated with increased mental health challenges. A 2020 study found that K-12 students who participated in school-based mental health treatment were over 15 times more likely to attain improved mental health status. Increasing high school graduation rates for students and prioritizing the need for school-based mental health services are critical to preventing homelessness and improving mental health.
Healthcare Access and Quality
Barriers that prevent individuals who are experiencing homelessness from accessing health care may contribute to the increase in individuals experiencing chronic homelessness and can lead to increased risks of adverse health outcomes. Sixty percent of individuals experiencing homelessness lack health insurance, which restricts them from obtaining another vital social determinant of health: preventive and primary care services. Research has shown that health insurance coverage is associated with improved health monitoring and lower mortality rates. Additionally, participants with mental and substance use disorders experiencing homelessness in a 2020 study felt that they received poor quality care due to clinician bias. Increasing healthcare access and culturally competent care can ensure that concerns are adequately addressed for individuals experiencing homelessness.
Social and Community Context
Stigma involves negative stereotypes that lead to discrimination against individuals experiencing homelessness. Individuals experiencing homelessness are erroneously stereotyped as lazy, dangerous, and solely responsible for their homelessness. However, research has shown that experiencing domestic violence can precipitate homelessness. Moreover, homelessness disproportionately impacts LGBTQ+ youth due to discrimination and increased risks for mental and substance use disorders. In the United States, 10 percent of the general youth population identifies as LGBTQ+; however, nearly 40 percent of LGBTQ+ youth comprise the homeless youth population. The intersectional stigma surrounding homelessness and mental and substance use disorders worsens health and well-being by creating barriers that prevent recovery. Addressing stigma within healthcare and the general public is vital to ending discrimination and supporting individuals experiencing homelessness.
What SAMHSA is Doing to Address Social Determinants of Health Among People with Mental and Substance Use Disorders
Expanding Access to and Use of Behavioral Health Services for People Experiencing Homelessness offers evidence-based practices for behavioral health providers to directly support and maintain relationships with people experiencing homelessness, provide mental health and substance use treatments, and boost retention in treatment services. The Projects for Assistance in Transition from Homelessness (PATH) supports outreach and engagement, case management, and housing assistance for individuals. Grants for the Benefit of Homeless Individuals (GBHI) supports treatment and recovery services, housing services, and health insurance enrollment guidance. Treatment for Individuals Experiencing Homelessness (TIEH) promotes access to treatment services, peer support, and resources for permanent housing. Supplemental Security Income/Social Security Disability Insurance Outreach, Access, and Recovery (SOAR) aims to increase Social Security disability benefits for eligible children and adults with medical impairments and co-occurring disorders.
The Certified Community Behavioral Health Clinic (CCBHC) program addresses disparities in the behavioral health care system by increasing access to high-quality, coordinated comprehensive behavioral health care to individuals regardless of their age, ability to pay, or place of residence – including individuals experiencing homelessness. CCBHCs also provide housing assistance and 24/7 crisis intervention services for individuals experiencing a mental health or substance use crisis. The Assertive Community Treatment (ACT) and Assisted Outpatient Treatment (AOT) grant programs aim to reduce homelessness, hospitalization, and mental and substance use disorders. Lastly, the Homeless and Housing Resource Center (HHRC) provides accessible, no-cost training for health and housing professionals in evidence-based practices on housing stability, recovery, and homelessness to effectively meet the needs of individuals experiencing homelessness.
Homelessness and behavioral health are inextricably linked, and recognizing the social determinants of health is crucial to ending homelessness. Homelessness is an intricate and multifaceted issue with systemic issues related to housing affordability, economic opportunities, healthcare access, and stigma. SAMHSA utilizes its national surveys and grantee data to create effective programs and services to prevent and end homelessness among people with mental and substance use disorders. Efforts to increase accessibility to stable housing and treatment services while simultaneously addressing the social determinants of health can be an effective strategy to reduce health disparities for individuals experiencing homelessness.
Mark Saldua is an Intern at SAMHSA’s Center for Behavioral Health Statistics and Quality.
This article was originally published on SAMHSA on November 15, 2023.