Stable Housing: Key to Closing the Mortality Gap

Stable housing is critical to closing the disparity in life expectancy between people with serious mental illness and the general population. Providing it should be a major part of the effort to confront the mortality gap.

People with serious mental illness die considerably younger than the general population. Most people these days say 25 years younger, because of a study of 8 states in which this was the average difference in life expectancy.1 Other studies have put the gap at about ten years.2 25 or 10 — either way it’s a dreadful fact that has finally become a major concern of mental health policy and resulted in several mental health policy changes that were long overdue. These include: (1) health promotion activities designed to get people with serious mental illness to stop smoking, to avoid obesity or lose weight, and to exercise, (2) improved access to good physical health care, and (3) integrated physical and behavioral healthcare services.

This is all for the good. But it is not enough. It leaves out of account the fact that many, if not most, people with serious and persistent mental illness have hard, dangerous lives at some point along the way because of substance abuse and/or homelessness.

Substance abuse contributes to exposure to communicable diseases such as hepatitis, venereal diseases, and HIV/AIDS. It also exposes vulnerable people with mental illnesses to criminals who often prey on them. People with co-occurring mental and substance use disorders are frequently victims of crime, including assault. They suffer injuries that often weaken them even if they seem to heal fully.

Homelessness is also dangerous. Living on the street when it is freezing cold or pouring rain is not good for one’s health. Sleeping under a cardboard box or huddled on a heating grate is not safe. Homeless people—whether substance abusers or not—are frequently victims of violent crime that can leave them physically and psychologically scarred for life.

Here Are Some Facts3

  1. People with co-occurring serious mental and substance use disorders are far more likely than other poor people to have heart disease (over 4 times as likely), asthma (over 3 times), other acute respiratory problems (about 2 times), cancer (about 2 times), and diabetes (1.5 times).
  2. People with co-occurring serious mental and substance use disorders are at higher risk for infectious diseases, especially hepatitis B (19 per 100,000 vs. less than 1 per 100,000), hepatitis C (16.2 vs. 1.9), and HIV 5.5 vs. .5).
  3. People with serious mental illness are 12 times as likely to be victims of crime compared to other urban poor people.
  4. People with serious mental illness alone or with co-occurring mental and substance use disorders are more than 5 times as likely to experience physical and sexual abuse than the general population.
  5. Transient housing status triples the risk of criminal victimization.
  6. People with serious mental illness or with co-occurring disorders are 4-5 times more likely to become and remain homeless than people without serious mental illness.


The implications of these terrible facts are clear. We need to do more to address the dangers of life on the streets and consequent risks to health and life faced by people with serious mental illness, particularly those with co-occurring substance use disorders. This should include major efforts to prevent exposure to crime and dangerous, infectious diseases.

The single greatest antidote to these dangers is stable housing.

Sadly, housing development for people with serious mental illness has slowed considerably due to the determination of current governments in the United States to reduce the costs of caring for people who rely on our society to survive and hopefully to recover. What a travesty!

Michael Friedman retired as the Director of the Center for Policy, Advocacy, and Education of the Mental Health Association of New York City in 2010. He continues to teach at Columbia University’s schools of social work and public health. Mr. Friedman can be reached at


  1. Colton, C. and Manderscheid R. “Congruencies in Increase Mortality Rates, Years of Potential Life Lost, and Causes of Death Among Public Mental Health Clients in Eight States”, Preventing Chronic Disease: Public Health Research, Practice, and Policy, April 2006.
  2. For example, Dembling, B., et al. “Life Expectancy and Causes of Death in a Population Treated for Serious Mental Illness”, Psychiatric Services, August 1999.
  3. All of these facts with references to numerous studies can be found in Alexander, MJ et al. Co-Occurring Severe Mental Illness and Substance Abuse: A Policy Background Book. The Mental Health Association of NYC, 2007. (

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