Mental disorders and the use of primary health care services among homeless shelter users in the Helsinki metropolitan area, Finland

Homeless people constitute a highly vulnerable part of the population with multiple social and health care needs [1, 2]. Homelessness has been found to be associated with increased morbidity and mortality in several settings [1, 3‐10]. A systematic review on mental health disorders among homeless persons in Western countries by Fazel and coworkers showed that the most common mental disorders among homeless persons were alcohol dependence and drug dependence followed by psychotic illness and major depression [6]. Dual diagnosis with concurrent substance use disorders (SUDs) and other mental disorders is also commonly presenting among homeless persons using shelters and care programs for homeless [4, 5, 11, 12].

Additionally, the somatic disease burden has been shown to be high among homeless persons, with increased rates of infectious diseases, such as human immunodeficiency virus (HIV), hepatitis, tuberculosis and pneumonia; and chronic medical conditions, such as cardiovascular disease, obesity and chronic obstructive lung disease [1]. Both somatic and mental illnesses are predictors of mortality among homeless persons [13, 14]. Swedish and Danish studies have shown that SUDs and dual diagnosis especially are associated with high mortality among homeless persons [3, 5].

Studies from several settings have shown that homeless persons have more hospitalizations and emergency department (ED) visits than the general population [1, 8, 12, 15‐17]. However, utilization of primary health care services seems to differ from one setting to another. In the United States, a setting with an insurance based health care system, the utilization of ambulatory health care for homeless persons using missions shelters is lower than that for the general population [18] and homeless persons use EDs for their primary health care needs [19]. While in Canada and Belgium, settings with universal health care and therefore lower barriers to primary health care, homeless persons using shelters and meal programs do use ambulatory services and primary health care more than the general population, though the use of EDs and hospital services still remain high [20, 21]. We know that the homeless persons use ED for visits related to injuries, substance use and psychiatric conditions [22‐24] but to our knowledge, there are no previous studies on the reasons why homeless persons seek primary health care services.

Several barriers to care have been identified such as stigmatizing attitudes of health care personnel, lack of insurance, or difficulties registering with general practitioners, as well as competing more immediate needs such as food and shelter [25, 26]. To meet the primary health care needs of the homeless population many bigger cities have developed systems with targeted primary health care for homeless and some studies suggest that these are more efficient in reaching the homeless population [27, 28]. There is suggestive evidence that tailored primary health care services for homeless persons improve the delivery of care at the right level and reduce the number of nonacute ED visits [29, 30].

Health service use has been shown to be unevenly distributed in the homeless population, with a small proportion of the homeless persons being responsible for a majority of hospitalizations and ED visits [1, 20, 31]. Chronic health conditions and mental health and substance use problems are factors that are known to be associated with ED use among homeless persons [12, 31‐33]. However, we still lack knowledge about how mental disorders and chronic health conditions are associated with the use of primary health care services in the homeless population.

In November 2008, at the time of the sampling for this study, there were 7955 single homeless persons in Finland and in addition to them about 300 homeless families [34]. These national statistics on homelessness in Finland are gathered yearly by the Housing Finance and Development Centre of Finland (ARA) as cross-sectional data and despite their apparent exactness they are estimates made with varying methods in different municipalities. Out of Finland’s 7955 single homeless persons 4247 (53%) lived in the capital region [34]. The gender distribution of the homeless people in Finland was 80% male and 20% female [34]. The definition of homeless in Finland includes persons staying with families or friends and persons in institutions such as hospitals or prisons but without a permanent address. Due to the hard Finnish climate only a very few homeless persons actually sleep rough, and in the national statistics those sleeping outdoors are reported grouped together with those staying in shelters (162 persons in Helsinki, Vantaa and Espoo in 2008 were sleeping rough or in shelters [34]).

The aim of this study was to examine the prevalence of mental disorders in the shelter population in Helsinki metropolitan area, Finland, and to analyze how much these homeless persons seek primary health care services daytime and during after hours. We also wanted to study whether there is a relationship between the mental disorders and service utilization. We chose to focus on the homeless staying in shelters since these individuals, with the exception of those few individuals sleeping outdoors, constitute the most vulnerable group in the homeless population and could be sampled using the registers from the shelters.

The study cohort consists of all 158 homeless persons using the four shelters operating in the Helsinki metropolitan area during two selected nights (16th of June 2008 and 16th of September 2008). The nights were selected 3 months apart in order to catch more of the short-term homeless population who spent only a shorter period in shelters. The selected nights were a Monday and a Tuesday (in Helsinki metropolitan area the level of shelter usage is not higher during particular days of the week). For those 45 homeless persons who used the shelters on both of the selected nights the latter one was used as the sample date. The shelter services in Helsinki metropolitan area are free of charge and open to all homeless residents on a walk-in basis, but as the services are not automatically available for non-local residents, homeless persons without place of domicile such as unregistered migrants and tourists without lodging do not have access to shelter services and are therefore not included in this study.

The study sample included 158 homeless persons. Their mean age was 47.3 years (range 18–73), they were predominantly men (73.4%), Finnish citizens (95.6%) and unemployed (43.7%) or living on age-related or disability pensions (43.7%) (Table 1). Many of the study subjects had been homeless for a long time, more than half (55.1%) had been homeless for at least 1 year and almost a quarter (23.4%) for more than 5 years. Repeated previous periods of homelessness were also observed in more than a third of the sample. There was a large variance in the length of stay in shelter, some had stayed only for a few days, while others had lived in the shelter for many years (71.5% had stayed for more than a month, 7.6% over 11 months during the last year).

We analyzed the use of primary health care services among homeless shelter users in Finland and found that mental disorders were strongly associated with primary health care daytime visits and after hours visits to PHERs. To our knowledge there are no previous studies on associations between primary health care use and mental disorders among homeless people in settings with universal health care. US based studies have shown that homeless persons with mental disorders have more ambulatory visits and ED visits than homeless persons with no mental disorder [12, 33], and that especially ED visits were common among homeless persons with co-occurring SUDs and other mental illnesses [33]. Our findings suggest that in systems with universal health care the homeless population’s daytime visits to primary health care are strongly associated with mental disorders and especially with dual diagnosis.

The prevalence of SUDs in our cohort was high compared with previous studies. For example, a Swedish cohort study of homeless persons using shelters and social services for homeless [10] that used hospital discharge registers to define prevalence of mental disorders found that 42.0% of the men in their cohort had SUDs (follow-up period 1996–2002), while our cohort with morbidity data based on primary health care records had a SUD prevalence of 81.2% in the 3 year follow-up period. A large Danish cohort study of homeless shelter users [5] that used psychiatric hospital and outpatient register data to define psychiatric morbidity found it to have a similar prevalence as in the Swedish study. The difference could be explained by differing health care data used. Using primary health care records is probably a more sensitive method of finding homeless persons with SUDs since a bigger proportion of the homeless population has contact with primary health care than with specialized care. Only severe cases of SUDs that require in-patient treatment are dealt with in specialized care, while less severe cases are treated either at primary health centers or at substance use outpatient clinics. For other mental disorders the 3-year prevalence rate in our study was in line with or lower than those presented in previous studies [6]. Hence, the high prevalence of SUDs in our study can be partly explained by the relatively sensitive method used to gather data on mental disorders used, but it is also a consequence of a fairly well developed welfare system and housing services for the mentally ill that prevent the main part of homelessness due to poverty or mental health problems alone.

We did not have a matched control group in this study, but comparing to the total amount of visits to primary health care centers in Helsinki in 2008 we observe that the homeless shelter users have more visits than the average citizen in Helsinki. The residents of Helsinki made on average 0.8 daytime visits to a physician in primary health care [40]. Thus, compared with the general population in Helsinki the homeless persons made 2.5 times the number of daytime primary health care centers visits. To PHERs the homeless persons made 6.8 times the number of visits compared with the average person living in Helsinki (1.4 visits for the homeless persons compared to 0.2 for the average person in Helsinki [40]). These findings are in line with studies from other settings with universal health systems [20, 21].

The three most common reasons for visits to primary health care during daytime were visits related to mental health and substance use (over one third of all daytime visits), infections, and trauma. As medications for mental health related problems are only in exceptional cases prescribed in PHERs, persons seeking help for SUDs and other mental disorders are more likely to visit primary health centers during daytime than PHERs after hours. Visits due to infections were the second most common reason to visit primary health care, and the most common infections were dermatological infections (more than half of all visits due to infections). These infections as well as visits due to trauma were often related to substance use, i.e. the patient typically had an skin infection caused by injecting drugs or has suffered a trauma while being intoxicated, and offer a part of the explanation to why patients with dual diagnosis and SUDs have more visits to primary health care daytime.

Previous studies have shown that ED visits among homeless persons are linked to mental health and substance use problems [31, 33] and the same association can be seen for primary health care utilization. While it is of course a logical consequence that people with diagnoses seek health care, our study provides more in depth knowledge about the relationship between mental disorders and the utilization of primary health care services daytime and PHER. Looking at the PHER visits we found that SUDs (including those with dual diagnosis) were strongly linked to the number of visits, while those homeless persons with other mental disorders than SUDs had had clearly fewer visits to PHER. The most common reasons for visiting PHERs, trauma and intoxications and convulsions, were also often indirectly caused by substance use, thus explaining our finding. This is in line with previous studies on ED use showing that a substantial proportion of ED visits made by homeless persons are directly related to SUDs [16]. Effective interventions such as detoxifications and case-management programs could reduce the number of visits made by homeless persons to PHERs [41‐43]. In Finland, the municipalities organize treatment for SUDs, including both outpatient care and inpatient detoxification and rehabilitation, practically always on a voluntary basis. However, this study also shows that the treatment for addiction problems in the homeless population in Helsinki is insufficient, despite the commonly occurring substance use and dependency problems only 39% of the homeless persons had been in detoxification-treatment in the past 3 years. Considering that SUDs have also been shown to be linked to high mortality among homeless using shelters and social services for homeless [3], active treatment for SUDs and lower thresholds to treatment would be important.

Many of the visits that the homeless persons made were due to acute health problems such as trauma, infections and intoxications. When grouping the visits, we also formed a group for planned check-up visits due to hypertension or diabetes, causes that are known to be common reasons for visiting primary health centers. These types of prescheduled secondary preventive visits were very scarce among the homeless population, during 3 years only 14 prescheduled control visits for hypertension or diabetes (1.0% of all visits, included in the other reasons group in Fig. 1) were made to primary health care. Considering that 22 persons in the cohort were diagnosed as hypertensive and 8 as diabetic, both conditions that according to current guidelines should be checked yearly in the primary health care [44, 45], this low number of control visits shows that despite the relatively high number of visits to primary health care, treatment for chronic disease is insufficient among the homeless population in Helsinki region. These findings support previous study results showing that homeless persons seek help late due to barriers to health care and competing needs [25, 26]. In the analyses adjusting for somatic comorbidity had only little effect on the results which also suggests that the treatment of chronic diseases is responsible for only a small proportion of the total amount of visits.

The Finnish municipalities organize primary health care services for all their residents, though several barriers to health for mentally ill have been identified [46]. At the time of the study (years 2005–2008) a person registered as homeless was automatically appointed treatment at the primary health care center in the catchment area of his/her previous address. For acute cases people were entitled to use any health center’s services but for more chronic conditions one was referred to the health care center according to one’s address. Though officially this system offered primary health care for all, it also constituted a barrier to health for homeless persons. Especially the long-term homeless persons might not have any former address in the primary health care record system or the area could be very far away from where the person actually spent his or her days. This led to situations where homeless persons were turned away with the argument of not belonging to the catchment area of the health center. In order to improve access and offer freedom of choice the system has since been changed and a homeless person can now register at any primary health care center of his or her choice. Since 2009 there are also targeted primary health care services for homeless persons in conjunction with the main shelter, and the homeless persons can choose either this tailored service or any other primary health care center. Further research is needed to study whether these efforts to improve access to primary health care have improved the health situation for the homeless population in Helsinki. However, relying on previous studies [27, 28] and clinical experience by the research group it can be assumed that this tailored service reaches the homeless population better. Considering the high prevalence of SUDs in this Finnish homeless cohort it would also be relevant to study how the mortality and service utilization differ from other settings with lower prevalence of SUDs among the homeless.

In this study we examined the utilization of primary health care services among homeless people and found that dual diagnosis was particularly strongly associated with primary health care daytime visits among homeless persons, while after hours visits to primary health care level emergency rooms were strongly associated with both dual diagnosis and SUDs. Active treatment for SUDs could reduce the amount of emergency visits made by homeless shelter users. Despite a relatively high number of visits to primary health care, treatment for chronic disease such as diabetes and hypertension is insufficient among homeless persons in Helsinki metropolitan area.