The recently discharged mentally ill all too often find life on the 'outside' a downward spiral ending in homelessness. But a new program called "critical time intervention" (CTI) seems to set ex-patients on a better path. "The transfer of care for chronic patients (into the community) is a delicate process that may be likened to two trapeze artists' grasping hands in midair," explain a team of New York City psychiatrists in the latest issue of the American Journal of Public Health. "The purpose of CTI is to strengthen the caregivers' grasp at the critical moment." They point out that those with chronic mental illnesses, conditions like schizophrenia or bipolar disorders, have 10 to 20 times the risk of homelessness than that of the general population. And conditions such as alcoholism, drug dependence, and HIV infection exacerbate the difficulties of adjusting to community living.

The researchers say the first few months after institutional discharge are crucial. "Generally during these first months, relationships are exquisitely fragile," say the study authors, who were led by experts from New York's Columbia University. "Mutual obligations are being negotiated between the deinstitutionalized individual and those who may offer formal or informal support in community living." For 18 months, the researchers followed the progress of 96 recently discharged male mental patients, released on their own recognizance into the New York City area. Some of the men received the usual postdischarge assistance -- generally consisting of the availability of various community counseling and assistance services. However, "the connections among the various agencies in regard to the care of an individual... were generally weak and unsystematized," the researchers say.

The rest of the study group were offered the CTI program. CTI staff included caseworkers who did not necessarily have any professional degree, "but did need to have experience working with this population and enough 'street smarts' to work with these men in the community." In the first three months after discharge, the CTI staffers made home visits on a regular basis, accompanied patients to doctors, welfare, and other appointments, and acted as mediators between patients and their caregivers. For example, a mentally ill "son might wish to live with his mother, but the son might have habits (e.g., poor hygiene, open use of drugs) that the mother would find intolerable. The CTI worker could help the mother and son reach an understanding about the ground rules for living together." This kind of intervention and observation, would continue for the subsequent six months, until, it was hoped, living habits were formed and daily survival resources were firmly established.

At the end of the nine-month CTI program, a party or meeting was held to celebrate the ex-patient's full entry into the community. And the program seems to be successful, the researchers report. "Compared with the (usual services) group, the CTI group had one-third the number of homeless nights (average of 30 nights vs. 91 nights). Similarly, in the last month of the study, 8% of the men in the CTI group but 23% of the men in the (usual services) group were homeless." The study team notes that other programs devised to help the recently discharged have failed to produce enduring results, probably because the patient comes to rely too heavily on the caseworker for support. In those programs, as soon as the caseworker terminated the relationship with the patient, the patient too often reverted to old habits and subsequent homelessness. But the researchers say CTI has a different structure altogether. "The explicit aim of CTI was to build durable ties between patients and their long-term supports. The CTI worker was instructed not to become the primary source of care."

The study says the program requires little training and is relatively inexpensive. They believe the program's success debunks current notions that "these patients suffer homelessness and other deprivations because they cannot be reached." "Homelessness among the mentally ill is, to some degree, preventable by readily available means," the researchers conclude. In a comment on the study in the same journal, Dr. Graham Thornicroft, of London's Institute of Psychiatry, says the program may have even wider applications. "Two classes who might benefit are released prisoners and children leaving care," he says. "Those undergoing such life transitions might be enabled to avoid a "make-or-break" trapeze leap." "Homelessness is not as rare as most of us would like to believe," writes a second editorialist, Dr. William R. Breakey of the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine in Baltimore. "The most recent estimate, based on a nationwide U.S. sample, suggests that as many as 7.4% of the population (13.5 million people) may have experienced homelessness at some time in their lives." "Homelessness should be recognized as a major public health concern. We should be as much concerned about the thousands of people who are homeless in American cities and the thousands of children in residentially unstable families as we are when there is an epidemic of an infectious disease affecting a few hundred people, and we should respond with the same urgency," writes Breakey.

SOURCE: American Journal of Public Health (1997;87:256-262, 153-155, 158-159)

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