Housing First Improves Adherence to Antipsychotic Medication Among Formerly Homeless Adults With Schizophrenia: Results of a Randomized Controlled Trial.

Stefanie N. Rezansoff,Seena Fazel,Julian M. Somers,Ric Procyshyn,Lawrence McCandless,Akm Moniruzzaman

doi:10.1093/schbul/sbw136

Abstract

Adherence to antipsychotic medication is a significant challenge among homeless patients. No experimental trials have investigated the impact of Housing First on adherence among patients with schizophrenia. We investigated whether Housing First in congregate and scattered-site configurations resulted in superior adherence compared to usual care. Adult participants (n = 165) met criteria for homelessness, schizophrenia, and initiation of antipsychotic pharmacotherapy prior to recruitment to an unblinded, 3-arm randomized controlled trial in Vancouver, Canada. Randomization arms were: congregate Housing First (CHF) with on-site supports (including physician and pharmacy services); scattered-site Housing First (SHF) with Assertive Community Treatment; or treatment as usual (TAU) consisting of existing services. Participants were followed for an average of 2.6 years. Adherence to antipsychotic medication was measured using the medication possession ratio (MPR), and 1-way ANOVA was used to compare outcomes between the 3 conditions. Data were drawn from comprehensive pharmacy records. Prior to randomization, mean MPR among participants was very low (0.44–0.48). Mean MPR in the follow-up period was significantly different between study arms (P < .001) and approached the guideline threshold of 0.80 in SHF. Compared to TAU, antipsychotic adherence was significantly higher in SHF but not in CHF. The results demonstrate that further implementation of SHF is indicated among homeless people with schizophrenia, and that urgent action is needed to address very low levels of antipsychotic adherence in this population (trial registration: ISRCTN57595077).

Highlights

Serving homeless people with psychiatric disorders is a complex and global challenge
No significant differences were found between individuals randomized to congregate Housing First (CHF), site Housing First (SHF), and treatment as usual (TAU), including prerandomization medication possession ratio (MPR)
Scores from the SF-12 Health Summary and the Multnomah Community Ability scales demonstrate no significant differences in illness severity and level of impairment between treatment groups

Summary

Introduction

Serving homeless people with psychiatric disorders is a complex and global challenge. Reports released prior to the current refugee crisis estimated that more than 400 000 people in the European Union were homeless on any given night,[1] and another 700 000 in the United States and Canada.[2,3] The prevalence of schizophrenia among the homeless has been estimated at approximately 11%.4. Poor adherence to antipsychotic medication is a significant problem among homeless people,[5,6] leading to increased risk of relapse, hospitalization and suicide,[7] arrest, violence and victimization,[8] and greater overall public costs.[9] Duration of homelessness is significantly associated with suboptimal adherence to prescribed antipsychotic regimens.[10] Current antipsychotic treatment protocols provide little guidance on how to care for individuals who are concurrently homeless and seriously mentally ill

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Conclusion