OBJECTIVES: This study examined a strategy to prevent homelessness among individuals with severe mental illness by providing a bridge between institutional and community care. METHODS: Ninety-six men with severe mental illness who were entering community housing from a shelter institution were randomized to receive 9 months of a "critical time" intervention plus usual services or usual services only. The primary analysis compared the mean number of homeless nights for the two groups during the 18-month follow-up period. To elucidate time trends, survival curves were used. RESULTS: Over the 18-month follow-up period, the average number of homeless nights was 30 for the critical time intervention group and 91 for the usual services group. Survival curves showed that after the 9-month period of active intervention, the difference between the two groups did not diminish. CONCLUSIONS: Strategies that focus on a critical time of transition may contribute to the prevention of recurrent homelessness among individuals with mental illness, even after the period of active intervention.

Although in Brazil the rate increased 29.5% in 26 years, the national rate is still considered to be low when compared to worldwide suicide rates (average of 4.9 per 100,000 inhabitants). Suicide rates in Brazilian regions vary broadly, ranging from 2.7 to 9.3.

This intervention successfully reduced sexual risk behaviors of homeless men with mental illness. The effect diminished over 18 months but did not disappear. Similar approaches may be effective in other impaired high-risk groups.

We report on the prevalence of human immunodeficiency virus (HIV) infection among psychiatric patients in a New York City shelter for homeless men. We reviewed the records of all 90 men discharged from the shelter psychiatry program to community housing over a 2-year period. HIV serostatus was recorded for 62 of the 90 men. Of these 62, 12 (19.4%) were positive. There were 28 men whose serostatus was not recorded. Data on the HIV risk behaviors of these 28 men suggested that seroprevalence could have been similarly high among them. The results indicate an urgent need to develop and apply preventive interventions for HIV in this population.

S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.

We describe the impact of a psychosocial intervention, critical time intervention (CTI), on the cardinal symptom dimensions of schizophrenia, namely negative, positive, and general psychopathology. Ninety-six men with schizophrenia and other psychotic disorders who were discharged from a homeless shelter were randomly assigned to receive either CTI or usual services only. CTI is a time-limited intervention designed to enhance continuity of care during the transition from institution to community. Symptom severity at baseline and at 6 months was assessed using the Positive and Negative Syndrome Scale. Using data on 76 subjects for whom we have complete symptom data, we assessed the impact of CTI on change in symptoms. The results suggest that CTI was associated with a statistically significant decrease in negative symptoms at the 6-month follow-up, reflecting modest clinical improvement. There was no significant effect on positive or general psychopathology symptoms.

Different cultural contexts contribute to substantial variation in the stigma faced by people with psychosis globally. We propose a new formulation of how culture affects stigma to create psychometrically-validated tools to assess stigma’s culture-specific effects. We propose to construct culture-specific stigma measures for the Chilean context via: 1) open-ended administration of ‘universal’ stigma scales to a sample of individuals with psychosis, relatives, and community respondents; 2) qualitative analyses to identify how culture shapes stigma and to derive initial ‘culture-specific’ stigma items; 3) construction and pilot-testing of final ‘culture-specific’ stigma measures; 4) initial psychometric validation among a sample of individuals with psychosis. We identify initial hypotheses for how stigma might threaten the capacities to participate in fundamental activities that ‘matter most’ in the Chilean context. These include mental illness stigma threatening the man’s ability to protect the honor of the family, and the woman’s ability to be a ‘holy and pure’ mother. Mental illness stigma may further endanger the ability of the family to uphold reciprocal obligations within their social network. Developing such measures promises to aid efforts to address culture-specific forms of stigma, and to facilitate implementation of community mental health services, in Chile and other Latin American contexts.

The Critical Time Intervention Project is a three-year clinical trial which tests a time-limited, supportive intervention to reduce recurrent homelessness among mentally ill men moving from a shelter to the community. Along with a comparison of nights spent homeless and other outcomes, the evaluation of the Critical Time Intervention includes a comparison of the relative costs of the intervention, compared to usual treatment. Such cost effectiveness analyses are difficult to perform and are rarely applied to mental health treatments. This paper presents the general scheme of this analysis and discusses critical issues in the construction and measurement of cost variables. Preliminary results which have implications for the cost analysis are presented.