Physical illness, mental illness and substance addiction go hand-in-hand in the single-room occupancy hotels of the Downtown Eastside of Vancouver, British Columbia, says a team of 16 researchers representing multiple health professions.
The median number of illnesses among residents of this marginalized-housing community is three, according to the first study to examine multimorbidity in this population (Am J Psychiatry 2013; doi:10.1176/appi.ajp.2013.12111439). Substance abuse, psychosis, HIV infection and hepatitis C rates are all high.
The hotels once provided off-season housing to seasonal labourers, but are now considered just one step up from homelessness. “There was always a lot of alcohol, and being a port city, there was quite a bit of heroin as well,” says Dr. William Honer, the study’s principal author and head of the University of British Columbia’s psychiatry department. “It’s always had that character.”
The many health problems of the hotels’ residents often go undiagnosed and untreated. The researchers found a mortality rate that is nearly five times higher than that of the general population. “Resources are not optimally configured to care for people who have this complicated mix-up of mental illness, addiction, and physical illness,” says Honer.
The study followed 293 adults for a median of 23.7 months. Two-thirds of the occupants were previously homeless. Almost all had substance addictions (95.2%) and most had injected drugs in the previous year (61.7%). Over time, the substances of choice have shifted from alcohol and opioids to cocaine and methamphetamine, says Honer.
HIV was common, with 18.4% of participants testing positive, as was hepatitis C, with a rate of 70.3%. Nearly half of participants had psychosis and 45.8% had a neurological disorder.
“I’ve been doing diagnostic work for all my career, and these are some of the most challenging cases I’ve ever had to try to sort out,” says Honer. “There are contributions of family history, of functional mental illness, brain injuries they may have had, consequences of drug addiction and so on.”
The findings underscore the need for a different configuration of health care, says Honer. Merely using medication to treat a hepatitis C infection, for example, will not be enough. Health professionals should also be addressing addiction and mental illness in an effort to prevent high-risk behaviour that could lead to reinfection.
It is also important to build trust with a population wary of mainstream health care. This will require the creation of interdisciplinary health care teams willing to spend time building relationships with patients.
“Many of these people come from various socially disadvantaged backgrounds and have a lot of trauma,” he says. “They have not had even ordinary interactions with society and with people in the health care system.”