摘要：Objectives. We assessed the association between homelessness and incarceration in Veterans Affairs patients with bipolar disorder. Methods. We used logistic regression to model each participant's risk of incarceration or homelessness after we controlled for known risk factors. Results. Of 435 participants, 12% reported recent homelessness (within the past month), and 55% reported lifetime homelessness. Recent and lifetime incarceration rates were 2% and 55%, respectively. In multivariate models, current medication adherence (based on a 5-point scale) was independently associated with a lower risk of lifetime homelessness (odds ratio [OR] = 0.80 per point, range 0–4; 95% confidence interval [CI] = 0.66, 0.96), and lifetime incarceration increased the risk of lifetime homelessness (OR = 4.4; 95% CI = 2.8, 6.9). Recent homelessness was associated with recent incarceration (OR = 26.4; 95% CI = 5.2, 133.4). Lifetime incarceration was associated with current substance use (OR = 2.6; 95% CI = 2.7, 6.7) after control for lifetime homelessness (OR = 4.2; 95% CI = 2.7, 6.7). Conclusions. Recent and lifetime incarceration and homelessness were strongly associated with each other. Potentially avoidable or treatable correlates included current medication nonadherence and substance use. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption within this vulnerable patient population. Bipolar disorder, characterized by alternating manic and depressive episodes (manic depression), is a chronic mental illness associated with significant functional and social impairments as well as poor overall health outcomes. The World Health Organization has ranked bipolar disorder among the top 10 conditions associated with quality-adjusted life-year decrements in the Global Burden of Disease report. 1 Up to 5.5% of the US population has bipolar disorder. 2 Persons with bipolar disorder exhibit unique symptoms that can worsen public health outcomes, including homelessness and incarceration. 3 Intermittent manic episodes can lead to medication nonadherence, risky behaviors (e.g., substance use to sustain highs experienced during manic episodes), social consequences, and interaction with the legal system. Some risk factors for homelessness occur disproportionately in persons with bipolar disorder, such as substance-use disorders, 4 which affect up to 72% of those with this condition. Individuals with bipolar disorder are more likely to be incarcerated than those with other mental disorders. 5 They also experience high residential instability 6 and are likely to leave supported housing earlier than persons with schizophrenia, schizoaffective disorder, or depression, which further exacerbates problems with nonadherence and substance use. 7 Moreover, persons with bipolar disorder are better educated than individuals with other chronic mental illnesses, which leads to greater social, occupational, and economic losses when their illness is not adequately managed. 8 Although mental illness and substance-use disorders generally are associated with increased risk of homelessness, 9 , 10 the interplay between homelessness and incarceration among persons with mental illness has not been fully explored, particularly for those with bipolar disorder. Incarceration is strongly and bidirectionally associated with homelessness in persons with mental disorders. 11 , 12 Loss of a stable home can interfere with treatment retention 7 and is associated with poor medication adherence, 13 which can facilitate another cycle of incarceration, homelessness, and symptom exacerbation. Incarceration is also associated with job loss, housing instability, and lost health care benefits. 14 This jail–homelessness cycle was described by Hopper et al., 15 who referred to an “institutional circuit” in which socially excluded populations were shifted from place to place and where potentially manageable clinical aspects of mental illness were complicated by social determinants of the patients' situations (e.g., poverty). Studies have pointed to the need to examine treatable contributors to the jail–homelessness cycle, such as symptoms, adherence, and substance use, 16 but these studies have primarily focused on administrative data and have used little behavioral, clinical, or socioeconomic information. There is also little information on the risk factors associated with homelessness and incarceration among veterans. Approximately 40% of homeless individuals in the United States are veterans, 17 – 19 although only 8% of the overall US population are veterans. In fiscal year 2005, 1% of the users of the Veterans Administration (VA) health care system were homeless, but 7% of VA mental health care patients were homeless, per our queries of VA databases. Among homeless veterans, 41% in one study and 70% in another reported using VA health care services, 20 , 21 which makes the VA health care system a promising contact point for interventions targeting homeless veterans. A better understanding of the associations among treatment and behavioral factors, homelessness, and incarceration could inform the development and implementation of interventions that could interrupt the jail–homelessness cycle and improve patients' outcomes. To that end, we conducted this study to: (1) estimate current and lifetime incidence of homelessness and incarceration among VA patients with bipolar disorder, (2) explore factors related to homelessness and incarceration, and (3) determine the variance in each condition that was accounted for by the other condition. We hypothesized that the risks of homelessness and incarceration would be increased among those with substance use, poor adherence, and low therapeutic alliance, after controlling for sociodemographic and clinical factors. We chose to focus on these potentially treatable factors in light of studies that have suggested that improving adherence, 22 , 23 reducing substance use, 24 and strengthening therapeutic alliances 23 led to improved remission rates and outcomes in patients with bipolar disorder and other mental disorders.
