According to the National Law Center on Homelessness and Poverty, nationwide, more than 3 million individuals each year are homeless (1); about 58% of these individuals have substance use disorders, and approximately 25% have chronic psychiatric disorders (2). Mental illness threatens the core foundations of financial security and social support that protect against homelessness. Reciprocally, homelessness can either aggravate pre-existing mental health conditions or contribute to the risk of development of new disorders.

Despite a need to identify mental health disorders in homeless populations, a search of the literature found no published descriptions of medical-student initiatives in this setting. However, there were a number of articles describing the operation of student-run clinics catering to underserved populations (usually homeless and/or uninsured); these were primarily focused on physical health issues (3, 4).

In light of the paucity of literature, a program was implemented by a medical student to provide mental health screening and education within the homeless community. The goals of this article are to describe the program and how the medical student managed the challenges of initiating it. One additional goal is to document the educational benefits for medical students developing student-led outreach initiatives.

Program Conception

Medical students at our academic institution expressed a desire to lead a mental health outreach program within the homeless community. As a student, one author developed a mentor relationship with a co-author to identify funding and provide assistance with program design and implementation. Faculty supporters were instrumental in supervising these efforts, as well as in connecting the program with collaborating/supporting organizations, including the Texas Regional Psychiatry Minority Mentor Network (TRPMMN) (5), All Healers Mental Health Alliance (AHMHA), Mental Health Association of Greater Houston – the Partners in Healing Program (MHA–PIH), and Baylor College of Medicine Psychiatry Residents Outreach to the Public Sector (PROPS) (6). The culmination of these efforts and funding by the American Psychiatric Foundation led to a mental health screening and educational initiative being realized in a Houston-area homeless shelter, The Mission of Yahweh. This program was inspired in part by the expressed need of local homeless shelter staff to learn more about mental health diagnosis and treatment. Houston’s homeless population numbers about 10,500, more than half of whom are severely mentally ill (7). Of the homeless population that are mentally ill, 40% utilize mental health services (7). The goals of the initiative were to 1) implement a mental health screening for a diverse population of homeless individuals; 2) offer appropriate referrals for those individuals who screen positive for one or more psychiatric disorders; and 3) educate shelter staff on the recognition of mental illness.

Program Design and Evaluation

After Institutional Review Board approval, the research team contacted area homeless shelter directors and completed an informal needs-assessment to determine the comfort of staff with handling psychiatric concerns of homeless clients as well as with referral for mental health screening and resources. Based on this information, the program was designed and then piloted at the Mission of Yahweh shelter with the hopes that, ultimately, it might be expanded to include additional sites.

An educational curriculum and 90-minute workshop was developed, based on the needs-assessment and information provided by shelter directors. This curriculum used didactic and interactive teaching strategies for the training of shelter staff in the basics of diagnosis and treatment of severe mental illnesses. The content of the workshop, as designed in consultation with an attending psychiatrist, also included essentials of culturally-competent mental health care and information about community mental health resources in the greater-Houston area. Also, multiple-choice pre-test and post-test questionnaires (10 and 14 questions, respectively) were created to be administered to all participants of the educational workshop in order to measure the knowledge gained from this educational outreach experience.

For the mental health screening arm of this study, the research staff acquired, by donation through AHMHA, Shedler’s Quick Psycho-Diagnostics computer panels pre-loaded with a screening questionnaire that has been used to assess patients for a variety of mental disorders, with the exception of psychosis. Screening panels had been validated against the Structured Clinical Interview for DSM-IV, and, on average, required 10 minutes to complete (8, 9). Responses were in True/False format and required minimal computer literacy.

A team of four medical students, one resident physician, and two attending physicians were recruited to staff a screening event. The role of medical students was to organize and direct clients during the screening process, including reading screening questions for those who had difficulty with reading. A medical student also concurrently led the educational workshop for the shelter staff. The role of resident and attending physicians was to review the results of screening with clients and to offer appropriate referral if necessary. Along with reviewing data from the mental health screen, the physicians ensured that appropriate emergency referral services were made, if needed. The shelter staff members were also contacted 3 months after the intervention to assess rates of client-referral engagement.

Study Participants

Study participants were recruited in the Mission of Yahweh shelter on a voluntary basis. All 20 homeless individuals residing in the shelter were invited to participate in the mental health screening; 19 consented to participate in the screening. The subjects were given a complimentary meal, but did not receive monetary compensation. Simultaneously, on site, the seven shelter staff members who were present consented and attended the educational workshop. Shelter staff members were administered pre- and post-workshop questionnaires to evaluate changing knowledge of mental health-related issues of diagnosis and treatment.

Shelter staff and clergy’s overall psychiatric fund of knowledge improved by a statistically significant average of 23%, based on results of the pre-/post-test questionnaire (p=0.005). Responses to test items on knowledge of psychotropic medications, principles of cultural competence, and diagnostic criteria improved by averages of 27%, 17%, and 25%, respectively. Participants uniformly reported the training was very useful or somewhat useful to their work in understanding and assisting homeless persons with mental illness, and in identifying referral sources.

Of those screened, 68% were positive for at least one psychiatric disorder, each of whom was referred to a follow-up clinic in the public healthcare system. The most prevalent psychiatric diagnoses were depression: 26%, anxiety: 21%, and posttraumatic stress disorder (PTSD): 16%. Participants uniformly reported that the computerized diagnostic panels were quick and easy to use; 46% of screened clients had accessed their referral services for further treatment recommendations by 3 months, as reported by the shelter coordinator, who was designated to follow up with these homeless clients.

The obstacles to effective service provision (screening and mental health education) were primarily related to logistics of scheduling and difficulty in engaging homeless clients, some of whom distrusted service-providers. Barriers to care included the lack of healthcare benefits, population transience, and impediments to follow-up, such as transportation problems. Additional improvements to consider in future such events include providing formal screening for psychotic disorders and transportation services for homeless clients. It would also be useful to consider including outcome measures that would reflect the impact of the educational workshop on staff behaviors and interactions with their mentally-ill homeless clients.

Essential skills were gained in leadership and in the development and implementation of an intervention program. The four medical students who participated in various phases of the project also learned how to delegate roles so that each member (from student to faculty) of the treatment team was effectively utilized. They learned how to distribute resources and grant money to ensure that all essential aspects of the project could be successfully undertaken. Collaboration skills were also developed by aligning with the supporting organizations, interested shelters, and participating students, residents, and faculty.

Especially rewarding components of medical student involvement included the reinforcement of core psychiatric concepts and the application of those concepts to address an important need area. Identified areas for improvement included further training on how to navigate the IRB, instruction on how to develop valid tools for data-gathering to highlight more useful outcome measures, and training to assist with development of alternative behavioral measures for referral success after screening. From the perspective of one author, the largest hurdle as a student was overcoming a lack of confidence, given a relative inexperience in leading the development of a novel program.

Establishing positive interactions with homeless individuals and encouraging the involvement of a wide range of people and organizations are paramount to building a sense of community. The educational programming generated lively discussion; shelter staff learned that racial, ethnic, linguistic, religious, and other cultural factors carry significant weight in influencing interpersonal relationships in the shelter setting. These efforts, together, should increase understanding and reduce stigma and barriers to services for homeless individuals. One hope was to reduce the rates of undiagnosed mental illness by educating shelter staff about psychiatric screening and about how to employ the necessary diagnostic and treatment resources. By the end of the grant period, several more homeless shelters had expressed an interest in incorporating a mental-health educational component into their staff training, as well as in utilizing shelter-based mental health screening tools for purposes of referral. Such student initiatives should assist in reducing mental health disparities and in improving access to care.

The authors extend appreciation to Larry Laufman, Ed.D., Phyllis Harrison-Ross, M.D., Jonathan Shedler, Ph.D., the members of PROPS at Baylor College of Medicine, the All Healers Mental Health Alliance, the Coalition of Urban Resource Experts, and the Texas Regional Psychiatry Minority Mentor Network for your support and mentorship. Sincere thanks to the staff and residents of Mission of Yahweh for participating in this collaboration.

Thanks to the American Psychiatric Foundation and Otsuka Pharmaceutical America for funding and supporting the development and implementation of this program and the presentation of its findings in various venues at annual meetings of the Association for Academic Psychiatry and the American Psychiatric Association.

Authors have no conflicts of interest to disclose.