Schizophrenia and homelessness: Why intervention is needed

In clinical settings, considerations for schizophrenia typically focus on symptom control, relapse prevention and functional recovery; however, these considerations do not tell the full story.¹ The social and public health implications of this disorder require equal attention, particularly the increased risk of homelessness among people living with schizophrenia.¹ Homelessness and schizophrenia intersect in ways that compound clinical complexity and worsen long-term outcomes.² Understanding the bidirectional influence is critical for clinicians seeking to improve both psychiatric and social outcomes in this vulnerable population.

A closer look at the evidence: Prevalence and risk

Schizophrenia is vastly overrepresented among the homeless population. A diagnosis of a serious mental illness increases an individuals’ risk of becoming unhoused by 10–20 times compared with the general population.¹ The risk is even greater in specific subgroups; among veterans, 28.2% of those with schizophrenia experience homelessness compared with 7.2% of veterans without serious mental illness and just 0.2% of the general population.³ Reflecting these disparities, an estimated 10.3% of homeless individuals across developed and developing countries live with schizophrenia.² Together, these statistics demonstrate that homelessness occurs among people living with schizophrenia at a rate that far exceeds that seen in the general population.

Why does schizophrenia increase the risk of homelessness?

The increased risk of homelessness in schizophrenia reflects the complex and multifaceted nature of the disorder. Persistent positive symptoms, negative symptoms, and cognitive impairments can undermine everyday functioning, limiting the ability to sustain employment, relationships and independent living.^1,4 Anosognosia, a lack of awareness of the disorder affecting 30–50% of individuals living with schizophrenia, further complicates outcomes by reducing the capacity to accept or maintain treatment.¹

The clinical implications of homelessness in schizophrenia

Homelessness magnifies the burden of schizophrenia by increasing exposure to conditions known to worsen physical and mental health, such as violence, infection, sleep deprivation and environmental stressors.^1,5 As a result, unhoused individuals living with schizophrenia experience higher rates of premature mortality and suicide compared with housed individuals.¹

Housing instability also impacts medication adherence, contributing to relapse and hospital readmissions.⁶ Delays in diagnosis and longer durations of untreated psychosis are more common among unhoused individuals. This has a notable impact on health outcomes, resulting in poorer symptom remission, reduced social functioning and increased suicide risk.⁷ Together, these factors create a self-reinforcing cycle in which homelessness and untreated psychosis drive ongoing clinical deterioration.

What works? Addressing homelessness in schizophrenia

Housing intervention models

Historically, a ‘treatment first’ approach to addressing homelessness has been taken. This model follows a stepwise approach, requiring individuals to maintain sobriety, engage in treatment and demonstrate housing readiness in order to obtain permanent housing.⁸ This approach has been criticised owing to the need to adhere to strict rules whilst dealing with the challenges of housing instability.¹ In light of this, the ‘housing first’ approach has emerged. As the name suggests, the ‘housing first’ approach provides immediate access to permanent housing as a basic right, regardless of substance use or treatment adherence.^1,9

‘Housing first’ interventions have been associated with improvements in housing stability and a reduction in non-routine use of healthcare services compared with a ‘treatment first’ approach.⁹ Despite these potential benefits, the impact of such initiatives on health and quality of life outcomes, as well as concurrent substance use disorders remains unclear.⁹ These findings demonstrate that housing interventions alone are not effective for the treatment of psychotic symptoms of schizophrenia.¹

Treatment intervention models

Antipsychotic medications remain central to the management of schizophrenia, with both oral and long-acting injectable agents serving as effective treatment options.^1,6 However, many individuals with active psychosis refuse treatment, in some cases due to the presence of anosognosia.^1,6 Failure to treat the active psychosis can lead to long durations of untreated psychosis, posing the risk of deterioration, reduced treatment response over time, functional disability and suicide.^10,11 Owing to the adverse consequences of remaining untreated, it is important to evaluate the individual’s awareness of their mental disorder and their ability to make informed decisions about treatment.¹

Compulsory community treatment orders (CTOs) may be considered for those who refuse treatment.^1,12 Under CTOs, identified individuals are required to receive psychiatric treatment, and failure to do so can result in involuntary psychiatric hospital readmission.^1,12 This can take the form of 24-hour, involuntary, structured treatment.¹³ In cases or regions where CTOs are not applicable or appropriate, intensive case management and assertive community treatment can provide essential support.¹

There is a need for intervention

Overall, the markedly increased risk of homelessness among people living with schizophrenia often reflects the consequences of untreated or inadequately treated psychosis rather than housing instability alone.¹ Reducing homelessness in this population requires integrated models of care that prioritise effective antipsychotic treatment alongside housing stability, and appropriately intensive community-based support.¹