Mental disorders keep thousands of homeless on streets


Moving them off the streets

Costs can run into the millions

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Joggers trot along freshly paved paths, and sunbathers stretch out on the manicured grass of Georgetown Waterfront Park in Washington.

Nearby but oblivious to most, Janice lines up six garbage bags swollen with soiled blankets and clothes on a stretch of sidewalk where she sleeps each night. "I'm not homeless," she says when asked how long she's been living on the streets. "I'm waiting for the movie star." Like other homeless people interviewed for this article, Janice identified herself only by first name.

More than 124,000 – or one-fifth – of the 610,000 homeless people across the USA suffer from a severe mental illness, according to the U.S. Department of Housing and Urban Development. They're gripped by schizophrenia, bipolar disorder or severe depression — all manageable with the right medication and counseling but debilitating if left untreated. In the absence of such care, their plight costs the federal government millions of dollars a year in housing and services and prolongs their disorders.

A few blocks away, David, 56, says he's been sleeping on a park bench in Washington Circle Park for 22 years because he's conducting a "long-term socioeconomic study." Miguel, 57, lives under a nearby overpass because he claims his identity was stolen by federal agents.

Gunther Stern, executive director of the Georgetown Ministry Center, greets them each by name, asks them if police are harassing them or if they're getting enough to eat. He's seen the same faces nearly every day for years.

"It's frustrating," Stern says, briskly moving from one huddle of homeless people to the next. "You see the same people over and over again. It's just so hard to move people like this off the street."

Each day, thousands of people with severe mental illness, such as those Stern encounters on his weekly outreach walks, wind up living on the streets of cities and towns across America.

HUD's figure placing the homeless population at 610,000 is lower than other estimates, which range as high as 3.5 million. The government's number represents a count done one time a year. The number of Americans who are homeless at some point during a year changes constantly as people move in and out of homelessness, sometimes for days at a time, sometimes weeks or months.

In a series of stories this year, USA TODAY is exploring the human and financial costs the country pays for not caring more for the nearly 10 million Americans battling severe mental illnesses. The mentally ill homeless are some of the hardest to reach and toughest to treat, often self-medicating with drugs and alcohol and teetering between lucidity and crippling despair.

"There are so many people out there who are mentally ill that need to be treated," says Deborah Zelinsky, 45, of Pacoima, Calif., who spent more than two decades homeless before being diagnosed with bipolar disorder, getting treatment and finding an apartment. "On the streets, you don't have time to get treated. You are trying to survive."

As they cycle between street corner, jail cell and hospital bed, the homeless who are mentally ill cost local, state and federal agencies millions of dollars a year. This fiscal year, the federal government will spend $5 billion on programs for the homeless. Next year, that figure is likely to grow to nearly $5.7 billion.

Services that can work

Housing, then treatment, helps many

Heather Russell, 35, is one of a growing number of people dealing with mental illness and homelessness. Homeless since 2006, she recently found housing and is off the streets. Richard J. Carson for USA TODAY

Two strategies gaining favor in treating the homeless who are mentally ill are the "Housing First" approach, which puts homeless individuals into housing first, then treats their ailments, and permanent-supportive housing, which couples housing with counseling and access to meds. The initiatives are rapidly moving the mentally ill off the streets and saving the country tens of millions of dollars each year in homeless costs.

Because of a lack of federal financial and political commitment, they're not happening fast enough.

"It's like bailing a leaking boat: As fast as we can get people into housing, we get more people coming in," says Nan Roman, head of the National Alliance to End Homelessness. "We clearly know what to do. We're just not doing enough of it."

The number of mentally ill homeless surged in the 1970s and '80s as the second half of the Baby Boom generation reached the age of onset for schizophrenia, which typically begins when a person reaches their 20s, and psychiatric hospitals and group homes struggled to keep up with demand, says Dennis Culhane, a University of Pennsylvania researcher who has studied the issue for more than a decade.

Having nowhere to go, many of those people hit the streets.

In the early 1990s, homeless advocates began embracing the Housing First system, Culhane says. The clients were assigned caseworkers who helped them navigate the process and made sure they kept up with treatment.

In a landmark study released in 2002, Culhane and two colleagues tracked the costs of 4,600 homeless people with mental illness in New York City over nine years. Those who remained on the street, shuffling in and out of jails and hospitals, cost the city and state $40,451 a year in services. Those placed in supportive housing cost $17,277 to house. Those given supportive housing tended to stay off the street.

"We have the solution; no one can say we don't have the solution," Culhane says. "The problem remaining is figuring out how we take this to scale."

Starting under President George W. Bush, the federal government made permanent-supportive housing a national priority. The number of beds has steadily climbed, from 188,636 in 2007 to 284,298 today, slightly more than half of which go to people with mental health disabilities, according to the National Alliance to End Homelessness.

More are needed, says Andrew Sperling, a housing and homelessness policy expert at the National Alliance on Mental Illness. "Just a little more money will get the job done," he says.

This year, President Obama requested a $301 million housing budget increase that would create 37,000 more permanent-supportive housing units and potentially wipe out chronic homelessness in America, says Jennifer Ho, a HUD senior adviser . That request stalled in Congress.

A more politically popular request for an increase in supportive housing for military veterans passed overwhelmingly and could eradicate veteran homelessness in the USA by next year, she says.

"We've got study after study showing that it actually works," Ho says. "We've debunked the myth that certain people can't be housed."

But the programs are not reaching those who need it most fast enough.

Despair can take lives

Stories of those lost to the streets

Greg Sherman had all the signs of a normal life: raised in a middle-class family, graduated from law school, married his college sweetheart, helped raise two kids, on track to make partner at his law firm.

As the kids grew into teenagers, something in Sherman went awry. He became distant, staring at the wall for stretches at a time or glaring at his family in what his son Matt calls "focused anger." He began drinking heavily, lost his job and got divorced.

"The way he acted, this just wasn't Dad anymore," Matt Sherman says.

In 1999, Greg Sherman disappeared. One day, while a freshman at college in Southern California, Matt Sherman discovered his father among the homeless living at the beach in Santa Monica. Greg stuck around for a few weeks, then promptly disappeared again.

Desperate to learn the whereabouts of their father, Matt Sherman and his sister, Anne, reached out to the Social Security Administration. A few months later, they received a form reply letter, informing them their dad was dead. Greg Sherman had died of sepsis in 2006 while homeless in Washington.

Matt Sherman says it pains him to have lost his father to a curable disease when so many programs exist to get the mentally ill off the street. The perception of people with mental disorders on the street needs to change, he says.

"Don't be so quick to objectify them," Matt Sherman says. "That could be a very dear family member you grew up with that just lost their way."

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Dorothy Edwards knows the despair and paranoia that cripple the mentally ill from seeking help and finding an apartment. For eight years, Edwards, 56, wandered the streets of Pasadena, Calif., sleeping in alleys, scouring Dumpsters for scraps of food and smoking meth to fend off a crushing depression. Her teeth were rotting, and sores broke out all her over body. She was sexually assaulted repeatedly and had her belongings stolen multiple times.

When things got truly bleak, Edwards would check herself into the psych ward of a hospital, only to be back on the streets within days. Various friends ravaged emotionally by the homeless life had flung themselves off the Colorado Street Bridge in Pasadena, known locally as "suicide bridge." She considered using the bridge herself, she says.

"It was looking pretty good to me," Edwards says. "I had run out of options."

Shortly after, she was approached by a worker from Housing Works, a Los Angeles homeless outreach center. The worker escorted Edwards to a processing center, where counselors diagnosed her with depression and post-traumatic stress disorder, found her an apartment and assigned her a caseworker.

Today, Edwards lives in a one-bedroom apartment in Pasadena with her 8-year-old mixed-breed dog, Gunner. The paranoia and anxiety still creep in periodically, especially late at night, but the meds and a watchful caseworker help her through it. She's looking for a job.

"The system is broken, and they found a way to make it work," Edwards says. "And it's awesome."

Housing benefits clear early

Country catches on to programs' benefits

Sam Tsemberis, executive director of Pathways to Housing, a New York-based housing group that works in cities across the USA, says the ability to house people like Edwards comes not just from new housing strategies but from a fundamental shift in how Americans view people with mental illness.

As a homeless specialist at New York's Bellevue Hospital in the late 1980s, Tsemberis witnessed firsthand the seemingly endless stream of mentally ill patients who visited the hospital's emergency room before returning to the streets. He began recording how patients with schizophrenia, given proper housing and treatment, were able to hold jobs, manage their bills and cook their own meals, and he encouraged advocates to house first, treat later.

Slowly, the rest of the country caught on. Tsemberis helped popularize the Housing First initiative that led to permanent-supportive housing.

"We have misunderstood profoundly what it means to be mentally ill," he says. "They're capable of far more than we ever imagined."

Officials in Houston and surrounding Harris County decided not to wait for more federal help. Faced with a growing chronic homeless population and diminishing federal aid, officials from the Houston Housing Authority, Houston Police Department and other agencies joined forces in 2011 to create a computerized countywide housing-first network that helps place chronic homeless people in apartments quickly. It's become a model across the USA.

Outreach workers in Houston identify homeless individuals and make an assessment of their vulnerability, including how long they've been on the streets and signs of mental illness. Using iPads and laptops, the workers tap into the network of more than 3,000 supportive housing apartments in the region to see which are available. Average wait time from assessment to move-in: 56 days.

In the three years since the system launched, the number of chronic homeless in the greater Houston area has dropped from 1,791 in 2011 to 763 today – a 57% decrease.

The key has been getting the mentally ill homeless person housed as quickly as possible, says Tory Gunsolley, president and chief executive of the Houston Housing Authority. "Every time you have the homeless person in front of you, that's the time to get stuff done," he says. "Every time you let them go, they wind up back on the street."

Farther west on I-10, officials in San Antonio created a system for housing the mentally ill that's being replicated throughout the country. Homeless people picked up on the street are taken to the Restoration Center, a large building northwest of downtown that offers medical treatment, psychological analysis, sobriety wings and information on apartments — all under one roof. Police are trained to bring homeless individuals showing signs of mental instability directly to the center.

Besides getting more mentally ill homeless off the street, the system has freed up police officers from spending hours escorting a homeless person to an emergency room and kept the homeless out of jails. Over the past four years, the system has saved the city and county an average of $10 million a year in emergency room and jail visits, according to the Center for Health Care Services, a non-profit mental health system that services San Antonio and Bexar County and oversees the network.

"There are a lot of folks out there who think you can arrest the homeless issue away," says San Antonio Police Chief William McManus, who requires each police recruit to take a training course on how to handle the homeless. "And you can't."

On a recent morning at the Restoration Center, people filled the welcome lobby, waiting to meet with a counselor about getting treatment or seeking a new apartment. Sam Lott flitted between the visitors, shaking hands, calling some by name or sitting down to carefully hear their requests.

Sam Lott spent two years homeless in San Antonio. He now counsels other men as they enter the same recovery program that turned his life around.

Lott, 50, runs the in-house recovery wing of the Restoration Center. For three years, he was a homeless drug addict, drifting from Dallas to Fort Worth and finally to San Antonio. He slept in parks or wooded lots on San Antonio's outskirts and smoked meth to dull alternating bouts of anxiety and depression. He tried seeking help, but over and over again, his mental anguish prevailed, and he returned to the streets.

A few years ago, after being arrested for assault and spending three months in jail, Lott came to the Restoration Center, met with a counselor and was diagnosed with Type I bipolar disorder. He was prescribed Prozac and found an apartment. He's been clean and sober for 14 months.

He spends each day doing what he loves most: helping others get off the street and trying to dispel myths about homeless people with mental disorders.

"Deep down, that person doesn't want to be there," Lott says. "There's a lot more to them than you see."

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