Untreated Mental Illness Has Created a National Tragedy A Pandemic of Homelessness

Jonathan, a gifted artist, dropped out of college his freshman year. He was attacked by paranoid delusions that a former girlfriend was stalking him and was convinced his brain had become “unable to
connect thoughts.” Jonathan began smoking marijuana daily to “quiet the demons in his mind.” Never
a violent person, he struck his father and threw rocks at his girlfriend’s house. He ran away from home
and lived on the street for 6 months. When his parents found him, he was disheveled, malnourished,
and disoriented. He was hospitalized, treated with antipsychotic medications, and discharged to an intensive outpatient program where he could continue treatment. Four years later, he has remained adherent to clozapine, graduated from a prestigious university, matriculated into a top fine arts graduate program, and has begun to create an extraordinary portfolio of writings, illustrations, and paintings.

Jonathan is one of the lucky ones. He was rescued from homelessness by a caring and supportive
family that could afford to provide him with state-of-the-art care. His family was able to persuade him
to accept treatment, and he responded to treatment. Most homeless individuals are not so fortunate.

Homelessness was deemed a “crisis” before the economic disruption and devastating housing insecurity
brought on by the COVID-19 pandemic.1 People experiencing homelessness die in our streets every
day, and the rate at which they are dying is increasing.2

The determinants of homelessness are complex and different for everyone, with psychiatric illness
and addiction as primary drivers.3,4 The California Policy Lab at UCLA has found that mental health
conditions affect 78% of unsheltered people, substance abuse conditions affect 75% of the unsheltered
population, and 50% of the unsheltered are “trimorbid”—affected by physical impairments, mental
health impairments, and substance abuse conditions.5 Our systems of delivering care to these individuals
are inadequate.

We propose 3 major policy changes that must be enacted nationally and administered locally, to address
homelessness caused by medical and psychiatric illness: (1) creation of housing in which to treat
people experiencing homelessness. This housing must include a dimension of care from hospitals, to residential treatment centers, to independent living situations where counseling, medical care, and supervision are provided to the residents. (2) Expert psychiatric medical care must be provided. (3) To take the first step from homelessness to treatment, we must change our commitment laws and make involuntary commitment more accessible. Personal freedoms must be carefully curtailed to limit severe outcomes— just as in the COVID-19 pandemic, we have enacted mask requirements, social distancing, selective vaccine mandates, and other measures to limit the spread of severe viral illness, and we must enforce commitment laws that will allow treatment of the homeless mentally ill.

Why is it that a person suffering from a myocardial infarction on a public street would receive immediate
emergency care and transfer to a hospital where lifesaving interventions can be conducted and
long-term rehabilitation can be arranged, whereas another person in the street who is confused and beset by hallucinations and delusions is ignored by those who pass by? We believe this is due to a longstanding historical dualism between medical illnesses and mental illnesses, when in fact they are scientifically one and the same.2

Untreated schizophrenia, like all forms of psychotic mental illnesses, is a genetically determined,
medical disorder. Many small genetic mutations—more than 100 at the time when we wrote this
article—determine 80%of the known vulnerability for schizophrenia.6 When added together, these gene
changes cause a profound derangement in brain circuits that give rise to the hallucinations, delusions,
cognitive disorganization, anxiety, and mood symptoms of schizophrenia. Schizophrenia impairs all aspects of daily living, often making it impossible for an untreated patient to adequately care for themselves. All “mental” illnesses are simply medical illnesses of the brain. As a nation, we must begin to treat schizophrenia and other serious mental disorders like any other medical disorder—
no more dualism.

Any system of care and housing for the homeless must begin with change in our commitment laws. These laws, part of a national legislative effort to protect mentally ill individuals from inappropriate detainment, have unfortunately contributed to widespread untreated mental illness. Absent changes, we will have few homeless people opting to engage in treatment or willing to access housing created for them. Under present state laws, most homeless individuals cannot be committed to treatment, and the vast majority will refuse to voluntarily agree to treatment.7 Assisted outpatient treatment programs, which are involuntary outpatient treatment programs created by laws such as Laura’s Law in California and Kendra’s Law in New York, have not been provided adequate resources to enable expansion, despite their proven track record in reducing homelessness and incarceration.8–11

Involuntary commitment laws are closely tied with patients’ rights to refuse treatment. Before the landmark 1979 First Circuit Court of Appeals Rogers v. Okin decision, it was assumed that psychiatric patients could be compelled to accept their psychiatrists’ medication recommendations, even if this involved involuntary intramuscular medications. However, the decision created a new standard that involuntarily committed patients must be assumed to be competent to refuse treatment until it is determined that they are incompetent. Currently, states generally fall into 2 models of adjudicating patients’ competence to deny treatment: the rights-driven model and the treatment-driven model. Patients who live in states that use the rights-driven model must have their competency assessed by a judge during a full adversarial hearing, and the patient’s right to refuse treatment is lost only if the judge finds the patient incompetent. Patients who live in states that use the treatment-driven model are assumed to be competent to refuse medications, unless a second physician or treatment panel determines the medications can be administered against their will. Utah is the only state to not use one of these models—in Utah, patients must lack competence to consent to treatment as a requisite for involuntary psychiatric hospitalization.12

Although advocates of patients’ right to refuse treatment celebrate the expansion in civil liberties, we must consider the associated aftermath—limiting the availability of involuntary medication administration has resulted in increasing illness severity, decreases in community functioning, and patients left to bear the burden of psychosis without the aid of modern medicine. Prominent forensic psychiatrists Paul Appelbaum and Thomas Gutheil declared in 1979 that patients were “rotting with their rights on” because of these harmful aftereffects of the Rogers decision.13 Commitment laws must be changed to allow greater access to involuntary administration of medication.

Even if our patients were to be forcibly hospitalized or were to accept hospitalization, there is a dearth of available resources. The reduction in the number of beds in state-funded psychiatric hospitals over the past 65 years is staggering. In 1955, there were 560,000 beds available for approximately 3.3 million Americans living with severe mental illness, whereas by 2016, there were fewer than 38,000 beds for 8.1 million Americans with the same mental illnesses.14 It often seems that the threshold for involuntary psychiatric hospitalization is most frequently determined by the availability of limited beds rather than the symptoms or disability of the patient. No changes in commitment laws will result in effective treatment without the requisite increases in psychiatric hospital beds and community treatment centers.

Therapeutic housing for the homeless mentally ill will not be enough to improve outcomes. Greater access to long-acting injectable antipsychotic medications must be made available. Long-acting injectable antipsychotics demonstrate superior efficacy in the acute and chronic treatment of schizophrenia, decreasing the likelihood of relapse and hospitalization.15,16 The superior efficacy of long-acting injectable antipsychotics is demonstrated in real-world observational studies rather than randomized controlled trials because compliance, monitoring, and follow-up are inherent in the structure of randomized controlled trials and not observational studies. The greater efficacy of long-acting preparations compared with oral medications in observational studies is thus thought to be due to improved compliance. Some experts have recommended first episode psychosis be treated with long-acting injectable antipsychotics because of their demonstrated improved outcomes.17 However, there are currently significant barriers to the use of long-acting injectable antipsychotics, including cost, stigma, clinician lack of awareness of superior outcomes, fear of needles, and patients’ fear of coercion.18

Another underutilized treatment of psychosis is the use of combinations of antipsychotics. Combination therapy has demonstrated superior outcomes in prevention of rehospitalization and symptom relapse; however, outdated treatment guidelines generally recommend against antipsychotic polypharmacy.19,20 Anecdotally, we have experienced repeated denials of insurance company reimbursement for long-acting injectable antipsychotics when combined with other oral antipsychotics on the basis of these outdated guidelines.

Despite its well-known reputation as the most effective antipsychotic for treatment-refractory schizophrenia, clozapine is similarly underutilized in homeless individuals. There is frequent unnecessary delay in treating patients with clozapine, causing further suffering and prolongation of psychosis. Barriers to increased clozapine utilization include negative prescriber attitudes toward clozapine, administrative burden, and the need for frequent laboratory monitoring.21 These barriers have successfully been reduced by methods such as introduction of specific clozapine clinics, centralized auditing of community mental health center practices, point-of-care blood monitoring, and supervised medication administration.21–23 Greater access to clozapine treatment is an essential component in restoring the function of patients suffering from schizophrenia.

Gwendolyn is a pleasant woman in her 80s suffering from schizophrenia who lives under a store awning in Los Angeles. She has the delusional belief that she has won the lottery and that the county sheriff has asked her to live in the streets for years before she can collect her prize. When evaluated by psychiatric emergency staff, Gwendolyn cannot be committed for hospitalization because she is able to say she knows how to access food, clothing, and shelter and is not deemed to be suicidal or homicidal. Even though she has been hospitalized more than 6 times in the past year for severe leg swelling, congestive heart failure, and repeated urinary tract infections, she is left to live on the streets at high risk of malnutrition, morbid medical illness, and violence. She does not believe she has a mental illness, and refuses treatment with psychiatric medications. Her social workers labeled their services to her “hospice on wheels,” anticipating her torturous decline toward a premature death. Her problems cannot be solved without implementing the policy changes we have outlined.

The movement to expand access to treatment for like Gwendolyn and Jonathan is slowly growing. Some states such as Arkansas have expanded criteria for involuntary commitment to include individuals who cannot understand their illness and need for treatment and are thus at risk of “harmful deterioration.”24 Other states such as California and Washington have expanded or considered expanding the criteria for involuntary commitment to include individuals who are not able to remain safe or care for their serious medical needs because of mental illness.25–27

The Los Angeles Office of Diversion and Reentry, led by psychiatrist Kristen Ochoa and former judge Peter Espinoza, is a government agency that has successfully diverted thousands of mentally ill individuals from incarcerated and homeless settings into the community with adequate psychiatric treatment. We must follow this model and the model adopted by other cities and countries such as Trieste, Italy, where financial resources previously appropriated for now-closed mental health hospitals were actually redirected to new systems and approaches to care.28

Funds provided by federal and state budgets to house the homeless must go to building treatment centers, not to makeshift shelters and hotels. This housing must include a dimension of care from hospitals to residential treatment centers and independent living situations where counseling, medical care, and supervision are provided to the residents. Individuals who cannot live independently deserve care in a structured, humane setting, not the destitute conditions they face on the streets.29 We are not arguing for a return to the institutionalization seen in the mid-20th century —in fact, we must be mindful not to recreate the oppressive and prison-like environment of many state-funded psychiatric hospitals of that era.30 We can do better than that this time.

No grant support or other material support was received for the work described in the article.
The authors declare no conflicts of interest.


Thrush G. Homelessness in U.S. rose for 4th straight year, report says [New
York Times Web site]. March 18, 2021. Available at: https://www.nytimes.
com/2021/03/18/us/politics/homelessness-coronavirus.html. Accessed
September 23, 2021.

  1. Glick ID, Shader RI. The problem of medical-psychiatric illness in the
    homeless and its occurrence in the midst of a viral pandemic: a
    commentary. Psychiatry Res. 2020;290:113118.
  2. Solis HL, Mitchell H, Kuehl S, et al. Recent trends in mortality rates and
    causes of death among people experiencing homelessness in Los Angeles
    County [Los Angeles County Department of Public Health Web site].
    January 2021. Available at: http://www.publichealth.lacounty.gov/chie/
    reports/HomelessMortality2020_CHIEBrief_Final.pdf. Accessed
    October 8, 2021.
  3. Katz MH. Homelessness—challenges and progress. JAMA. 2017;318:
  4. Roundtree J, Hess N, Lyke A. Health conditions among unsheltered adults
    in the US. California Policy Lab October 6, 2019. Available at: https://
    s/. Accessed September 23, 2021.
  5. Hilker R, Helenius D, Fagerlund B, et al. Heritability of schizophrenia and
    schizophrenia spectrum based on the nationwide Danish twin register. Biol
    Psychiatry. 2018;83:492–498.
  6. Appelbaum PS. Assessment of patients’ competence to consent to
    treatment. N Engl JMed. 2007;357:1834–1840.
  7. Gilbert AR, Moser LL, Van Dorn RA, et al. Reductions in arrest under
    assisted outpatient treatment in New York. Psychiatr Serv. 2010;61:996–999.
  8. Kendra’s Law: final report on the status of assisted outpatient treatment
    [New York State Office ofMental HealthWeb site], March 2005. Available
    at: https://my.omh.ny.gov/analyticsRes1/files/aot/AOTFinal2005.pdf.
    Accessed October 8, 2021.
  9. Swanson JW, Borum R, Swartz MS, et al. Can involuntary outpatient
    commitment reduce arrests among persons with severe mental illness?
    Crim Justice Behav. 2001;28:156–189.
  10. Esposito R, Westhead V, Berko J. Florida’s outpatient commitment law:
    effective but underused. Psychiatr Serv. 2008;59:328.
  11. Hicks C,WestW. Does your patient have the right to refusemedications?A
    brief guide to the legal aspects of administering involuntary medications.
    Curr Psychiatr. 2020;19:23–32.
  12. Appelbaum PS, Gutheil TG. “Rotting with their rights on”: constitutional
    theory and clinical reality in drug refusal by psychiatric patients. Bull Am
    Acad Psychiatry Law. 1979;7:306–315.
  13. Fuller DA, Sinclair E, Snook J. Released, relapsed, rehospitalized: length of
    stay and readmission rates in state hospitals: a comparative state survey
    [Treatment Advocacy Center Web site]. November 2016. Available at:
    rehospitalized.pdf. Accessed October 8, 2021.
  14. Miura G, Misawa F, Kawade Y, et al. Long-acting injectables versus oral
    antipsychotics: a retrospective bidirectional mirror-image study. J Clin
    Psychopharmacol. 2019;39:441–445.
  15. Tiihonen J, Taipale H, Mehtälä J, et al. Association of antipsychotic
    polypharmacy vs monotherapy with psychiatric rehospitalization among
    adults with schizophrenia. JAMA Psychiat. 2019;76:499–507.
  16. Salgueiro M, Segarra R. Long-acting injectable second-generation
    antipsychotics in first-episode psychosis: a narrative review. Int Clin
    Psychopharmacol. 2019;34:51–56.
  17. Lindenmayer JP, Glick ID, Talreja H, et al. Persistent barriers to the use of
    long-acting injectable antipsychotics for the treatment of schizophrenia.
    J Clin Psychopharmacol. 2020;40:346–349.
  18. Lin SK. Antipsychotic polypharmacy: a dirty little secret or a fashion? Int J
    Neuropsychopharmacol. 2020;23:125–131.
  19. Leucht S, Tiihonen J. Clozapine, long-acting injectables (and polypharmacy?)
    superior in U.S. and international registries. Am J Psychiatry. 2021;178:
  20. Kelly DL, Freudenreich O, SayerMA, et al. Addressing barriers to clozapine
    underutilization: a national effort. Psychiatr Serv. 2018;69:224–227.
  21. Bogers JP, Schulte PF, Van Dijk D, et al. Clozapine underutilization in the
    treatment of schizophrenia: how can clozapine prescription rates be
    improved? J Clin Psychopharmacol. 2016;36:109–111.
  22. Kelly DL, Ponomareva OY, Mackowick M, et al. Feasibility and patientreported
    satisfaction using a novel point-of-care fingerstick method for
    monitoring absolute neutrophil count for clozapine. Ann Clin Psychiatry.
  23. Arkansas Code Title 20: Public Health and Welfare §20–47-207.
    Involuntary admission petition (2014).
  24. Washington Revised CodeRCW71.05.020. Mental illness definitions (2005).
  25. Greenberg J. Bulletin: changes to the Involuntary Treatment Act (ITA)—
    part 1—key changes [Washington State Hospital Association Web site].
    May 21, 2020. Available at: https://www.wsha.org/articles/bulletinchanges-
    Accessed September 23, 2021.
  26. Curwens T. Should California expand what it means to be ‘gravely
    disabled’? Los Angeles Times [Internet]. April 18, 2018. Available at:
    20180418-story.html. Accessed September 23, 2021.
  27. Mezzina R. Communitymental health care in Trieste and beyond: an “open
    door-no restraint” system of care for recovery and citizenship. J NervMent
    Dis. 2014;202:440–445.
  28. Glick ID, Berlant J, Eisenberg N. Psychopharmacologists and the medical,
    legal, and societal problems of the homeless mentally ill: an opinion. J Clin
    Psychiatry. 2021;82:21ac13960.
  29. Fakhoury W, Priebe S. Deinstitutionalization and reinstitutionalization:
    major changes in the provision of mental healthcare. Psychiatry. 2007;6: