Homelessness in China and the West

Robert A.ROSENHECK

The recent paper by Chen，Xu and Wang［1］is perhaps the most thorough and rigorously designed study of mental illness and homelessness to emerge from China thus far.Based on a careful clinical description of hospitalized homelessness people treated at the Jiading District Mental Health Center in Shanghai between 2007 and 2009，the study compares a well-characterized homeless sample with a similar sample of hospitalized psychiatric patients who were not homeless.The homeless sample turned out to be more likely than the non-homeless sample to be male，single，from another province，and to lack a source of income.There was little difference in the psychiatric diagnoses of homeless patients compared to other hospitalized patients(a high proportion of both groups had schizophrenia) but the homeless were more likely to have comorbid general medical problems and to have had a pre-admission episode that disrupted social order in the community.Strikingly，the proportion of all admitted patients at the Jiading Mental Health Center who were homeless almost doubled from May 2008 to April 2009.

The report is an important early-warning sign for mental health practitioners in China.The migration of hundreds of millions of single adults from poor rural communities to large cities where they are often disconnected from their families has serious mental health consequences.In China，like in other parts of the world，homeless people are often less visible or，if visible，do not really come to the attention of the general public unless they are socially disruptive or until they become the focus of concern of poverty-oriented advocacy groups.

Homelessness has emerged and re-emerged as a social problem in European and North American countries over and over again since the 1600s，often in response to major social changes;for example，in post-war situations when large numbers of discharged soldiers roamed the highways of Europe as vagabonds and beggars threatening the safety of travelers［2］.The recent re-emergence of homelessness as a recognized social problem in North America and Western Europe started in the 1980s and first appeared—like this report from Shanghai—to reflect problems in the community management of persons withseverementalillnesses.InNorth America and Europe this was related to the closure of many large，government-run psychiatric hospitals and the failure to develop services to take care of the discharged patients in non-institutional community settings［2，3］.Gradually，however，it was recognized that the homeless mentally ill were only one part of an even larger social problem.Homelessness can also occur when decreased public support for low-cost housing or the gentrification of poor urban neighborhoods decreases the availability of inexpensive housing［3］.And in many Western settings high levels of alcohol and substance addiction appear to be a relatively more important cause of homelessness than other serious mental illness［4］. The low rate of substance abuse in the homeless individuals identified in the Shanghai study is a remarkable finding that highlights the differences between the homeless situation in China versus that seen in western countries.

As Chen，Xu and Wang aptly note in their discussion，housing，poverty，law enforcement policies and the characteristics of the mental health service system may be more important determinants of homelessness than the prevalence of mental illnesses.Thus，homelessness is a social problem that affects several vulnerable groups in the community—including those with disabling mental illnesses.But it is not a problem that is limited to those with mental illnesses so it must be addressed by social policy rather than by medical technology［5］.

The pioneering study of Chen，Xu and Wang represents the beginning of the study of homelessness in China.There is much more to be learned about the broader Chinese context before it will be possible to recommend social policies that could help reduce the problem.Learning about how homelessness in China is similar to and different from homelessness in North America and Europe will help elaborate more realistic theoretical models for this complex social problem and，thus，generatenew ideas for intervention.We look forward to increased exchange and collaboration between Chinese and international researchers on this important issue.

1. Chen Q，Xu JN，Wang JJ.Retrospective comparison of the characteristics of 98 homeless psychiatric inpatients in Shanghai with those of 98 inpatients who were not homeless.Shanghai Archives of Psychiatry，2011，23(3)：148-153.

2. Caton CL Homeless in America.New York：Oxford University Press，1990.

3. Burt M，Aron LY，Lee E.Helping America's Homeless：Emergency Shelter or Affordable Housing.Washington DC：Urban Institute Press，2001.

4. Greenberg G，Rosenheck RA.Mental Health Correlates of Past Homelessness in the National Comorbidity Study Replication. Journal of Health Care for the Poor and Underserved，2010，21：1234-1249.

5. Rosenheck RA.Service Models for Assisting Homeless People with Mental Health Problems：Cost-Effectiveness and Policy Relevance.In Ellen IG，O'Flaherty B(Eds.)，How to House the Homeless.New York：Russell Sage Foundation，2010：17-36.

10.3969/j.issn.1002-0829.2011.04.007

VA New England Mental Illness Research and Education Center，Yale School of Medicine，West Haven，CT，USA

E-mail：Robert.Rosenheck@yale.edu