Victimization and posttraumatic stress disorder in homeless women with mental illness are associated with depression, suicide, and quality of life

Figures & data

Table 1 Sociodemographic and homeless trajectory characteristics based on gender in 703 homeless individuals

Variables	Total sample, N=703 N (%) or M (SD)	Men N=580 N (%) or M (SD)	Women N=123 N (%) or M (SD)	p-value
Sociodemographic characteristics
Age (years)	38.8 (10.0)	38.6 (9.8)	39.3 (10.9)	0.503
Educational level (high school diploma or higher)	181 (27%)	133 (24.1%)	48 (40.0%)	0.001
French nationality	575 (85.8%)	476 (86.4%)	99 (83.2%)	0.447
Marital status (single)	521 (77.8%)	440 (80.0%)	81 (67.5%)	0.004
Current parenthood	250 (37.4%)	194 (35.3%)	56 (46.7%)	0.026
Average monthly income (euros)	628.7 (402)	632.8 (419)	609.6 (313)	0.494
Social support
Current contact with family (at least once a week)	180 (27.4%)	148 (27.4%)	32 (27.6%)	0.999
Current contact with friend (at least once a week)	248 (37.5%)	200 (36.6%)	48 (41.7%)	0.356
Current contact with association (at least once a week)	483 (74.2%)	396 (73.9%)	87 (75.7%)	0.782
Homelessness history
Total length of homelessness during lifetime (years)	8.5 (7.9)	9 (8.0)	6.6 (6.9)	0.002
Age of first homelessness (years)	25.6 (11.2)	25.1 (10.6)	27.9 (13.8)	0.044
Accumulated number of nights spent during the 180 past nights (ETHOS *)
In streets or public spaces (nights spent during 180 past nights)	53.9 (68.5)	57.3 (69.4)	38.1 (61.7)	0.003
In emergency shelters (nights spent during 180 past nights)	22.8 (46.5)	23.3 (46.9)	20.5 (44.9)	0.549
Living temporarily with family or friends (nights spent during 180 past nights)	28.9 (51.3)	26.6 (49.7)	39.5 (57.1)	0.025

Notes:

* The location and the number of nights spent over the past 6 months were recoded according the European Typology of Homelessness and Housing Exclusion (ETHOS), which describes all living situations, from sleeping in public spaces to living in extreme over-crowding. Values in bold indicate statistically significant (p<0.01). N (%) – effective (percentage); M (SD) – mean (standard deviation).

Table 2 Gender differences in mental and physical health comorbidities and self-reported health status and quality of life between the 123 homeless women and the 580 homeless men with schizophrenia (SZ) or bipolar disorders (BD)

Variables	Total sample N=703 N (%) or M (SD)	Men N=580 N (%) or M (SD)	Women N=123 N (%) or M (SD)	AOR or β* (95% CI)	p-value
Diagnosis based on the DSM-IV-TR criteria
SZ	487 (69.3%)	418 (72.1%)	69 (56.1%)	0.48 (0.33–0.69)	<0.001
BD	216 (30.7%)	162 (27.9%)	54 (43.9%)
Current psychiatric comorbidities (MINI)
Major depressive episode	388 (55.2%)	316 (54.7%)	72 (59.0%)	1.24 (0.89–1.73)	0.207
Manic episode	117 (17.2%)	95 (17.0%)	22 (18.3%)	1.03 (0.91–1.16)	0.692
Hypomanic episode	24 (3.5%)	20 (3.6%)	4 (3.4%)	0.70 (0.21–2.31)	0.556
Posttraumatic stress disorder	109 (18.0%)	83 (16.4%)	26 (25.7%)	1.96 (1.23–3.11)	<0.001
High suicide risk**	190 (43.6%)	148 (41.8%)	42 (51.2%)	2.40 (1.53–3.75)	<0.001
Alcohol dependence	274 (39.3%)	227 (39.5%)	47 (38.5%)	0.89 (0.52–1.52)	0.682
Substance dependence***	322 (46.3%)	272 (47.4%)	50 (41.3%)	0.78 (0.51–1.21)	0.260
Alcohol abuse	44 (6.4%)	39 (6.8%)	5 (4.2%)	0.46 (0.17–1.28)	0.138
Substance abuse***	70 (10.3%)	58 (10.3%)	12 (10.1%)	0.83 (0.35–2.00)	0.677
Physical health
Updated vaccinations	391 (77.6%)	336 (79.1%)	55 (69.6%)	0.63 (0.35–1.12)	0.630
Need dental care	470 (71.8%)	389 (72.0%)	81 (71.5%)	1.14 (0.69–1.88)	0.598
Had fractures (past 6 months)	54 (8.2%)	41 (7.5%)	13 (11.3%)	1.37 (1.12–1.69)	0.002
Had sprains (past 6 months)	80 (12.3%)	54 (10.0%)	26 (22.6%)	3.30 (2.29–4.74)	<0.001
Had ectoparasitosis (past 6 months)	79 (12.1%)	64 (11.8%)	15 (13.2%)	1.10 (0.50–2.43)	0.808
Self-reported health status
MCSI score	21.4 (11.5)	21.1 (11.4)	22.8 (11.7)	1.37 (−0.64 to 3.38)	0.182
Psychotic symptoms	13.5 (8.4)	13.4 (8.4)	14.2 (8.4)	0.75 (−1.43 to 2.92)	0.502
Depressive symptoms	7.1 (3.6)	6.9 (3.5)	7.8 (3.8)	0.59 (0.32 to 0.86)	<0.001
Impulsivity	1.1 (1.8)	1.1 (1.7)	1.1 (1.9)	0.12 (−0.08 to 0.32)	0.230
PCS SF-36 score	50.8 (10.6)	51.3 (10.3)	47.9 (11.4)	−3.04 (−3.07 to −2.38)	<0.001
MCS SF-36 score	34.8 (9.7)	35.0 (9.5)	33.7 (10.8)	−1.35 (−2.88 to 0.18)	0.084
S-QOL 18 score	47.5 (17.5)	48.3 (17.3)	43.4 (17.7)	−4.53 (−5.89 to −3.15)	<0.001

Notes:

* Regression coefficients included AORs and standardized beta with 95% CI (men = reference). Each coefficient was adjusted for main confounding factors: age, marital status, education level, age, age of first homelessness, having SZ or BD, and a random effect for clusters (n=4 towns).

** High suicide risk was defined when the MINI score was >17.

*** Substance abuse is any pattern of substance use that results in repeated adverse social consequences related to drug taking. Substance dependence is characterized by physiological and behavioral symptoms related to substance use. N (%) – effective (percentage); M (SD) – mean (standard deviation). Values in bold indicate a statistically significant difference between genders (p<0.01).

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; SZ, schizophrenia; BD, bipolar disorder; MINI, Mini-International Neuropsychiatric Interview; MCSI, Modified Colorado Symptom Index; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; PCS, physical composite score; MCS, mental composite score; S-QoL, Schizophrenia Quality of Life Scale.

Table 3 A comparison of victimization in the past 6 months between the 123 women and the 580 men

Variables	Total sample N=703	Men N (%)	Women N (%)	AOR* (95% CI)	p-value
Total victimization	417 (59.3%)	333 (60.0%)	84 (70.0%)	1.47 (1.22–1.78)	<0.001
Non-violent victimization	358 (50.9%)	285 (51.3%)	73 (60.8%)	1.58 (1.45–1.72)	<0.001
Stolen property	238 (35.3%)	191 (34.4%)	47 (39.2%)	1.21 (0.94–1.56)	0.130
Verbal assault	207 (30.7%)	158 (28.5%)	49 (40.8%)	1.88 (1.35–2.62)	<0.001
Offensive behavior	239 (35.4%)	192 (34.6%)	47 (39.2%)	1.28 (0.84–1.95)	0.245
Violent victimization	223 (31.7%)	172 (31.0%)	51 (42.5%)	1.46 (1.20–1.77)	<0.001
Physical assault	157 (23.3%)	116 (20.9%)	41 (34.2%)	1.70 (1.28–2.25)	<0.001
Sexual assault	22 (3.3%)	10 (1.8%)	12 (10.0%)	5.90 (4.12–8.46)	<0.001
Attacks/fights	120 (17.8%)	100 (18.1%)	20 (16.7%)	0.81 (0.41–1.60)	0.540

Notes:

* Regression coefficients included AORs with 95% CI (men = reference). Each coefficient was adjusted for main confounding factors: age, marital status, education level, age of first homelessness, having SZ or BD, and a random effect for clusters (n=4 towns). N (%) – effective (percentage). Values in bold indicate a statistically significant difference between genders (p<0.01).

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; SZ, schizophrenia; BD, bipolar disorder.

Table 4 Differences and overlap of homeless women with schizophrenia and bipolar disorder – sociodemographic and homelessness trajectory characteristics

Variables	Women with SZ N=69 N (%) or M (SD)	Women with BD N=54 N (%) or M (SD)	p-value
Sociodemographic characteristics	40.4 (11.8)	38 (9.5)	0.225
Age (years)
Educational level (high school diploma or higher)	30 (44.8%)	18 (34.0%)	0.311
French nationality	54 (81.8%)	45 (84.9%)	0.841
Marital status (single)	45 (67.2%)	36 (67.9%)	0.999
Current parenthood	35 (52.2%)	21 (39.6%)	0.233
Average monthly income (euros)	659.1 (291.2)	548.8 (330.0)	0.060
Social support
Current contact with family (at least once a week)	19 (29.7%)	13 (25.0%)	0.724
Current contact with friend (at least once a week)	26 (40.6%)	22 (43.1%)	0.935
Current contact with association (at least once a week)	46 (71.9%)	41 (80.4%)	0.402
Homelessness history
Total length of homelessness during lifetime (years)	6.4 (7.4)	6.8 (6.3)	0.780
Age of first homelessness (years)	30.0 (15.1)	25.4 (11.7)	0.074
Accumulated number of nights spent during the 180 past nights (ETHOS*)
In streets or public spaces (nights spent during 180 past nights)	28.9 (53.5)	49.6 (69.4)	0.080
In emergency shelters (nights spent during 180 past nights)	25.8 (52.6)	13.8 (32.1)	0.131
Living temporarily with family or friends (nights spent during 180 past nights)	34.0 (55.8)	46.2 (58.5)	0.255

Notes:

* The location and the number of nights spent over the past 6 months were recoded according to the European Typology of Homelessness and Housing Exclusion (ETHOS), which describes all living situations, from sleeping in public spaces to living in extreme over-crowding. N (%) – effective (percentage); M (SD) – mean (standard deviation).

Abbreviations: SZ, schizophrenia; BD, bipolar disorder.

Table 5 Differences and overlap of homeless women with schizophrenia and bipolar disorder – mental and physical health comorbidities, self-reported health status, quality of life, and victimization

Variables	Women with SZ N=69 N (%) or M (SD)	Women with BD N=54 N (%) or M (SD)	AOR* (95% CI)	p-value
Current psychiatric comorbidities (MINI)
Major depressive episode	32 (47.1%)	40 (74.1%)	0.32 (0.22–0.47)	<0.001
Manic episode	9 (13.2%)	13 (25%)	–	–
Hypomanic episode	0 (0%)	4 (7.7%)	–	–
Posttraumatic stress disorder	13 (22.8%)	13 (29.5%)	0.91 (0.38–2.16)	0.831
High suicide risk**	16 (43.2%)	26 (57.8%)	0.72 (0.44–1.2)	0.210
Alcohol dependence	21 (30.4%)	26 (49.1%)	0.39 (0.18–0.87)	0.022
Substance dependence***	21 (30.9%)	29 (54.7%)	0.47 (0.31–0.72)	<0.001
Alcohol abuse	2 (2.9%)	3 (5.8%)	–	–
Substance abuse***	7 (10.4%)	5 (9.6%)	0.77 (0.22–2.65)	0.673
Physical health
Updated vaccinations	34 (75.6%)	21 (61.8%)	3.72 (1.78–7.81)	0.001
Need dental care	41 (65.1%)	40 (78.4%)	0.53 (0.41–0.71)	<0.001
Had fractures (past 6 months)	6 (9.5%)	7 (13.5%)	0.48 (0.15–1.53)	0.212
Had sprains (past 6 months)	13 (20.6%)	13 (25%)	0.7 (0.4–1.23)	0.215
Had ectoparasitosis (past 6 months)	10 (15.9%)	5 (9.8%)	2.01 (0.91–4.44)	0.085
Self-reported health status
MCSI score	19.9 (12.1)	26.4 (10.5)	−4.81 (−6.92 to −2.71)	<0.001
Psychotic symptoms	12.5 (8.9)	16.2 (7.5)	−2.51 (−4.56 to −0.47)	0.016
Depressive symptoms	6.6 (3.9)	9 (3.2)	−1.77 (−2.68 to −0.85)	<0.001
Impulsivity	0.9 (1.6)	1.5 (2.2)	−0.28 (−0.64 to 0.07)	0.114
PCS SF-36 score	49.7 (12)	45.9 (10.5)	3.91 (0.64 to 7.19)	0.019
MCS SF-36 score	35.2 (11.4)	32.0 (9.9)	1.98 (−0.68 to 4.63)	0.145
S-QOL 18 score	44.9 (17.2)	41.6 (18.3)	2.31 (−4.61 to 9.24)	0.512
Victimization
Total victimization	45 (67.2%)	39 (73.6%)	0.65 (0.25–1.64)	0.360
Non-violent victimization	39 (58.2%)	34 (64.2%)	0.79 (0.34–1.79)	0.565
Violent victimization	23 (34.3%)	28 (52.8%)	0.34 (0.21–0.56)	<0.001

Notes:

* Regression coefficients included AORs with 95% CI (women with BD = reference). Each coefficient was adjusted for main confounding factors: age, marital status, education level, age of first homelessness, and a random effect for clusters (n=4 towns).

** High suicide risk was defined when the MINI score was >17.

*** Substance abuse is any pattern of substance use that results in repeated adverse social consequences related to drug taking. Substance dependence is characterized by physiological and behavioral symptoms related to substance use. N (%) – effective (percentage); M (SD) – mean (standard deviation). Values in bold indicate a statistically significant difference between SZ and BD.

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; SZ, schizophrenia; BD, bipolar disorder; MINI, Mini-International Neuropsychiatric Interview; MCSI, Modified Colorado Symptom Index; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; PCS, physical composite score; MCS, mental composite score; S-QoL, Schizophrenia Quality of Life Scale.

Figure 1 Path analysis with posttraumatic stress disorder, violent victimization, depression, suicide risk, physical health status, and quality of life in homeless women.

Notes: Goodness of fit: chi square =78.309, DF =15, CFI =0.960, WRMR =0.510. Indirect effects from posttraumatic disorder to quality of life =−0.27 and to suicide risk =0.30. Indirect effects from violent victimization to depression =0.17. P represents standardized path coefficient. All the data were measured at baseline, except violent victimization in the past 6 months.
Abbreviations: DF, degrees of freedom; CFI, comparative fit index; WRMR, weighted root mean square residual.