Objective: This study aimed to determine the following: 1) the proportion of women in the homeless population with schizophrenia (SZ) or bipolar disorder (BD), in addition to the trajectory of their homelessness (ie, homelessness history, number of nights spent without home during the 180 past nights) and the characteristics of their illnesses compared to men (ie, illness severity, suicide risk, physical health status, and quality of life [QoL]); 2) whether these women were victimized more frequently than similarly situated men; 3) the impact of victimization on these women in terms of illness severity, suicide risk, physical health status, and QoL; and lastly 4) the differences and overlap of homeless women with SZ and BD. Methods: This study employed data at baseline from a multicenter randomized controlled trial conducted in the following four large French cities: Lille, Marseille, Paris, and Toulouse. Mobile mental health outreach teams recruited SZ/BD homeless patients in the street, emergency shelters, hospitals, and jails from August 2011 to April 2014. Evaluations were performed during face-to-face interviews by psychiatrists and research assistants in the offices of mobile mental health outreach teams that were located in the downtown area of each city. The quantitative data were analyzed using descriptive analyses, chi-square and Student’s t-tests, generalized estimating equation regression models, and path analysis. Results: A total of 703 patients were included in this study. The proportion of women in the SZ/BD homeless population was 123/703 (17.5%). In this population, women were more likely than men to declare that they were subjected to physical or sexual assault during the past 6 months, that they had been diagnosed with posttraumatic stress disorder (PTSD), and that they had experienced more severe depressive symptoms. Moreover, these women presented a higher suicide risk, worse physical health status, and lower QoL than similarly situated men. Homeless women with BD were more vulnerable than women with SZ. A path analysis revealed that PTSD and violent victimization might explain the higher levels of depression and suicide risk and the lower levels of physical health status and QoL in homeless women. Conclusion: SZ/BD homeless women experience more PTSD and victimization than men, which are both associated with poor clinical outcomes. These results confirm the vulnerability of homeless women in this high need population and should be considered by public health policy.

Background: Recent studies in North American contexts have suggested that the Housing First model is a promising strategy for providing effective services to homeless people with mental illness. In the context of the highly generous French national health and social care system, which is easily accessible and does not require out-of-pocket payment, the French Health Ministry insists on rigorous techniques, including randomized protocols, to evaluate the impact of Housing First approaches in France. Method and design: A prospective randomized trial was designed to assess the impact of a Housing First intervention on health outcomes and costs over a period of 24 months on homeless people with severe mental illness, compared to Treatment-As-Usual. The study is being conducted in four cities in France: Lille, Marseille, Paris and Toulouse. The inclusion criteria are as follows: over 18 years of age, absolutely homeless or in precarious housing, and possessing a ‘high’ level of need: diagnosis of schizophrenia or bipolar disorder and moderate to severe disability according to the Multnomah Community Ability Scale (score ≤ 62) and at least one of the following three criteria: 1) having been hospitalized for mental illness two or more times in any one year during the preceding five years; 2) co-morbid alcohol or substance use; and 3) having been recently arrested or incarcerated. Participants will be randomized to receiving the Housing First intervention or Treatment-As-Usual. The Housing First intervention provides immediate access to independent housing and community care. The primary outcome criterion is the use of high-cost health services (that is,, number of hospital admissions and number of emergency department visits) during the 24-month follow-up period. Secondary outcome measures include health outcomes, social functioning, housing stability and contact with police services. An evaluation of the cost-effectiveness and cost-utility of Housing First will also be conducted. A total of 300 individuals per group will be included. Discussion: This is the first study to examine the impact of a Housing First intervention compared to Treatment-As-Usual in France. It should provide key information to policymakers concerning the cost-effectiveness and health outcomes of the Housing First model in the French context. Trial registration: The current clinical trial number is NCT01570712

This paper is a qualitative analysis of the effects of accompagnement, a support framework, on recovery trajectories of people with long-term homelessness and severe psychiatric disorders during 24 months in a Housing First-type program in France. A comprehensive methodology based on grounded theory was used to construct an interview guide, conduct multiple interviews with 35 Housing First participants sampled for heterogeneity, and produce memos on their trajectories before and after entering the program based on interview information. Thematic analysis of a representative subsample (n = 13) of memos identified 12 objective factors and 6 subjective factors key to the recovery process. An in-depth re-analysis of the memos generated four recovery themes: (1) the need for secure space favorable to self-reflexivity; (2) a “honeymoon” effect; (3) the importance of even weak social ties; (4) support from and hope among peers. Three challenges to recovery were identified: (1) finding a balance between protection and risk; (2) breaking downward spirals; (3) bifurcating the trajectory. This study provides new insight into the recovery process, understood as a non-linear transformation of an experience—the relationship between objective life conditions and subjective perception of those conditions—which reinforces protective support over risk elements.

In 2006, a local collective combating homelessness set up an ‘experimental squat’ in an abandoned building in Marseille, France’s second largest city. They envisioned the squat as an alternative to conventional health and social services for individuals experiencing long-term homelessness and severe psychiatric disorders. Building on what they learned from the squat, some then joined a larger coalition that succeeded in convincing national government decision-makers to develop a scientific, intervention-based programme based on the Housing First model. This article analyses the political process through which social movement activism gave way to support for a state-funded programme for homeless people with mental disorders. A qualitative study of this political process was conducted between 2006 and 2014, using a hybrid theoretical perspective that combines attention to both top-down and bottom-up actions with a modified Advocacy Coalition Framework. In addition to document analysis of published and grey literature linked to the policy process, researchers drew on participant observation and observant participation of the political process. Data analysis consisted primarily of a thematic analysis of field-notes and semi-structured interviews with 65 relevant actors. A coalition of local activists, state officials and national service providers transformed knowledge about a local innovation (an experimental therapeutic squat) into the rationale for a national, scientifically based project consisting of a randomised controlled trial of four state-supported Housing First sites, costing several million euros. The coalition’s strategy was two-pronged, namely to defend a social cause (the right to housing) and to promote a scientifically validated means of realising positive outcomes (housing tenure) and cost-effectiveness (reduced hospitalisation costs). Activists’ self-agency, especially that of making themselves audible to public authorities, was enhanced by the coalition’s ability to seize ‘windows of opportunities’ to their advantage. However, in contrast to the United States and Canadian Housing First contexts, which are driven by implementation science and related approaches, it was grassroots activists who promoted a scientific-technical approach among government officials unfamiliar with evidence-based practices in France. The windows of opportunity nevertheless failed to attract participation of those most in need of housing, raising the question of whether and how marginalised and/or subordinate groups can be integrated into collaborative research when a social movement-driven innovation turns into a scientific approach. The current clinical trial number is NCT01570712 . Registered July 17, 2011. First patient enrolled August 18, 2011.