Independent Supported Housing for non-homeless individuals with severe mental illness

Adamus, Christine (2023). Independent Supported Housing for non-homeless individuals with severe mental illness (Submitted). (Dissertation, Universität Bern, Graduate School of Health Sciences)

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Background. Current policies and guidelines require the end of the institutionalised housing rehabilitation and advocate for individualised support to help individuals with severe mental illness (SMI) live independently in the community. However, housing rehabilitation for persons with SMI still commonly takes place in institutionalised facilities (the housing rehabilitation as usual, HAU) in many countries. The housing rehabilitation intervention Independent Supported Housing (ISH) provides outreach housing support for people with SMI in their own homes. While ISH has good evidence in supporting homeless persons, evidence of its effectiveness in supporting non-homeless persons is weak and show mixed results. In addition, strong preferences for independent living limit the feasibility of randomized controlled studies (RCT) in the non-homeless population, challenging possibilities to advance the evidence.
Aim. The aim of this thesis was to improve evidence on the effectiveness of ISH for non-homeless persons with SMI from an effectiveness, a methodological and a provider perspective.
Methods. Study I and Study II are part of the funded study, which builds the main body of this thesis. This study prospectively investigated the effectiveness of ISH in comparison with HAU settings for non-homeless persons with SMI in two study centres. One centre applied a randomised study (RCT) and the other centre applied an observational study (OS). Study I reports on the first RCT on the effectiveness of ISH for non-homeless persons with SMI. Study II provides a methodological comparison of the RCT and the OS after one year. Study III explored the retrospective self-controlled mirror-image design known from pharmacological research to investigate the effectiveness of ISH without confounding by sample characteristics. Study IV describes a fidelity scale for services supporting independent and supported housing in German speaking countries, and Study V reports on a survey among housing rehabilitation staff.
Results. In Study I, ISH emerged as a strongly preferred and effective rehabilitation offer. The strong preferences for ISH in the control condition persisted over a long time. Study II revealed that these preferences led to significant limitations of the RCT, while the OS yielded valid effectiveness estimates with well-balanced and more stable groups. Study III demonstrated good applicability of the mirror-image design in this research area and the study offers suggestions to improve the design in further applications. The fidelity scale results in Study IV indicated higher fidelity for ISH than for HAU facilities overall and in terms of housing conditions and social inclusion. The multitude of obstacles faced by professionals in Study V suggest that social inclusion of individuals with SMI would hardly be possible without professional rehabilitation support.
Discussion. This thesis illuminated different perspectives on and confirmed the effectiveness of ISH in the housing rehabilitation of non-homeless persons with SMI. The utilised non-randomised study designs proved to be well feasible and to provide valid findings on the effectiveness of ISH. Thesefindings showed promising effectiveness of ISH in the housing rehabilitation of persons with SMI. Furthermore, the strong preferences of service users and the higher fidelity with criteria for self-determination and social inclusion indicate an urgent need to improve access to ISH interventions. The results of this thesis strongly supports the requirements of current policies and treatment guidelines to allow all persons with SMI to freely choose their place of residence and support services, thereby allowing service users to live and feel at home.

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