Address mental health link to homelessness

About a year ago, a young man in his early 20s spent cold winter nights living under one of the I-380 bridges near downtown Cedar Rapids. Discharged to outpatient care following involuntary committal, he did not follow through with treatment, nor did the agency responsible for providing him with outpatient care.

Unmedicated, unclean, and poorly fed, he refused to communicate with his parents, who were desperate to help him. They faced rejection by him as well as by the system — he insisted on continuing to live under the bridge, and no one seemed able to help his parents get him to conditions more safe. This begs the question: Is this the best we can do?

Homelessness and mental illness have deep and long-standing and alarming links. Nationally, 20 to 25% of the homeless population experiences mental illness, according to the National Institute of Mental Health (NIMH). In Linn County, however, we may have it worse. A 2018 study by the Continuum of Care Planning and Policy Council revealed that 35% of the Linn homeless population identified mental health issues as their most prominent concern, and 22% reported physical or medical disabilities.

Although eliminating homelessness entirely is unlikely, increasing support for people with mental illness can help reduce its prevalence. Mental illness is not a character defect or a choice; it is a brain disorder. Individuals suffering from brain disorders often do not recognize their need for treatment — a symptom of the disease itself. The longer someone in psychosis goes without medical help, the lower the chances that treatment will succeed.

NAMI Iowa, along with its local affiliate NAMI Linn County, supports two bills aimed at improving outcomes for people with mental illness: HF312 and HF385. HF312 would boost the likelihood of treating individuals with mental illness by broadening the criteria for intervention. HF385 focuses on enhancing aftercare following treatment.

Assisted Outpatient Treatment (AOT) is another tool available in Iowa, currently implemented in neighboring Johnson County. AOT provides outpatient treatment under civil court order to individuals with severe mental illness who have difficulty engaging in voluntary treatment. Expanding AOT to Linn County could help ensure those with severe mental illness receive ongoing care, rather than relying on agency promises alone.

Currently, the threshold for involuntary commitment is high, and for good reason. A judge must be convinced that a person is a danger to themselves or others before they can be hospitalized against their will. However, while this protects individual liberty, it can result in waiting until people reach a crisis point — one that is difficult to reverse — before intervening. HF312 proposes a new standard, allowing intervention when a patient is in a state of deterioration, defined by:

The person does not understand they need treatment.

Their personal history indicates they are unlikely to seek treatment on their own.

Medical certainty suggests that, without treatment, their condition will decline and lead to serious mental impairment.

This approach aims to limit brain damage from sustained psychosis and prevent negative outcomes such as suicide, homicide, arrests, and homelessness.

HF385 would significantly improve care after involuntary hospitalization. It mandates that discharging institutions:

Assess patients for suicide risk.

Refer patients to an administrative services organization for evaluation, case management, and post-discharge services.

Provide a 30-day supply of all prescribed medications, both psychiatric and nonpsychiatric.

Develop a written, patient-centered aftercare plan that includes crisis prevention, ongoing care needs, and educational materials for both the patient and their support network.

Notify the patient’s legal guardian, parent, spouse, attorney, or adult siblings upon discharge, as applicable.

These measures, not always implemented now, should instead be standard practice.

Implementing AOT in Linn County courts would help confirm individuals receive the ongoing care they need. While we cannot cure mental illness, we do know treatment can dramatically reduce hospitalization, criminalization, and other adverse outcomes. The Treatment Advocacy Center emphasizes that adequately resourced and systematically implemented AOT can yield significant benefits for its target population.

Mental health care is expensive and complex. Some individuals suffer from treatment-resistant illnesses. Iowa’s mental health system currently lacks sufficient capacity. Addressing all this will require further legislative and social reforms. Meanwhile, some hospitals oppose the proposed bills due to concerns about cost and burden. However, earlier intervention and responsible discharge planning could reduce the churn of repeated hospitalizations, crisis interventions, homelessness, and criminalization. These two bills, along with expanded AOT, can reduce strain on multiple systems and improve outcomes for those in need.

Let’s do something about the continuing link between homelessness and mental illness. Help us enact these new laws and practices. It is time we reconsider the costs of jailing, imprisoning, or abandoning people to homelessness simply because they are sick.

Kurt Rogahn of Cedar Rapids has been active in NAMI Linn County since 2017, co-facilitating a support group and co-teaching classes for family members of people with serious mental illness. Although they were not homeless, his son, two brothers, and a cousin all experienced lives shortened by serious mental illness.