Trajectories and mental health-related predictors of perceived discrimination and stigma among homeless adults with mental illness

Stigma and discrimination toward individuals experiencing homelessness and mental disorders remain pervasive across societies. However, there are few longitudinal studies of stigma and discrimination among homeless adults with mental illness. This study aimed to identify the two-year group trajectories of stigma and discrimination and examine the predictive role of mental health characteristics among 414 homeless adults with mental illness participating in the extended follow-up phase of the Toronto At Home/Chez Soi (AH/CS) randomized trial site. Mental health-related perceived stigma and discrimination were measured at baseline, one, and two years using validated scales. Group-based-trajectory modelling was used to identify stigma and discrimination group trajectory memberships and the effect of the Housing First treatment (rent supplements and mental health support services) vs treatment as usual on these trajectories. The associations between mental health-related characteristics and trajectory group memberships were also assessed using multinomial logistic regression. Over two-years, three group trajectories of stigma and discrimination were identified. For discrimination, participants followed a low, moderate, or increasingly high discrimination group trajectory, while for stigma, participants followed a low, moderate or high stigma group trajectory. The Housing First treatment had no significant effect on discrimination or stigma trajectories groups. For the discrimination trajectories, major depressive episode, mood disorder with psychotic features, alcohol abuse, suicidality, severity of mental health symptoms, and substance use severity in the previous year were predictors of moderate and increasingly high discrimination trajectories. History of discrimination within healthcare setting was also positively associated with following a moderate or high discrimination trajectory. For the stigma trajectories, substance dependence, high mental health symptoms severity, substance use severity, and discrimination experiences within healthcare settings were the main predictors for the moderate trajectory group; while substance dependence, suicidality, mental health symptom severity, substance use severity and discrimination experiences within health care setting were also positive predictors for the high stigma trajectory group. Ethno-racial status modified the association between having a major depression episode, alcohol dependence, and the likelihood of being a member of the high stigma trajectory group. This study showed that adults experiencing mental illness and homelessness followed distinct stigma and discrimination group trajectories based on their mental health-problems. There is an urgent need to increase focus on strategies and policies to reduce stigma and discrimination in this population.

社会各阶层普遍存在对无家可归且患有精神疾病个体的污名化和歧视现象。然而，关于无家可归成年人精神疾病中污名化和歧视的纵向研究寥寥无几。本研究旨在识别无家可归成年人精神疾病患者两年内的污名化和歧视群体轨迹，并考察心理健康特征在414名参与多伦多“在家/在舍”（Toronto At Home/Chez Soi，简称AH/CS）随机对照试验延长期随访的该群体中的预测作用。使用经过验证的量表，在基线、一年和两年时测量了与心理健康相关的感知污名化和歧视。采用基于群体的轨迹模型来识别污名化和歧视的群体轨迹归属，并研究住房第一（提供租金补贴和心理健康支持服务）与常规治疗对上述轨迹的影响。此外，还运用多项逻辑回归分析评估了心理健康相关特征与轨迹群体归属之间的关联。在两年时间内，识别出三种污名化和歧视的群体轨迹。对于歧视，参与者遵循低、中或逐渐增高的歧视群体轨迹，而对于污名化，参与者则遵循低、中或高污名化群体轨迹。住房第一治疗对歧视或污名化轨迹群体没有显著影响。在歧视轨迹中，重度抑郁发作、具有精神症状的情感障碍、酒精滥用、自杀倾向、心理健康症状的严重程度以及前一年的物质使用严重程度是预测中度和逐渐增高的歧视轨迹的主要因素。在医疗保健环境中遭受歧视的历史也与遵循中度高歧视轨迹呈正相关。在污名化轨迹中，物质依赖、高心理健康症状严重程度、物质使用严重程度以及医疗保健环境中的歧视经历是中度轨迹群体的主要预测因素；而物质依赖、自杀倾向、心理健康症状严重程度、物质使用严重程度以及医疗保健环境中的歧视经历也是高污名化轨迹群体呈正相关的预测因素。种族-民族地位调节了重大抑郁发作、酒精依赖与成为高污名化轨迹群体成员的可能性之间的关联。本研究表明，经历精神疾病和无家可归的成年人根据其心理健康问题遵循独特的污名化和歧视群体轨迹。迫切需要关注并实施策略和政策，以减少该人群中的污名化和歧视。