Head injuries high among the homeless

More than half of the homeless population has suffered traumatic brain injury in their lifetime, and approximately 70 per cent of these injuries occurred before the incidence of homelessness, according to a new, Toronto-based study.

The study, published in the Canadian Medical Association Journal (CMAJ), looks at the prevalence of traumatic brain injury and current health situations of the homeless. Approximately 900 homeless men and women who frequent Toronto homeless shelters were asked to self-report cases of brain injury that “left the person dazed, confused, disoriented, or unconscious.” It is currently the largest study of its kind worldwide.

The study results show a 58 per cent incidence rate of brain injury in homeless men, and 48 per cent in homeless women – a prevalence rate 5 times higher than the US average. According to coauthor Dr. Stephen Hwang of the Centre for Research on Inner City Health at St. Michael’s Hospital in Toronto, the fact that a majority of respondents sustained traumatic brain injury before they became homeless suggests a causational link.

“I think that this article doesn’t make the link definitively, but it is hypothesis generating. It raises a possibility which has not been discussed by researchers before,” Hwang said.

He added that further research is needed to provide strong causational evidence for the connection between traumatic brain injury and homelessness.

The CMAJ study concludes that doctors and clinical professionals need to pay closer attention to signs of traumatic brain injury in the homeless. It also emphasizes the need to routinely ask homeless patients if they have suffered from such disturbances, since those suffering from traumatic brain injury may require different therapies than would otherwise be prescribed.

According to Hwang, there are two other major conclusions to be drawn from the study.

“The second point is that these individuals may require constant support to avoid homelessness because of their cognitive impairment [due to traumatic brain injury]. The third point is the speculative one that this may be a causal factor and that we need to do further research to explore that,” Hwang said.

Matthew Pearce, director general of the Old Brewery Mission, the largest men’s shelter in Quebec and largest women’s shelter in Canada pointed out that there is nothing new about the connection between mental illness and homelessness.

While the majority of their clients do not suffer from serious mental problems, Pearce said that the Old Brewery Mission’s figures indicate that about 35 per cent exhibit some form of mental illness. Pearce noted that the Old Brewery Mission’s shelter services take into account the mental state of those in need. Their off-the-streets program, l’Étape, provides 24-hour counselling support to aid the transition to a more stable and secure living arrangement.

Though traumatic brain injury is a separate issue which has received less attention in the analyses of homeless people’s mental health status, Pearce argued that a range of factors contribute to the mental health and stability of homeless people.

“[The homeless] are complex as a group. They are homeless, but they are people. There is more than one cause of homelessness, and more than one cause of mental illness; and there is more than one set of circumstances that causes the two to come together. Head injury is just one of them,” Pearce said.

Denis Nault, one frequenter of the Old brewery Mission, now homeless for three years, gave a similar assessment. While he reported not to have suffered from any mental health problems himself, he noted that for many, life on the street tends to foster a cyclical process of mental breakdown, no matter which causational factor – brain injury, substance abuse, or genetics – may be to blame.

“We’re all depressed. Everyone has psychiatric or substance abuse [problems]. Me too, I drink. What else can I do?” Nault asked. “[For some] it’s worse, but everyone has something. The game is surviving all day, every day outside.”

While the CMAJ study poses some loose links between traumatic brain injury and other mental problems, including substance abuse, the authors maintain that more studies need to be pursued before any concrete conclusions can be reached.

Aaccording to coauthor Dr. Angela Conatonio, Senior Research Scientist at Toronto rehab, the CMAJ study is significant despite being preliminary.

Colantonio pointed to the often overlooked fact that traumatic brain injury is the leading cause of death in people under 45 in Canada, and added that, despite its incidence, traumatic brain injury does not garner enough attention.

“[What] we are saying is that [the homeless] should be screened,” she said. “It should be a factor one should look for.”

Colantonio added that screening for previous traumatic brain injury may be beneficial – such a finding might account for otherwise unexplained behavioural issues. Identifying the root cause of such issues could allow for better treatment. Expanding on Hwang’s second conclusion, Colantonio suggested a range of other options that may be worth pursuing for homeless people suffering from traumatic brain injuries.

“Cognitive rehab [may be beneficial to those who have suffered traumatic brain injuries] for example, or they might benefit from some assisted technology, such as help with their memory,” she said.

“No two brain injuries are alike. Depending on where the injury is, it needs to be individualized,” Colantonio said. “Down the road we need to look at intervention studies, [we need to] look at the supportive approach, [and we need to] look at treating the person as well as the environment. Even educating the [homeless] about their brain injury would be a step in the right direction. Even if they have a history of cognitive sequelae but no symptoms, they need to be educated about it.”