A Randomized Trial of Critical Time Intervention to Prevent Homelessness in Persons with Severe Mental Illness following Institutional Discharge

While a growing body of research has begun to assess the effectiveness of a variety of outreach, housing and treatment approaches in meeting the complex needs of persons with mental illness who are homeless or residentially unstable, there remain very few randomized trials of carefully documented models intended to reduce the incidence of homelessness among persons with severe mental illness. The period following hospital discharge is one in which persons with severe mental illness are at high risk for either first- episode or recurrent homelessness (1,2). This is also a high risk period for other adverse outcomes including suicide (3–5), psychiatric re-hospitalization (6,7) and violence against others (8). Reasons for this may include both the impact of enduring psychiatric symptoms that preceded the inpatient episode plus difficulties in establishing effective connections to sources of treatment, housing and support in the community. Furthermore, like many transitional periods, the time following institutional treatment is commonly a period of significant personal disequilibrium. Critical Time Intervention (CTI) aims to prevent recurrent homelessness and other adverse outcomes following discharge in two ways: by strengthening the individual's long-term ties to services, family, and friends; and by providing emotional and practical support during the critical time of transition. An important aspect of CTI is that post-discharge services are delivered by a worker who has established a relationship with the client before discharge. CTI shares with long-term assertive community treatment models a focus on promoting in vivo development of independent living skills and building effective support networks in the community (9). The emphasis, however, is on maintaining continuity of care during the critical period of transition while primary responsibility gradually passes to existing community supports that will remain in place after the intervention ends. Such an approach, we believe, increases the likelihood that the impact of a time-limited intervention will persist beyond its actual endpoint, which is the primary goal of CTI. Previous studies provide evidence of CTI’s effectiveness in producing an enduring positive effect on housing outcomes among homeless adults with severe mental illness. The first was a randomized trial among 96 homeless men with severe mental illness placed into housing from a large shelter institution in New York City (10). In this study, a nine-month CTI produced a significant reduction in post-discharge homelessness which, crucially, remained evident up to the end of an eighteen month follow-up period. Subsequently, a six month version of CTI was tested at eight Department of Veterans’ Affairs medical centers. A quasi-experimental study compared the outcomes of two cohorts of homeless persons with severe mental illness after discharge from inpatient psychiatric treatment. One cohort (n=278) received standard case management and the other (n=206) received CTI. Controlling for baseline differences, investigators found that the CTI cohort had significantly more days housed than did the comparison cohort over the one-year follow-up period and that this effect also persisted after the intervention ended (11). In this article, we report the results of a single-blind randomized trial testing whether nine months of CTI would produce an enduring effect in preventing homelessness among formerly homeless men and women with severe mental illness following discharge from inpatient psychiatric treatment. The trial was approved by the discharging hospital’s institutional review board under a multi-site collaborative agreement overseen by the NYS Office of Mental Health.