Sufficient standardized epidemiological studies have not yet been conducted to clarify the incidence, types, patterns, severity, and trajectories of mental health and substance use problems among rural homeless persons. Nevertheless, growing evidence supports the prevalence of behavioral health problems among this population. In the national NSHAPC study, the great majority of homeless adults from all areas (rural, central city, and urban/suburban) reported at least one behavioral health problem (i.e., alcohol, drug, or mental health) in the previous 30 days (6467 percent), during the past year (7272 percent), and in their lifetimes (82 percent87 percent) (Burt et al., 1999). However, significant differences in prevalence of specific disorders were found between rural and urban homeless samples. Rural homeless adults had more current problems with alcohol; however, they had fewer current problems with mental illness or drug use compared to more urban homeless clients (Burt et al., 1999). For example, compared to central city and suburban homeless adults, rural homeless adults consistently reported dramatically higher rates of alcohol use 50 percent of the rural homeless adults reported alcohol problems in the previous 30 days, and 66 percent reported alcohol use problems in their lifetimes. Rural homeless adults also reported generally high rates of mental health, drug use, or comorbid psychiatric and substance use problems; however, the rural rates were dramatically lower than rates reported by the more urban homeless adults.
In the California survey, homeless adults were screened for probable lifetime major mental disorders and lifetime substance use disorders with an instrument derived from the Diagnostic Interview Schedule (DIS-III) (Robins et al., 1981). Because the study used a short screener that identified people who have a high probability of having a lifetime disorder rather than the entire diagnostic interview, the rates of disorder are likely overestimated (Vernez et al., 1988). Nevertheless, homeless persons in the rural county screened higher for severe mental illness (SMI) (especially major affective disorder), substance use disorder (especially for alcohol), and for dual disorders (mental and substance use disorders). The rural county sample (Yolo County) screened positive for severe mental disorders, including high rates of major affective disorders (e.g., major recurring depression and bipolar disorders) and schizophrenia. The rural county had a higher rate of severe mental illness compared to the two more urban counties (Alameda and Orange Counties) (Vernez et al., 1988). Virtually all subjects who screened positive for severe mental disorder also screened positive for either alcohol or drug disorders or both, for a dual diagnosis rate of 37 percent of the total sample (Vernez et al., 1988).
In Montana, self-reported diagnosed conditions included mental illness (18 percent) and alcohol or drug abuse (15 percent) (Montana Council on Homelessness, 2007). About one-quarter of the total sample (26 percent) reported that chronic drug or alcohol abuse was a cause of their homelessness. Among these, 60 percent were male and 40 percent were female. About 17 percent of families with children identified drug or alcohol abuse as a cause of their homelessness.
Because proxy measures for mental health problems (such as psychiatric hospitalization) are often used in studies, the identification of specific mental health problems and their severity is impossible (Patton, 1988; Robertson & Greenblatt, 1992). For instance, in the Ohio study, non-urban and urban samples were about equally likely to have histories of psychiatric hospitalization, and they had similar rates of psychiatric symptoms and similar levels of perceived mental health status and life satisfaction (Roth et al., 1985). Vermont informants estimated that 30 percent of rural homeless adults were deinstitutionalized, that is, people who in years past would have been sent to a state hospital, before changes to the mental health commitment law (Agency Planning Division, 1986). In the Post (2002) study, clinicians serving rural homeless persons reported seeing a number of clients who were disabled with serious mental illnesses (e.g., schizophrenia and affective disorders such as depression or bipolar disorder) and other serious conditions (including personality disorders and posttraumatic stress disorder secondary to childhood abuse, domestic violence, or war-related injuries).
In the general U.S. adult population, substance use and abuse are less common in non-metropolitan areas compared to metropolitan areas, and within non-metropolitan areas, substance use is lowest in the most rural areas (Strong et al., 2005). The prevalence and distribution of substance use problems (alcohol or illicit drugs) reportedly varies by region and population (Post, 2002). In the California survey, the rural county had higher rates of any substance use disorders (alcohol or drugs) compared with the more urban counties. Specific findings on alcohol use and related problems among rural homeless adults are mixed. Some researchers have reported higher rates of alcohol problems among homeless persons in rural areas ( Burt, 1996; New Freedom Commission on Mental Health, 2004; Office of Rural Mental Health Research, 2003; Vernez et al., 1988), while others report lower alcohol problems in rural areas (The Conservation Company, 1989, cited in Housing Assistance Council, 1991). In the NSHAPC national sample, rural clients had more current problems with alcohol compared to more urban clients (Burt et al., 1999). In the Ohio survey, few non-urban respondents identified alcoholism as a problem, although most had used alcohol in the previous 30 days and 20 percent had sought help for alcohol problems in their lifetimes (Roth et al., 1985; Roth & Bean, 1986).
Service providers report serious levels and severity of drug use across many rural areas (Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2006), yet empirical quantitative studies are limited so there is minimal assessment of the extent and specific nature of the drug problem among rural populations. For example, in her extensive interviews with health care providers, Post (2002) cites repeated anecdotes about extensive drug involvement of rural homeless persons, with the specific drugs used varying by geographic area. For example, prescription drugs such as OxyContin (also known as synthetic heroin) has become so widely used in places like Appalachia and rural Maine as to be called hillbilly heroin (National Institute on Drug Abuse & Community Epidemiology Work Group, 2001). Other more traditional street drugs, such as cocaine, heroin, or methamphetamine, are reportedly used in diverse rural areas. Anecdotal reports indicate that methamphetamine use in particular is increasing in rural areas (Strong, et al., 2005; Wilder Research Center, 2007a). Reportedly, methamphetamine use began in California and spread eastward as users started manufacturing the drug in home labs in rural areas in the South, Midwest, and other areas (Alligood, 2001, cited in Post, 2002). Empirical evidence of rural/urban differences in drug use is mixed. In the California study, the rural county had a high rate of drug abuse or dependence, which was similar to one urban county but lower than another urban county (Vernez, 1988). In the NSHAPC national sample, rural clients had fewer current problems with drug use compared to more urban clients (Burt et al., 1999). In the Ohio study, non-urban and urban counties reported similar rates of illicit drug use or problems with drugs (16 percent versus 15 percent urban) (Roth et al., 1985; Roth & Bean, 1986).