Hopelessness, or hope: Suicide among the homeless

I was walking through central London on a cold, soggy morning recently. It was early spring, but winter appeared not to notice as the climate was typically un-spring like. I was cold, jet lagged, a little hungover and generally feeling sorry for myself. A brisk walk through Hyde Park and surrounds had seemed just the thing to perk me up.  It was during my walk that morning that I encountered those tragic fixtures of metropolitan life, hidden beneath grimy bundles of blankets and coats, the homeless. Momentarily distracted from my reverie, I began to reflect on the insignificance of my woes compared to those destitute souls shivering in the frigid cold. A dark thought occurred to me, just how do they go on? When life is so utterly miserable, why do they not end their suffering? Since I first pondered the question, I have found the answer to be just as troubling.

There is no universally accepted definition of homelessness, but few would argue when they see it. The United Nations describes ‘primary’ homelessness as living on the streets without shelter that could be considered living quarters [1]. It is difficult to quantify the number of people living in these circumstances as homeless populations fluctuate and many nations track only the secondary definition of homelessness, which includes those who do not have a regular place to stay every night, but may be housed in shelters or boarding houses. Homelessness is also considered differently across societies; it is much more common in developing countries for instance, with a larger proportion of their population below the poverty line. While developed countries, with more extensive social welfare systems, closely monitor homeless populations and implement initiatives  to reduce the incidence of homeless citizens. In either case, the numbers of homeless around the world bear consideration.

In 2009, over 105,000 people were classed as homeless in Australia. England saw an increase in its homeless population of 26% between 2009 and 2013, of which London alone experienced a 75% increase. Complicated definitions and inadequate record keeping make it difficult to determine the precise number.  Northern Ireland leads the United Kingdom however, with 5.7% of the population reporting to have experienced homelessness. In 2014, the Russian population of homeless totalled over 5 million people. The intensely cold winter climate of this country makes homelessness particularly lethal with the death of 1,042 homeless reported in Saint Petersburg during the winter months of 2013 alone. Not surprisingly, developing nations fare much worse with a staggering 78 million people in India living without permanent shelter. The United Nations reports 44% of urban populations in the Philippines live in slums. Homeless statistics for many more countries can be found at the website of the Homeless World Cup Foundation [2].

While these figures reflect approximate numbers of homeless people, this article considers those literally living on the street according to the primary definition of homelessness. Australia reports 6% of its homeless population live on the streets or in improvised dwellings [3]. In England, over 4,700 people are estimated to ‘live rough’ every night, some 4% of the total homeless population [4]. The number is harder to quantify in the United States where 5% of homeless in the state of New York live rough compared to 50% in Hawaii [5]. In a nation of over 560,000 homeless, it is likely the number sleeping rough is in the tens of thousands [6]. It follows that primary homelessness accounts for approximately 5% of homeless populations in developed countries and likely much more in countries in which poverty is prevalent.

There is no single cause of homelessness, rather it occurs as factors compound over time. Shelter.org describes “a complex interplay between a person’s individual circumstances and adverse structural factors outside of their direct control” [7] .These structural factors may be economic or social, resulting from mental health issues, domestic abuse or addiction. Former service men and women make up a large proportion of homeless in both the UK and the United States. Often a significant life event occurs, such as the death of a loved one, a relationship breakup or the loss of a job, which triggers a cascade of compounding difficulties that ultimately lead to becoming homeless.

Bill, a well-paid and relatively successful insurance broker who faced challenges with alcohol that eventually saw him living on the streets of London comments, “no one makes themselves homeless, some people can see it happening but can’t stop it.” Elayne became homeless almost through no fault of her own, living a life “with plenty of money, doing whatever I wanted to do,” until she was made redundant [8]. The path to living on the street is not uniform, every story is unique, a confluence of contributing factors.  But, while each homeless person has a personal story, their experiences of life on the street have many similarities.

Homeless people suffer high levels of stress caused by not only their dire living conditions and fear of the unknown, but also from the threat of attack, abuse and harassment [9]. While mental health issues are common among the homeless, they are not always present at the outset, but can develop as a result of the stresses of life on the streets. Poor and inadequate nutrition commonly leads to illness and sleep quality is severely affected which has well established links with physiological and psychological well being [10]. It is not difficult to imagine the dark places the mind could go, and the appeal of relief from suffering, when faced with such a grim reality.

There has been relatively little research into the death by suicide of people living on the street despite many homeless people exhibiting one or more suicidal characteristics [11]. This may be in part as many deaths go unreported, but perhaps also due to the difficulties of conducting such research; nevertheless, several studies exist. A longitudinal study conducted in Tel Aviv for instance, identified 9 deaths by suicide among a population of 1,192 homeless people over a 9 year period [12]. This equates to a normalised rate of 83.9 deaths per 100,000 people, a common metric in mortality statistics. Similar studies of homeless populations conducted in Toronto and Queensland, Australia derived a rate of approximately 80.0 and 27.6 deaths by suicide per 100,000 respectively [13] [14] . Compared to the global mean of 10.7, there is clearly a large overrepresentation of homeless people in suicide statistics [15]. The answer to my initial question, “why do homeless people not end their suffering?” therefore has a tragic answer – many often do.

There is evidence of a correlation between external factors, homelessness and suicide risk. It is known, for instance, that anxiety is a high predictor of suicide ideation and attempts among the homeless.  It has also been reported that homeless people with drug and alcohol addictions are 1.2 times more likely to attempt suicide, while just having a history of such behaviours elevates suicide risk [16]. This suggests that some of the structural factors which lead to homelessness may also contribute to the high suicide rate. While this implies suicide may be inherent to the individual context rather than a direct result of homelessness, there can be little doubt that homelessness acts as a catalyst to suicidal behaviour if not an important influence in otherwise healthy individuals. That homelessness itself can lead directly to suicide was shown by a study conducted in Tokyo, which determined homelessness and perceived lack of emotional support were significantly correlated with suicidal thoughts and suicide attempts, even when the regression was controlled for depression [17].

While the path to homelessness is unique, whether it leads to suicide may be determined by factors which were present long before becoming homeless, the environment of homelessness serving as an expedient for an outcome that may have been under consideration for some time. For many though, the continued stress, deprivation and suffering of living rough may in itself be enough to lead to suicide. The tragedy of suicide in such a dire circumstance as homelessness is in no way diminished by antecedent factors, although they may in part account for the elevated rates. There can be little doubt though, that providing greater support to those facing homelessness or who are already living on the streets could contribute to reducing not just suicide related deaths but also all-cause mortality among homeless populations.

Many programmes currently exist to help the homeless, several of which have provided information for this article, but I am drawn to a simple answer found during my research. A Reddit forum user asked a question similar to my own, what keeps [homeless people] living in suffering? One answer proffered was naively succinct; hope [18]. Hope that a difference can be made is all that is needed to become involved in projects to help the homeless. Hope may be enough to help those individuals affected find the will to continue, hope that one day soon things will get better. While the number of homeless, and consequently suicides, are increasing, hope is the beginning of our best effort to stop the rising tide.

________________________________________________________________________________

Acknowledgements to Dr. Yoram Barak, Associate Professor at the University of Otago’s Department of Psychological Medicine, Dunedin School of Medicine. 

[1] Homelessness Australia. “What is homelessness?,” (n.d.). https://www.homelessnessaustralia.org.au/about/what-homelessness.

[2] Homeless World Cup Foundation. (2018). “Global homelessness statistics,” https://homelessworldcup.org/homelessness-statistics/.

[3] Homelessness Australia. “Homelessness statistics,” (n.d.). https://www.homelessnessaustralia.org.au/about/homelessness-statistics.

[4] Homeless Link. (2018). “Rough sleeping – our analysis,” https://www.homeless.org.uk/facts/homelessness-in-numbers/rough-sleeping/rough-sleeping-our-analysis.

[5] Alistair, G., Barney, L., & O’Malley, J. (2017).  “How America counts its homeless – and why so many are overlooked,” https://www.theguardian.com/us-news/2017/feb/16/homeless-count-population-america-shelters-people.

[6] Front Steps, (2018). “U.S Homelessness facts.” http://frontsteps.org/u-s-homelessness-facts/

[7] Shelter, (n.d.). “What causes homelessness.” http://england.shelter.org.uk/campaigns_/why_we_campaign/tackling_homelessness/What_causes_homelessness.

[8] Streets of London. (n.d.). “About homelessness.” http://www.streetsoflondon.org.uk/about-homelessness.

[9] Shelter (n.d.). “What is homelessness like?” http://england.shelter.org.uk/campaigns_/why_we_campaign/tackling_homelessness/what_is_homelessness_like

[10] Walker, M. (2017). Why we sleep. New York: Scribner.

[11] Christensen, C. & Garces, L. K. (2006). “Where is the research on homelessness and suicide?” Psychiatric Services, vol. 57, no. 4, p. 447.

[12] Barak, Y., Cohen, A., & Aizenberg, D. (2004). “Suicide among the homeless: A 9-year case study.” Crisis: The Journal of Crisis Intervention and Suicide Prevention, vol. 25, no. 2, pp. 51-53.

[13] Sinyor, N., Kolzoff, C., Reis & Schaffer, A. (2017). “An observational study of suicide death in homeless and precariously housed people in Toronto.” Can J Pyschiatry, vol. 62, no. 7, pp. 501-505.

[14] Arnautovska, U., Sveticic, U., & De Leo, D. (2014). “What differentiates homeless persons who died by suicide from other suicides in Australia? A comparative analysis using a unique mortality register.” Social psychiatry and psychiatric epidemiology, vol. 49, no. 4, pp. 583-589.

[15] Wikipedia. (2018). “List of countries by suicide rate.” https://en.wikipedia.org/wiki/List_of_countries_by_suicide_rate.

[16] Lee, K. H., Jun, J. S., Kim, Y. J., Roh, S., Moon, S. S., Bukondal, N., & Hines, L. (2017). “Mental health, substance abuse and suicide among homeless adults.” Journal of evidence informed social work, vol. 14, no. 4, pp. 229-242

[17] Okamura, T., Ito, K., Morikawa, S., & Awata,  S. (2014). “Suicidal behaviour among homeless people in Japan.” Social psychiatry and psychiatric epidemiology, vol. 49, no. 4, pp. 573-582.

[18] Reddit, why don’t homeless people commit suicides more often?  https://www.reddit.com/r/AskReddit/comments/2malam/why_dont_homeless_people_commit_suicides_more/?st=jh92rvrr&sh=189f244e

Cover photo credit, Anncio. http://www.pxleyes.com/photography-picture/4fd5b14b0d0f2/Hopeless.html

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