R E S E A R C H A R T I C LEOpen Access
McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:128 https://doi.org/10.1186/s12888-018-1725-8
Mentalhealthsupportedaccommodationservices:asys tematicreviewofmentalhealthandpsychosocialoutc omes
PeterMcPherson*,
JoannaKrotofilandHelenKillaspy
Abstract Background:Post-
deinstitutionalisation,mentalhealthsupportedaccommodationserviceshavebeenimplementedwidely.Theavailablere searchevidenceisheterogeneousinnatureandresistanttosynthesisattempts,leavingresearchersandpolicymakerswithno clearsummarywhatworksandforwhom.Inthiscontext,weundertookacomprehensivesystematicreviewofquantitatives tudiesinordertosynthesisethecurrentevidenceonmentalhealthandpsychosocialoutcomesforindividualsresidinginment alhealthsupportedaccommodationservices.
Methods:Usingacombinationofelectronicdatabasesearches,handsearches,forward-
backwardsnowballingandarticlerecommendationsfromanexpertpanel,115paperswereidentifiedforreview.Dataextra ctionandqualityassessmentswereconducted,and33articleswereexcludedduetolowquality,leaving82papersinthefina lreview.Variationinterminologyandservicecharacteristicsmadethecomparisonofservicemodelsunfeasible.Assuch,finding swerepresentedaccordingto thefollowingsub-
groups:‘Homeless’,‘Deinstitutionalisation’and‘GeneralSevereMentalIllness(SMI)’.
Results:Resultsweremixed,reflectingtheheterogeneityofthesupportedaccommodationliterature,intermsofresearchqu ality,experimentaldesign,population,servicetypesandoutcomesassessed.Thereissomeevidencethatsupportedaccommo dationiseffectiveacrossarangeofpsychosocialoutcomes.Themostrobust
evidencesupportstheeffectivenessofthepermanentsupportedaccommodationmodelforhomelessSMIingeneratingim provementsi n housingretentionandstability,andappropriateuseofclinicalservicesovertime,andforotherformsofsup portedaccommodationfordeinstitutionalisedpopulationsinreducinghospitalisationratesandimprovingappropriatese rviceuse.TheevidencebaseforgeneralSMIpopulationsislessdeveloped,andrequiresfurtherresearch.
Conclusions:Alackofhigh-
qualityexperimentalstudies,definitionalinconsistencyandpoorreportingcontinuetostymieourabilitytoidentifyeffectiv esupportedaccommodationmodelsandpractices.Theauthorsrecommendimprovedreportingstandardsandtheprio ritisationofexperimentalstudiesthatcompareoutcomesacrossdifferentservicemodels.
Keywords:Supportedaccommodation,Supportedhousing,Rehabilitation,Recovery,Effectiveness
*C o r r e s p o n d e n c e :p . m c p h e r s o n @ u c l . a c . u k
DivisionofPsychiatry,FacultyofBrainSciences,UCL,6thFloor,MapleHouse,149TottenhamC ourtRoad,LondonW1T7NF,UK
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McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:1
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Background
InW e s t e r n E u r o p e a n d N o r t h A m e r i c a , t h e p r o c e s s o f d e - i n s t i t u t i o n a l i s a t i o n , d e f i n e d as“…
thep r a ct i c e o f c a r -
i n g f o r i n d i v i d u a l s i n t h e c o m m u n i t y r a t h e r t h a n i n a n i n s t i t u t i o n a l environment ”(p.47),hasle dtoa si gni f i ca nt i n c r e a s e incommunitybasedcarefo rpeoplewithseverem e n t a l illness(SMI)
[1].Housing-basedsupport,orsup-
p o r t e d a c c o m m o d a t i o n , o p e r a t e s a s a c o m p o n e n t o f t h e b r o a d e r mentalhealth‘carepathway’a n d at temptstom e e t t h e n e e d s o f serviceu s e r s b y p r o v i d i n g f o c u s s e d , f l exi bl esu ppo rt. In t his con tex t,su pp ort aims to add ressf u n c t i o n a l impairment,develop practicallivingskills,im-
p r o v e socialfunctioningandpromoterecovery andin de-p e n d e n c e [2].M e n t a l h e a l t h
s u p p o r t e d a c c o m m o d a t i o n s e r v i c e s havebee nimplementedwidely;recentestimatesi n d i c a t e t h a t , i n t h e U K a l o n e , o v e r 6 0 , 0 0 0 i n d i v i d u a l s a r e c u r r e n t l y receivingsupporti n thesesettings[3].Duet o hi ghrateso f serviceuse,andexpenditurerelatedt o staffing,sup portandinfrastructure,thisformofinterven-
tionisalsoextremelycostly.However,despitethebroadimplem entationoftheseservicesandtheassociatedfinan-
cialburden,littleisknownabouttheireffectiveness.
Definitionali s s u e s a r e w e l l d o c u m e n t e d i n t h e l i t e r a -
t u r e , andp resentasign ifican tob st acleto theassess ment o f t h e e f f e c t i v e n e s s o f s u p p o r t e d a c c o m m o d a t i o n . B o t h w i t h i n andbetweencountries,su pportedaccommoda-
t i o n s e r v i c e s v a r y w i d e l y i n t e r m s o f p h y s i c a l s t r u c t u r e , s t a f f i n g a r r a n g e m e n t s , l ev e l s o f s u p p o r t , r ec o v e r y f o c u s , a n d d i s c h a r g e a n d m o v e - o n p o l i c i e s , c o n t r i b u t i n g t o c o n f u s i o n a s t o w h a t e x a c t l y a s u p p o r t e d a c c o m m o d a -
t i o n service‘ looks’l i k e . D e s p i t e t h e s e i s s u e s b e i n g d i s -
c u s s e d intheliteratureforover20years,therehaveb e e n f ewmeaningfulattemptstoaddressthem.Asar e s u l t , t h e a v a i l a b l e l i t e r a t u r e i s h et e r o g e n e o u s i n n a t u r e a n d r e s i s t a n t t o s y n t h e s i s a t t e m p t s , l e a v i n g r e s e a r c h e r s a n d p o l i c y m a k e r s w i t h n o c l e a r s u m m a r y o f t h e b i g g e r p i c tu r e;thatis,whatworksandfo rwhom.
Fort h e s e r e as o n s , p r e v i o u s a t t em p t s t o s u m m a r i s e t h e e v i d e n c e basehavebeenlargelyunsatisfactory.O
’Malleya n d Croucher[4]conductedascopingstudyofs up-
p o r t e d a c c o m m o d a t i o n s e r v i c e s f o r p e o p l e w i t h m e n t a l h e a l t h p r o b l e m s i n t h e UK,a i m i n g t o e x p l o r e e v i d e n c e f o r modelsofgoodpractice.Aft erreviewing131studiesf r o m anoriginalpoolof2506,th eauthorsconcludedt h a t m o s t s e r v i c e s ar e bas ed o n t h e as s um p ti o n th at ser-
v i c e u s e r s w i l l p r o g r e s s f r o m h i g h e r t o l o w e r l e v e l s o f s u p p o r t ed accommodationovertime,howe
vertheyc o u l d notidentifyany “concreteevidencetosup porta nyp a r t i c u l a r modelofho u si ng support”(p.841 ).Duetothem e t hodologyu s e d , t h e a u t h o r s d i d n o t u n d e r t a k e a n as-
s e s s m e n t o f t h e q u a l i t y o f t h e p u b l i c a t i o n s , t h u s s i g n i f i -
c a n t l y l i m i t i n g t h e v a l i d i t y o f t h e f i n d i n g s . I n a d d i t i o n , t h e stu dyfocu ssed so l e l y onU K pap ers a nd isalsono wmoret h a n 1 0 y e a r s o l d . M o r e r e c e n t l y , a C o c h r a n e
McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:1
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Review( in i ti a l l y c o n d u c t e d in 2 0 02 , and u p d at e d i n 2 0 0 6 )
[5,6]compared theeffi cacyof supported hou si ng s c h e m es , o u t r e a c h s u p p o r t a n d s t a n d a r d c a r e . T h e s y s -
t e m a t i c reviewconsideredonlyrandomisedcontroll edt r i a l s (RCT)andquasi-
randomisedtrials.Athoroughs e a r c h i d e n t i f i e d 1 3 9 p o t e n t i a l s t u d i e s f o r i n c l u s i o n , b u t af t e r r e v i e w , n o n e f u l f i l l e d t h e i n c l u s i o n c r i t e r i a . W h i l e t h e superiorityofRCTsasa‘goldstandard’forprovid inge v i d en c e foreffectivenessiswidelyacknowled ged,therei s alsoagrow ingargument forconsiderin gotherqu ant i-
t at i v e e v i d e n c e b e y o n d RCTstudies.T h i s i s p a r t i c u l a r l y s a l i e n t inc as es wh ere RCTsare n otpossibl e du e to eth -
i c a l o r p r a g m at i c c o n c e r n s , a s i s t y p i c al l y th e c a s e i n in su p p o r t ed a c c o m m o d a t i o n
r e s e a r c h . TheCochraner e v i e w p r o v i d e s a s t a r k c o m m e n t o n t h e s t a t e o f t h e lit-
e r a t u r e inthefield, howeveritdoeslittletodescrib ethee x i s t i n g evidencebase.
Inl i g h t o f t h e s e o b s e r v a t i o n s , i t i s c l e a r t h a t t h e r e i s a n u r g e n t n e e d t o s u m m a r i s e t h e c u r r e n t e v i d e n c e a s i t r el at e s t o m e n t a l h e a l t h s u p p o r t e d a c c o m m o d a t i o n ser-
v i c e s . W e t h e r e f o r e u n d e r t o o k a c o m p r e h e n s i v e s y s t e m -
a t i c reviewo fdatafromquan titativestudies inthef ield, i n c o r p o r a t i n g e v i d e n c e b e y o n d t h a t d e r i v e d f r o m RCTsa l o n e . O u r a i m wast o s y n t h e s i s e t h e c u r r e n t e v i d e n c e o n mentalhealthandp sychosocial outcomesforindivid-
u a l s residinginmentalhealthsupportedaccommoda -
t i o n , m a k i n g c o m p a r i s o n s b e t w e e n d i f f e r e n t m o d e l s , w h e r e thequalityofevidenceallowed.Ou robjectivewast o reportfindingslikelytobeofinterest tothoseprovid-
i n g a n d c o m m i s s i o n i n g m e n t a l h e a l t h s u p p o r t e d a c c o m -
m o d a t i o n , aswellaspolicymakers,andtohighlightar e a s forfutureresearch.
Thisr e v i e w f o l l o w s t h e P R I S M A g u i d e l i n e s [7].TheP R I S M A checklistandreviewprotocolarea vailableandc a n berequesteddirectlyfrom theaut ho rs.
Methods Inclusion criteria
Ther e v i e w i n c l u d e d q u a n t i t a t i v e s t u d i e s , a n d q u a n t i t a - t i v e componentsofmixed-
methodstudies,thatevalu-a t e d theeffectivenessof supported
accommodationont h e m e n t a l h e a l t h a n d p s y c h o s o c i a l o u t c o m e s o f p e o p l e w i t h m e n t a l h e a l t h p r o b l e m s , p u b l i s h e d a f t e r 1 9 9 0 . N o c o u n t r y -
b a s e d l i m i t a t i o n s w e r e i m p o s e d . Ther e v i e w c o n s i d e r e d a l l r e l e v a n t p a p e r s p u b l i s h e d i n L a
t i n a l p h a - b et text.Non-
Englishpapersweretranslatedpriortod a t a
e x t r a ct i o n . A separatereviewwas
carriedoutb y o u r researchteamthatfocussedonstudie sthatusedqualitativemethods.
Definitionofsupportedaccommodation
Therei s l a r g e v a r i a t i o n i n t h e t e r m i n o l o g y u s e d i n t h e su p p o r t e d accommodationsectorinternationall y.Fort h e purposeofthisreview,wedefinedmentalhealth
supporteda c c o m m o d a t i o n a s a n y servicet h a t p r o v i d e d s u p p o r t , d e l i v e r e d predominately by non- professionallyq u a l i f i e d staff,topeoplewithmentalhealth problemsl iv i n g i n c o m m u n i t y -
b a s e d a c c o m m o d a t i o n , e i t h e r a l o n e o r i n s h a r e d s e t t i n g s . T h e c o m p o n e n t s o f t h i s d e f i n i t i o n a r e c ommonintheliterature,andaimtodistinguishs u p p o r t e d a c c o m m o d a t i o n f r o m s p e c i a l i s t , i n p a t i e n t r e - h a b i l i t a t i o n services,s u c h asc o m m u n i t y - b a s e d r e h a b i l i -
t a t i o n u n i t s ( e . g . ‘ wardi n t h e c o m m u n i t y ’)a n d s t a t u t o r y m e n t a l h e a l t h t e a m s , w h er e s t a f f a r e r e q u i r e d to p o s s e s s a p p r o p r i a t e professionalqualifications.All studiesthati n v e s t i g a t e d mentalhealthand psychoso cialou t co m es int h e s e s e t t i n g s w e r e i n c l u d e d . C o s t -
e f f e c t i v e n e s s p a p e r s , a n d studiesexaminingspe cificinterventionswithintheses e t t i n g s (e.g.tokeneco nomies),wereexcluded.
Studyd esig n
Thereviewexaminedstudieswitha broadrangeofdesigns,incl udingexperimental,quasi-
experimental,cohort,casecontrolandobservationalstudieswit handwithoutcomparisongroups.Systematicreviews,clinicalg uidance,bookchapters,conferenceproceedingsandgen- eralcommentariesordiscussionpaperswereexcluded.
Population
Wei n c l u d e d s t u d i e s t h a t r e p o r t e d o u t c o m e s o n i n d i v i d -
u a l s w i t h a p r i m a r y m e n t a l h e a l t h d i a g n o s i s , a g e d 1 8 t o
65. Studiesr e p o r t i n g o u t c o m e s f o r serviceu s e r s w i t h a p r i m a r y d i a g n o s i s o f d e m e n t i a , l e a r n i n g d i s a b i l i t y , per-
s o n a l i t y disorder,substancemisuse,eatingdisorderorp h y s i c a l disabilitywereexcluded.Studies
withanexplicitf o c u s o n m e n t a l h e a l t h -
s u b s t a n c e m i s u s e d u a l d i a g n o s i s p o p u l a t i o n s , o r t h o s e t h a t i n c l u d e d a s a m p l e w i t h f e w e r t h a n 5 0
% o f p a r t i c i p a n t s w i t h a m e n t a l h e a l t h p r o b l e m w e r e alsoexcluded.
Outcomes
Duet o t h e h e t e r o g e n e i t y o f s t u d i e s , i t w a s n e c e s s a r y t o c o n s i d e r awiderangeofmental healthandpsyc hosocialo u t c o m e s . Theseweregroupedintofourcat egories:
– Serviceuse:Housings t a b i l i t y , including maintainingt enancy/beingevictedfromtenancy;h o s p i t a l i s a t i o n ; imprisonment;psychiatri cservicec o n t act;move-ont o m oreindependent accommodation.
– Mental healthand
wellbeing:Symptomsofmentali l l n e s s; death/suicide;self -esteem;mentalwell-being
– Function:S o c i a l f u n c t i o n i n g ( i n c l u d i n g e m p l o y m e n t ) ; a u t o n o m y ; q u a l i t y o f l i f e ( Q o L ) ; r e c o v e r y
– Serviceusersatisfactionwithcare
Search strategy
Anel e ct r o ni c d a t a b as e s ea r ch w a s c o n d u c t e d i n Ja nuary2 0 1 5 u si n g M E D L I N E , EMBASE,PsycINFO,C I N A H L
Plus,I n t e r n a t i o n a l B i b l i o g r a p h y o f t h e S o c i a l S c i e n c e s ( I B S S ) , AppliedSocialSciences Ind ex andAb stracts ( A S S I A ) , SociologicalAbstract s,WebofScienceandT h e C o c h r a n e L i b r a r y . T e r m s a n d c o n c e p t s r e l a t i n g t o ‘mentali l l n ess’,‘su pporteda c c o m modation’a n dk e y o u t-
comes,su ch a s q u alit y o fli fe, h o u s i n g r e t e n t io n an d so -
c i a l f u n c t i o n i n g , w e r e c o m b i n e d w i t h M e S H t e r m s , su b j e ct he adi ngs o r thesauru st erm s ( d e p en d i ng o n dat a-
b a s e ) . S e a r c h e s w e r e c o n d u c t e d a g a i n i n J u n e 2 0 1 7 t o e n s u r e c o m p r e h e n s i v e n e s s . L i m i t s r e l a t i n g t o a g e ( 1 8 –
65years)andpublicationdate(>1990)wereapplied.Th e o r i g i n a l s e a r c h s t r a t e g y , o r g a n i s e d a c c o r d i n g t o d ata ba se , isprovidedinAdditionalfile1.
Fourj o u r n a l s returningth ehi ghestnum ber o fret a ineda r t i c l e s i n t h e e l e c t r o n i c s e a r c h w e r e s e l e c t e d f o r h a n d -
s e a r c h i n g : CommunityMentalHealthJournal,Psych i-
a t r i c Services,P s y c h i a t r i c R e h a b i l i t a t i o n J o u r n a l a n d I n t e r n a t i o n a l J o u r n a l o f S o c i a l P s y c h i a t r y . T w o a u t h o r s (P M , JK)reviewedallissueso fthesejournalstoidentifya n y a r t i c l e s n o t r e t r i e v e d t h r o u g h t h e f o r m a l s e a r c h . A n e x p e r t p a n e l , c o m p r i s e d o f theProgrammeManagementGroupoftheQ ualityandEffectivenessofSupportedTen-
ancies(QuEST)researchproject( a nationalprogrammeo f r esearchintomentalhealthsupportedaccommodationfundedb y theNationalInstituteofHealthResearch[NIHR],Ref.RP- PG-0610-10,097),werealsoaskedtopro-
videkeypublications.Referencelistsfromsixkeypapers[8–
13]werealsoreviewedinordertoidentifyanyarticlesmissedt hroughtheothersearchstrategies.
Aftert h e i n i t i a l d a t a b a s e s e a r c h r e s u l t s w e r e c o l l a t e d , a n d duplicatesomitted,arelevancerevie wof10%ofar-
t i c l e s ( n=1066)wasc o n d u c t e d b y t h e r e v i e w e r s (PM,J K ) toensurefidelitytotheinclusioncriteria.
Therewas2 . 5 % discrepancybetweenthetworaters(n=2 7articles).T h es e 27publicationswerereviewedand discusseduntilc o n s e n s u s regardinginclusionwasr eached.
Dataextraction
Ad a t a e x t r a c t i o n f o r m w a s c r e a t e d t o f a c i l i t a t e r e c o r d -
i n g ofkeystudyinformation.Dataextractionwascarrie do u t b y t w o r e s e a r c h e r s (PM,J K ) , w i t h t h e f o l l o w i n g i n -
f o r m a t i o n recordedfromeachincludedarticle:
– Articlecharacteristics:Countryoforigin;language;p o p u l a t i o n ; subjectandcontext.
– Studycharacteristics:Aimsofthestudy;studydesig n;theoreticalframework;outcomes;
methods;participantnumbersbygroup(N);participa nteligibility;samplingmethod;
recruitmentprocedures;datacollectionprocedures;
dataanalysis.
– Findings:Reportedresults;interpretation
ofresults;s u m m a r y offindings;recommendations;pol icyandp r a cti ce implications.
Forn o n -
E n g l i s h l a n g u a g e a r t i c l e s , r e s e a r c h e r s a t U C L t h a t w e r e n a t i v e -
s p e a k e r s w e r e e m p l o y e d t o e x t r a c t t h e d a t a . J KandPMinstructedthesei ndividuals onthep r o c e s s ofdataextraction.
Qualityassessment
Qualityappraisalofarticleswascarriedouttoassessb i a s a n d informtherelativeweightingo f results.TheQ u a l i t y A s s e s s m e n t T o o l f o r Q u a n t i t a t i v e S t u d i e s (QAT QS)
[14]wasusedtoassessarticlequality;thetooli s recomm endedforu sein syst em a tic rev i ew sb y Deeksa n d col leagues[15]anddisplaysacceptablepsychometricp r o p e r t i e s [14].TheQATQSassessesthemethodologicals t r e n g t h o f a s t u d y a c r o ss e i g h t d o m a i n s ( se l e ct i o n b i a s
; s t u d y design;confounders;blinding;datacollectionm e t h o d s; w i t h d r a w a l s a n d d r o p o u t s ; i n t e r v e n t i o n i n t e g -
r i t y ; andanalysis)andprovidesaglobalqualityrating of‘strong’(high q u a l i t y ) , ‘moderate’(moderate q u a l i t y ) a n d ‘ weak’(lowquality).Duetothescoringsystem,iti spos-s i b l e forwell-designedande x e c u t e d non- experimentals t u d i e s t o b e r a t e d a s h i g h q u a l i t y ( e . g . c o h o r t a n a l y t i c , c a s e control,andinterruptedti meseriesratedas
‘moderate’i n t h e d e s i g n d o m a i n ) . A n y p a p e r s a s s e s s e d a s ‘weak’wereexcludedfromthesynthesis(seeb elow).
Datasynthesis
Duetotheheterogeneityoftheliterature,anarratives y n t h e s i s m e t h o d w a s e m p l o y e d . T h e s y n t h e s i s w a s s t r u c t u r e d u s i n g g u i d e l i n e s p u b l i s h e d b y P o p a y a n d c o l -
l e a g u e s [16],andincludeddevelopingapreliminarys yn-t h e s i s , e x p l o r i n g t h e r e l a t i o n s h i p s i n t h e
d a t a , a n d as s es si n g therobustnessofthefinalsynth esisproduct.
Results Descriptives
Theinitialreturncomprisedof16,080articlesfromelec -t r o n i c databases,and601articlesfromhand- searchesa n d
s n o w b a l l i n g . Aftertheremovalo f duplicates,andt h e a p p l i c a t i o n o f i n c l u s i o n -
e x c l u s i o n c r i t e r i a , t h e f i n a l s a m p l e consisted of115articles.APRISMAdiagram,il-
l u s t r a t i n g theretrievalpro cedur e andreturn s, ispr
e-s e n t e d i n F i g .1.Themajority
oft h e retrievedp a p e r s f o c u s s e d onAmericanpopulati ons,withsmallernum-
b e r s c o n s i d e r i n g C a n a d i a n , U n i t e d K i n g d o m , I t a l i a n , AustralianandGermancontexts(seeTable1).Inter msofexperimentaldesign,thereviewconsideredcohort(n=85) ,quasi-experimental(n=15),randomisedcontrol(n=
11)andcase-control(n=4)studies.Qualityassessment,
Fig. 1 PRISMA diagram: Retrieval process
Table1Retrievedpapersbycountryoforigin
Country Numberofpapers
USA 50
Australia 6
Germany 6
Denmark 3
HongKong 3
Israel 3
Japan 3
Holland 2
Albania 1
Finland 1
Greece 1
India 1
NewZealand 1
Taiwan 1
Total 115
usingtheQATQS,indicatedthatthemajorityofstudieswererate da s moderatequality(n=62),witha smallernumberratedas hi ghquality(n=20).Intotal,33 studieswereassessedaslowquali tyand,inlinewithourprotocol,excludedfromthesynthesis.
Initially,t h e r e v i e w w a s i n t e n d e d t o a s s e s s a n d c o n -
t r a s t outcomesaccordingtosupportedaccommodationse rvicet y p e s . However,t h e s i g n i f i c a n t v a r i a t i o n i n ter-
m i n o l o g y an d servicech a r ac t e r i s t i c si n ther ev ie we dpa-
p e r s madethisapproachunfeasible.Consequently,wee x a m i nedthecharacteristicsofindividualstudies,inline w i t h gui dan ce by Pop ay and col leagu es [16],andide nti-f i e d specificstudypopulations.Twoclearsub- groupse m e r g e d ; h o m e l e s s i n d i v i d u a l s w i t h m e n t a l i l l n e s s , a n d f o r m e r p at i e n ts oflarge hospit alst h at hadbeen reset tled i n t h e c o m m u n i t y . Ther e m a i n i n g p a p e r s c o n s i d e r e d su p p o r t e d a c c o m m o d a t i o n f o r n o n -
s p e c i f i e d m e n t a l l y i l l p o p u l a t i o n s . B a s e d o n t h e s e characteristics,i t w a s d e - c i d e d t o p r e s e n t t h e f i n d i n g s a c c o r d i n g t o t h e f o l l o w i n g p o p u l ationsub-
groups:‘Homeless’,‘Deinstitutionalisa-
tion’a n d ‘ GeneralS e v e r e M e n t a l I l l n e s s (SMI)’.T heset h r e e g r o u p s o f s t u d i e s a r e d e s c r i b e d i n t h e su b -
s e c t i o n s b e l o w . S e e A d d i t i o n a l f i l e2f o r a s u m m a r y t a b l e o f a l l r e v i e w e d studies.
Homeless
Thisgroupofpaperscomprisedofstudiesexaminingo u t c o m e s ofsupportedaccommodationfocussedonh o m e l e s s i n d i v i d u a l s w i t h S M I . Th e s e s t u d i e s w e r e t y p - i c a l l y fromthe USAorCanada,andincludedpermane nt
Canada 14
UK 11
Italy 8
supportedhousing pro jects (suchas HousingF irst [ HF ]) a n d t h e ‘HUD-
VASH’p r o g r a m ( D e p a r t m e n t o f H o u s i n g a n d U r b a n D e v e l o p m e n t -
V e t e r a n s A f f a i r s S u p p o r t i v e H o u s i n g P r o g r a m ) , w h i c h c a t e r s t o m i l i t a r y v e t e r a n s i n t h e U S A . T h e s e s t u d i e s a r e u n i q u e , n o t o n l y f o r t h e i r po p u l at i on -
f o c us b u t a l s o f o r t h e t y p e o f s u p p o r t e d a c c o m m o d a t i o n examined;thebulkofthe‘homeless’pa- p e r s e x a m i n e d t h e p e r m a n e n t s u p p o r t e d h o u s i n g a p - p r o a c h w h i c h a i m s to supporthomelessindividualst o a c h i e v e h o u s i n g s t a b i l i t y o r p e r m a n e n t a c c o m m o d a t i o n , a s wellp rovidingsupportwithmentalhealthissues.Spe- c i f i c a l l y , t h i s ap p r o a ch “ providesi nd i vi du a l sw it h i m m e-
d i a t e housing,clientchoiceisemphasizedineveryaspect o f treatment,housingisseparatedfromtreatment,a ndah a r m r ed u c t io n a pp ro a ch i s fo l l owe d ”[13]
(p . 2) .I t co n-
t r a s t s withtraditionalcontinuummodelswherebyser- v i c e usersprogressthrough‘levels’o f support(ofl e s s e n i n g i n t e n s i t y ) , w i t h t h e i n t e n t i o n o f a c h i e v i n g s t a b l e , perm anent h o using as anend - point.
Studydesign,qualityandoutcomes
The‘ homeless’g r o u p c o m p r i s e d o f t h e l a r g e s t n u m b e r o fe x a m i n e d s t u d i e s ; 4 0 p a p e r s i n t o t a l w e r e r e v i e w e d . O f this,11wereratedashighq uality[8,13,17–24,44]
and2 0 m o d e r a t e q u a l i t y [9,2 5–
43].N i n e p a p e r s w e r e o m i tt ed f r o m t h e s y n t h e s i s d u e t o l o w q u a l i t y . O f t h e r e t a i n e d p a p e r s , t h e m a j o r i t y w e r e cohortstudies(n=1 6 ) , fol lowedbyRCTs(n=8),quasi-
experimentalstudies( n=6),a n d a s i n g l e c a s e c o n t r o l s t u d y ( n=1)
( s e e A d d i t i o n a l fil e2fo rd et ail ) .T he out com esas sessedvar-
i e d , b u t r e f l e c t t h e h i g h n u m b e r o f H F st u d i e s a n d t h e i r p r i m a r y f o c i ; t h e m o s t c o m m o n o u t c o m e s w e r e h o u s i n g s t a b i l i t y , s e r v i c e u s e , s y m p t o m s o f m e n t a l i l l n e s s , s u b -
s t a n c e misuse,socialfunctioning,andQoL.
Supportedaccommodation types
Thestructureoftheexaminedsupportedaccommodationservi cesvariedconsiderably,a s didthedetailinwhichtheywerere ported.Themajorityofthepapersonhome-
lesssupportedaccommodationserviceswerebasedontheper manentsupportedhousingmodel[9,13,17,18,21–
23,25–27,30,31,33,36–44].Projectsadheringt o this modelincluded,amongothers,HF[13,17,18,26,27,31–
33,36,37,40,41],Pathwayst o Housing[34,44],A t Home/C hezSoi[42],andprojectsusingSection8housingcertificates[
39].Theprinciplesofpermanentsupportedhousingareimple mentedinvariousforms;accommoda-
tiontypesincludegrouphomes[24,35,43],individual
apartments[24,35,38,43],communityresidences(resi- dencesinbuildingswithsingleorsharedrooms,orstudioapartm ents,andcommondining,meeting,andservicesspace)
[21].Thepermanentsupportedhousingprojectsalsovariedaccor dingtointensityandnatureofsupport(in-
cludingintensivecasemanagement,assertivecommunity
treatmentanddifferentlevelsofon-
sitestaffsupport),levelofintegrationbetweenhousingandmenta lhealthserviceproviders,fidelitytotheprincipleofseparationbet weenhousingandtreatment,andrestrictionsaroundsobriety[9].
TraditionalhousingavailabletohomelesspopulationswithSMI, sucha s homelessshelters[29],nursinghomes[20],boardandcar ehomes[28]andresidentialcarefacilities[35]wereusedascomp arisonconditionsinsomestudies.
HousingstabilityInt o t a l , 1 9 s t u d i e s o f s u p p o r t e d a cc om m o d at i on forh omelessp o p ulationsassessedh o u singstabilityasa n o u t come,comprising7 h ighquality[8 ,1 8,1 9,21–23,4 4]and12m o d erateq u ality
studies[9,25,26,30–35,3 7,39,42].Supported ac- commodationappearst o b eeffectiveinp r o m o t i n ghousi ngr e t e n t i o n forh omelessadultswithm entalill-
ness;h ighq ualitystudiesconsistentlyr e p o r t edhighr a t e s o fh ousingr e t e n t ion,with37t o 84%ofpartici-
p a n t sstillh o u s e d a t follow-up(6m o n t h s t o 5 years)
[19,2 1,2 3,44,45].M o d e r ateq u alitystudiesgenerallys u p p o r t edt h esefindings,r e p o r tingh ighr a t eso f h o u singst ability[9,34,35],reductionsinnights
spenthomeless[26,33,37],andincreasesinnights spentino wnapartment[26,42].
An u m b e r o f f a c t o r s a p p e a r t o b e r e l a t e d t o h o u s i n g s t a b i l i t y includinggender,withwomenmore likelytobeh o u s ed andlesslik ely to beevicted [18,30 ],ag e( b e i n g o l d e r associatedwithlongertenure) [19,34]andincome[9],w i t h h i g h e r i n c o m e i n c r e a s i n g t h e p r o b a b i l i t y o f a ‘ positive’m o v e - o n . O t h e r r e l a t e d f a c t o r s i n c l u d e a c c e s s t o ho usingsubsidies[39],neighbourhood quality[9],s u p p o r t i v e relationshipswithsupportstaff[9],caseman- a g e r supporttoaccessappropriatebenefits[18],self- h a r m behaviours[30],chronicpain/illness[30],improve -
m e n t s inhousingproblems[8]andpast[9,19]andcu r r e nt su bstance misu se [30].Intensityofcasemanage- m e n t [39]andserviceusers’preferenceforh ousingty peand s a t i s f a c t i o n w i t h s u p p o r t w e r e n o t f o u n d t o b e p r e - di c t iv e ofhousingstability [31,32].
Serviceu s e Eights t u d i e s o f s u p p o r t e d a c c o m m o d a t i o n f o r h o m e l e s s p o p u l a t i o n s e x a m i n e d t h e a s s o c i a t i o n b e -
t w e e n t h e s u p p o r t e d a c c o m m o d a t i o n s e r v i c e a n d a p p r o -
p r i a t e s e r v i c e u s e ( t w o h i g h q u a l i t y s t u d i e s [8, 2 1]a n d s i x m o d e r a t e q u a l i t y s t u d i e s [28,2 9,3 5– 37,4 2]).T h e r e w a s generallyconsistentevidencetha tsu ppo rted accom-
m o d a t i o n f o r h o m e l e s s i n d i v i d u a l s l e a d t o a n i n c r e a s e d u s e o f a p p r o p r i a t e s u p p o r t services,s u c h aso u t p a t i e n t c l i n i c s andmedicationvisits[36, 37],areductioninhos-
p i t a l i s a t i o n s [28],h o m e l e s s s h e l t e r u s e [29]a n d t
h e u s e o f cri si s servi ce s[21]fo radu lt h om el es s popul ations.I nc o n t r a s t , a s i n g l e m o d e r a t e q u a l i t y s t u d y [42]f o u n d n o d i f f e r e n c e inhospitaldaysoremerg encyserviceuseb et w e en H F p a r t i c i p a n t s a n d t h o s e r e c e i v i n g t r e a t m e n t
asusual(TAU).One high quality studyfou ndapo siti vea s s o c i a t i o n betweenneighbourhoodqualityandle ngtho f
h o s p i t a l a d m i s s i o n s , a n d b e t w e e n h o u s i n g p r o b l e m s a n d s e r v i c e n e e d s [8].O n e m o d e r a t e q u a l i t y s t u d y [35]d e m o n s t r a t e d a s i g n i f i c a n t r e l a t i o n s h i p b e t w e e n h o u s i n g st a b i l i t y anda ppropriateserviceuse.
Symptomso f m e n t a l i l l n e s s Eights t u d i e s o f h o m e l e s s s u p p o r t e d accommodationservicesinvesti gatedmentalh e a l t h s y m p t o m s ( f i v e h i g h q u a l i t y [13,2 1,2 3,4 4,4 5]
andt h r e e m o d e r a t e q u a l i t y s t u d i e s [32,3 3,4 2]).S y m p -
t o m assessmentmethodsvaried(acrossallstudiesint hisr e v i e w ) , andincludedclinicalassessments,sta ff-ratedan d self-
reportinstrum ents. Allhighquality studi es sug- g e s t e d t h a t s u p p o r t e d a c c o m m o d a t i o n w a s a s s o c i a t e d w i t h s i g n i f i c a n t i m p r o v e m e n t s i n , o r s t a b i l i t y o f , m e n t a l h e a l t h symptoms[13,21,23,44,45 ].Nodeteriorationins y m p t o m s wasr e p o r t e d . R e s u l t s o f m o d e r a t e q u a l i t y s t u d i e s wereinconsistent;o nestudyfoundnodiffer-
e n c e s insymptomsovertimebetweenHFandTAUg r o u p s [42],w h i l e a n o t h e r r e p o r t e d t h a t i m p r o v e m e n t s i n s y m p t o m s w e r e n o t c o n s i s t e n t l y o b s e r v e d a n d , w h e r e t h e y didoccurtheywereslight[3 3].
Oneh i g h q u a l i t y s t u d y [13]r e p o r t e d a l l f i n d i n g s , i n -
c l u d i n g s y m p t o m s , i n t e r m s o f “ expectedt r a j e c t o r y ”,r e f e r r i n g t o a n i m p r o v e m e n t o r n o c h a n g e i n k e y v a r i -
a b l es . T h i s p r e s e n t e d a challengei n interpretingther e-
sults,a s improvements,andlacko f changei n outcomes,were notpresentedseparately.Althoughthisstudysug-
gestedthat71%ofparticipantsfollowedtheexpectedtra- jectoryforimprovementsinsymptomology,nodatawerepro videdtodistinguishwhatproportionofthisgroupim- proved,ordidnotchange.Thisobservationpertainstoallsubse quentreportingoffindingsfromthisstudy.
Ones t u d y r e p o r t e d a g r e a t e r i m p r o v e m e n t i n p s y c h i -
a t r i c s y m p t o m s i n s u p p o r t e d h o u s i n g s e t t i n g s w h e r e m e n t a l healthservicesareintegrated(seedesc riptionsa b o v e )
[23].Paradoxically, one high qualitystudyfoundt h a t a d i a g n o s i s of alcoholors u b s t a n c e a b u s e ordep en d en ce w a s a s s o c i a t e d w i t h a r e d u c t i o n i n p s y c h i - a t r i c symptoms[13].
Substanceu s e Int o t a l , s i x h o m e l e s s s u p p o r t e d a c c o m - m o d a t i o n servicestudiesexaminedthe associationb e -
t w e en t h e s u p p o r t e d a c c o m m o d a t i o n a n d s u b s t a n c e u s e ( f o u r highquality[13,23,44,45]andtwo moderatequalitys t u d i e s [33,4 2]).T h e r e w a s n o c
l e a r e v i d e n c e t h a t s u p p o r t e d a c c o m m o d a t i o n w a s a s s o c i a t e d w i t h r e - d u c t i o n i n d r u g and alcoholuseforh o m e l e s s p o p u l a - t i o n s . T h e m a j o r i t y o f h i g h q u a l i t y s t u d i e s r e p o r t e d n o c h a n g e i n t h i so u t c o m e o v e r t i m e [23,4 4 ,4 5].A s i n g l e hi g h q u a l i t y s t u d y r e p o r t e d i m p r o v e m e n t o r n o c h a n g e i n thisoutcome,with72%of thesamplemeetingtheex-
p e c t ed trajectoryforchange[13].Asinglemoderate
qualityp a p e r r e p o r t e d a s m a l l b u t s i g n i f i c a n t r e d u c t i o n i n ratingsofalcoholabuse,andintheprop ortionofpar-
ti ci p ant s w h o r e p o r t e d i l l i c i t s u b s t a n c e m i s u s e [33].S i m i l a r l y , amoderatestu d yreportedasigni ficant reduc-
t i o n n u m b e r o f d a y s e x p e r i e n c i n g a l c o h o l - r e l a t e d p r o b -
l e m s at 1 2 an d 2 4 m o n t hs , a n d i n t h e a m o u n t o f m o n e y s p e n t o n a l c o h o l a t 2 4 m o n t h s , i n t h e H F g r o u p c o m -
p a r e d t o TAU[42].A l t h o u g h w e d i d n o t f i n d e v i d e n c e t h a t s u p p o r t e d a c c o m m o d a t i o n w a s a s s o c i a t e d w i t h r e -
d u c t i o n i n s u b s t a n c e m i s u s e , i t i s i m p o r t a n t t o n o t e t h a t i t w a s n o t a s s o c i a t e d w i t h a n y i n c r e a s e a m o n g s t h o m e - l e s s individualseither.
Socialfunctioning,familysupportandcommunity i n t e g r a t i o n Acrosst h e s e v e n s t u d i e s ( t w o h i g h q u a l i t y [13,45],f i v e m od er at e q u a l i t y [31,3 3,38,4 1,42])t h at ex a m i n e d t h i s o u t c o m e , t h e r e w a s i n c o n s i s t e n t e v i d e n c e t o suggestthatsupportedaccomm odationwasassoci-
a t e d withimprovem ents insocialfuncti oning, fami lys u p p o r t o r c o m m u n i t y i n t e g r a t i o n . A s i n g l e h i g h q u a l i t y s t u d y reportedsignificantimprovementins atisfactionw i t h familyrelationships,perceivedavailab ilityoffamilya n d f r eq u en c y o f f am i l y i nt er a ct i o n s o v e r t i m e [45].S t u d y 13providesperhapsthestrongest evidenceinsup-
p o r t ofimprovementsintheseoutcomes:60,62and6 7
% o fpa rti cip ant sf o llo w ed the ‘expectedtr aje ct o r y ’o fi m p r o v e m e n t f or p h y s i ca l c o m m u n i t y i n t eg r a t i o n ( ac t u a l p a r t i c i p a t i o n i n c o m m u n i t y a c t i v i t y a n d u s e o f c o m m u -
n i t y r e s o u r c e s ) , p s y c h o l o g i c a l c o m m u n i t y i n t e g r a t i o n ( h o w anindividualperceivesthems elvesasamemberoft h e i r community)andcommunityf unctioningrespect-
i v e l y [13].However,asdescribedpreviously,themetho do f reportinginthisstudylimitsourabilitytoconfiden tlyi n t e r p r e t t h e f i n d i n g s . O n e s t u d y [41]d e m o n s t r a t e d s i g -
n i f i c a n t i m pr ov em ent s inpsychol ogical co m m u ni ty inte-g r a t i o n at12-monthfollow-
upforHFparticipants,whenc om p a r ed toTAU,howeve rtheyfoundn o changebe-
tweengroupsorovertimeinphysicalcommunityintegra- tion.Similarresultswerereportedi n anothermoderatequalityp aper[42].Amoderatequalitystudyfoundasmallbutstatistically significantincreasei n overallcommunityparticipationoverti me[33],however,fornineo f the1 8 activitiesassessed,therewa snosignificantchange;theau-
thorsreportedthat“Participants…remainedsociallyiso- latedandshowedlimitedimprovementi n otherdomainso f soc ialintegration”(p.427).
QualityoflifeThedatawereinconsistentindemon- s t r a t i n g a n y a s s o c i a t i o n b e t w e e n s u p p o r t e d a c c o m m o d a -
t i o n forhomelessindividualsandQoL.Intotal,ninep a p ers r eportedo n t h i s o u t c o m e (fourhighqualitys t u d i es[13,2 1,2 3,44]andfivem o d eratequality
studies[27,31,3 7,40,42]).Amongstt h e h ighqualityp apers, o n estudyr eportedimprovementi n Q o La t
18-
months[23],onereported66%ofparticipantsm e e t i n gth e“expectedtrajectory”forchangeinQoL[13],a n d o n e r e p o r t edn o changeovert i m e[21].An-
o t h e r h ighq ualitys t u d yr eportedn o significantd iffer- encei nQoLbetweenparti cipantsreceivingHFandc o n t r o l s a t sixm o n t h s follow-
up,h o w e v e r , b aselined ataweren o t r eportedsochange o vert imecouldn o t b eassessed[44].O n e m o d e r a t e q ualitystudyd e m o n stratedinitialimprovementi n QoLi n a HFgroup,c o m p a r edt o TAU,howevert h e effectwa sn o t sustained,withn o groupd ifferencesi n Q o Lobserv eda t 24monthfollow-up[42].Datafromothermoder- a t e q u a litystudiessuggestedt h a t s u p p o r t e d accom- m o d a t i o n i s associatedwithimprovementsi n QoLfor h o m e l e s s a d u lts[27,40],b u t t h e experimentaldesig nofanothermoderatequalitystudydidnotallowexamin
ationo f changeovertime [37].Timeininde-
p e n d e n t housingwassignificantlyassociatedwithQoL[
27].T h e samestudyshowedQoLwasnega-
t ivelyassociatedw i t h severityo f symptomsb u t itwasn o t associatedwithparticipationincommunityactiv-
ities[27].Anotherstudyfoundserviceusershavingc h o iceo verlivingenvironmentpredictedQoLatsixa n d 1 2 - m o n t h followu p,albeitweakly[31].
Deinstitutionalisation
The‘deinstitutionalisation’s u b g r o u p ofpapersiscom- p r i s e d o f s t u d i e s e x a m i n i n g o u t c o m e s o f p e o p l e p r e v i -
o u s l y residing longertermin largem ental hospital swhow e r e resettledinthecommunityfollowingthec losureoft h e s e institutions andthedevelopment ofc ommunityb a s e d mentalhealth services. These ind ividualsweret y p i c a l l y older,w i t h a l o n g i l l n e s s h i s t o r y a n d h a d b e e n i n hospitalforanextendedperio doftime.
Studydesign,qualityandoutcomes
Int o t a l , 3 5 d e i n s t i t u t i o n a l i s a t i o n p a p e r s w e r e r e v i e w e d ; f i v e wereratedashighquality[46–
50]and23asmoder-a t e q u a l i t y [51–
73].S e v e n w e r e o m i t t e d f r o m t h e s y n - th es i s d u e t o a l o w q u a l i t y r a t i n g . T h e i n c l u d e d a r t i c l e s w e r e typicallycohortstudies(n=24),withas mallern u m b e r o f q u a s i -
e x p e r i m e n t a l ( n=2)a n d a s i n g l e c a s e -
c o n t r o l (n=1)andrandomisedcontrolledtrial(n=1) (s ee Additionalfile2fordetail).Commonoutcomes a s s e s s e d forthisgroup wererat es o fh o sp i t al i s a t i o n , s y m p t o m s , socialfunctioning,employmentand QoL.
Supportedaccommodation types
Duet o t h e n a t u r a l i s t i c n a t u r e o f t h e d e i n s t i t u t i o n a l i s a -
t i o n p r o ce ss a nd t h e a s s o c i a t e d r e s ea r c h , t h e m a j o r i t y o f t h e studieswereuncontrolled,andoftenconsi deredar a n g e o f c o m m u n i t y -
b a s e d a c c o m m o d a t i o n s e t t i n g s w i t h i n a s i n g l
e s t u d y ; t h i s c o n t r i b u t e d , a t t i m e s , t o d e s c r i p t i o n s ofservicesthatlackeddetail.Identifiable
servicet y p e s i n c l u d e d n u r s i n g h o m e s [47,5 6,6 5],r e s i - d en t ia lc a r e u n i t s o r h i g h -
s u p p o r t h o s t e l s w i t h 2 4 h s t a f f i n g [46–
48,5 1,5 2,5 4,5 5,5 7,5 9,6 0,6 2,6 3,6 6], supportedgrouphomes[48,49,55,56,61,64,67], apartmentswithflexiblesupport[46,48,56,60],halfway houses[50,5 3,5 8,6 8,7 1,7 3],a n d b o a r d i n g / r o o m i n g
houses[56,59,61].Somestudiesreferto‘supportedh o u s i n g ’o r ‘supporteda c c o m m o d a t i o n ’servicesw i t h o u t p r o v i d i n g furtherdetail[70,72].
Rateso f h o s p i t a l i s a t i o n Twelves t u d i e s , includ ingonehighquality[48]and12m o d e r a t e qualitystudies[
51–53,56,5 8,6 0,6 3,67–69,7 1,72],examinedrates ofh o spitalisationasa n o u t come.Unfortunately,t h esingleh ighqualitystudydidn o t r e p o r t d a t a assessingchangeov ertime[48].Amongstthemoderatequalitystudies,however,su pportedaccommodationappearedt o b e relatedt o reducerate so f hospitalisation[51,53,60]anddurationofhospitaladmissi ons[53,69,71]overtime.Therewas,acrossalmostallstudies,cle arevidenceofhighrateso f rehospitalisation;a numbero f mod eratequalitystudies
[52,53,56,58,63,67,68,72]indicatedbetween35and87%ofpa rticipantsrequiredinpatienttreatmentatleastonceduringthefol low-upperiod(range4–
10years).Thesinglehighqualitystudyreporteda rehospitalisati onrateo f 22%duringthefollow-
upperiod[48].Thereissomeevidencetosuggestthatparticipant sfrommorehighlysupportedsettingsweremorelikelytohospit alised,thanthoseinmoreindependentsettings[56].
SymptomsT h e r e w a s s t r o n g e v i d e n c e f o r i m p r o v e m e n t o r alacko fdeteri oratio ninthe severity ofsy mptom s ofm e n t a l i l l n e s s f o r p a t i e n t s w h o w e r e d i s c h a r g e d t o c o m m u n i t y -
b a s e d s u p p o r t e d a c c o m m o d a t i o n s e t t i n g s f r o m largeinstitutions. Intotal,15studiesexaminedthiso u t c o m e , includingfourhighquality[46–
49]and11moderatequalitystudies[52,54,56,57,62,63,65,66, 70,72,73].Themajorityofhighqualitystudiesreportedim- provementsinsymptomsovertime[46,47,49].Improve- menti n positivesymptomsw a s mostcommon[47,50].Findin gsfromthemoderatequalitypaperswerelesscon-
sistent;mostreportedn o change[52,62,63,65,66,70, 72,73],ormixedresults[54,56,57].
Anumberofhighandmoderatequalitystudiesseem ed to indicat ethatmorerestrictivesetti ngs, su chasn u r s i n g homeswereassociatedwithpooreroutcomes,w i t h s o m e d e m o n s t r a t i n g a w o r s e n i n g o f s y m p t o m s i n p a t i e n t s dischargedtotheseenvironments[47, 73].
Socialf u n c t i o n i n g Fifteens t u d i e s examinedsocialfu nc-tioningasanoutcome,includingfourhighquality[47–
50]and11moderatequalitystudies[52,54–
58,62,63,65,66,70].Evidenceforanassociationbetweensuppor
tedaccom-
modationandimprovementinsocialfunctioningamongst
the‘deinstitutionalisation’sub-
groupwasmixed,althoughfindingssuggestedatrendtowardi mprovement.Twohighqualitystudiesreportedsignificantimpr ovementsinper-
formanceofsociallyexpectedactivities[50],socialcompe- tenceandsocialinterest[49],andasignificantreductioninbehav iouralproblems,suchashostility,over/underactivityandinapp ropriatesexualbehaviour[50].Twohighqualitystudies,howev er,foundnoimprovementsinsocialfunc-
tioningovertime[47,48].Datafromthemoderatequalitystudie scontributedtothemixedpicture;whilesomestud-
iesreportedsignificantimprovementsovertime[54,63,65],the evidencewascomplicatedbypoormethodologiesand,occasio nally,a lackofinferentialdata[55,62].Inaddition,severalmode ratequalitystudiesreportednochangeinthisdomain[52,65,66].
Severalstudiesshowednochangeinthesizeofsocialnetworkso vertime[57,70],whileothersdemonstrateda reductioninthefre quencyofcontactswithfamilyandfriends,withaparallelincrea seincontactswithfellowresidents[58].Similartothefindingsre portedpreviouslyforsymptoms,onestudyreportedade- teriorationinglobalsocialadjustmentinindividualsdis- chargedtomorerestrictivesettings,suchaspsychiatricnursing homes[47].
EmploymentTherewassomeevidencesupportinganassoci ationb etweens u pp o r t ed a c c o m m o d ationandemploy mentinthedeinstitutionalisedpopulation,howeverthen umberandqualityofstudieswaslim-ited.Employment ratesrangedfrom0to17%inthet h r eemoderatequalitystud iesthatassessedthisout-
c o m e [56,68,72].Onemoderatestudyreportedanuns pecifiedr e d u c t i o n i n r a t e s o fu n e m p l o y m e n t a t t h et imeo fd ischarge[53].N o h i g h qualityp apersex aminedt h i s outcome.
Qualityo f l i f e A r e l a t i v e l y s m a l l p r o p o r t i o n o f t h e r ev i e w e d s t u d i e s e x a m i n e d Q o L asa n o u t c o m e i n t h e d e i n s t i t u t i o n a l i s e d subgroup;intota l,eightstudies,i n c l u d i n g twohighquality[47,50]and sixmoderateq u al i t y s t u d i e s [54,6 1,6 3,6 6,7 2,7 3],e x a m i n e d t h i s v a r i ab l e . Therewasalack ofcl earevid ence f o ranyim -
p r o v e m e n t inQoLovertimeforthispopulation but m o s t s t u d i e s r e p o r t e d t h a t i t r e m a i n e d s t a b l e . T h e h i g h q u a l i t y paperssuggestedaninversere lati onshipbetweenQ o L andrestrictivenessofsetti ng,withstudiesreportings i g n i f i c a n t r e d u c t i o n i n Q o L f o r p a t i e n t s d i s c h a r g e d t o p s y c h i a t r i c n u r s i n g h om e s [47,5 0].S i m i l a r l y , o n e m o d - e r a t e q u a l i t y p a p e r f o u n d t h a t m o v i n g i n t o ‘ inappropri-
at e’residentials e t t i n g s r e s u l t e d i n a d e t e r i o r a t i o n i n Q o L [61].Thelackofassociationbetweensupporte da c co m m o d at i o n a n d s u b j e c t i v e Q o L o v e r t i m e r e p o r t e d i n t h e h i g h q u a l i t y p a p e r s w a s c o n s i s t e n t w i t h t h e e v i -
d e n c e fromthemoderatequalitypapers[54,72,73].
GeneralSMI
Althought h i s g r o u p i s l a r g e l y d e f i n e d b y n o n - i n c l u s i o n i n t h e H o m e l e s s a n d D e i n s t i t u t i o n a l i s a t i o n g r o u p s , a n u m b er o f c h a r a c t e r i s t i c s m a k e i t d i s t i n c t . T h e G e n e r a l S M I g r o u p r e p r e s e n t s s e r v i c e u s e r s o f t h e post-
d e i n s t i t u t i o n a l i s a t i o n r e h a b i l i t a t i o n p a t h w a y ; g e n e r a l l y , t h e y p r e s e n t w i t h c o m p l e x n e e d s a s s o c i a t e d w i t h p s y c h -
o t i c i l l n e s s a n d w i l l h a v e e n t e r e d t h e s u p p o r t e d a c c o m -
m od ati on systemthroughvariouspathways(e.g.refe rredfroma c u t e i n p a t i e n t u n i t s,d e t e r i o r a t e d a f t e r i n d e p e n d - en t communityliving,ormoved- onfromcommunity-
b a s e d rehabilitationunits/forensicservicesetc).Im- p o r t a n t l y , a s o p p o s e d t o t h e d e i n s t i t u t i o n a l i s a t i o n g r o u p , t h e y w i l l g e n e r a l l y n o t p r e s e n t w i t h t h e c l i n i c a l , s o c i a l and b e h a v i o u r a l i m p a i r m e n t s a s s o c i a t e d w i t h l o n g -
t e r m h o s p i t a l i s a t i o n . Studydesign,qualityandoutcomes
Intotal,40 general SMIpaperswerere vi ew ed. Them a- j o r i t y wereofmoderatequality(n=19)[74–
91,96],witha s m a l l e r n u m b e r r a t e d ash i g h q u a l i t y ( n=4)[92–
95].However,1 7 p a p e r s w e r e n o t i n c l u d e d i n t h i s s y n t h e s i s d u e t o l o w q u a l i t y . A s w i t h t h e p r e v i o u s s u b g r o u p s , t h e m a j o r i t y ofthestudieswerecohortde signs(n=18),witho n e quasi-
experimental(n=1)andonematchedcasec o n t r o l stu
dy(n=1)(see Additional
file2fordetail).Th ere w as a w i d e v a r i e t y o f o u t c o m e s a s s e s s e d i n t h es e p a p e r s , h o w e v e r t h e m o s t c o m m o n w e r e r a t e s o f h o s p i -
t al i s a ti o n , symptoms,socialfunctioning,andQoL.
Supportedaccommodation types
Fort h i s g r o u p o f p a p e r s , servicet y p e s r a n g e d f r o m i n -
t e n s i v e congregateresidentialcaresettings,with24hs t a f f i n g [76,7 8–
80,8 7,8 9,9 3,9 5],t o l e s s i n t e n s i v e l y s u p p o r t e d a ccommodation,includinggrouphomesands u p e r v i s e d in dividualapartments(e.g.staffed9am-5pmd a i l y ) [74,78,81,82,90,92–94],toindividualtenancies witho u t r e a c h s u p p o r t ( s t a f f b a s e d o f f - s i t e ) [75,8 1,8 3,
87,8 8,9 0,9 6].O t h e r s e r v i c e d e s c r i p t i o n s l a c k e d d e t a i l a n d wereunablet obeco n fi d en t ly categorise d,inclu ding “ shelteredh o u s i n g ”[77],“ sheltered- caref a c i l i t i e s ”[86],“ community-
basedhousing”[91],“transitional,high-
e x p e c t a t i o n , s h e l t e r e d c a r e e n v i r o n m e n t ”[85]
a n d “ sup-p o r t house”[84].
RatesofhospitalisationTwelve papers,includingtwoh i g h q u a l i t y [92,9 4]a n d t e n m o d e r a t e q u a l i t y s t u d i e s [74,77,78,81,82,84,88–
90,96],reporteddatarelatingt o c h an g es i n r at e s o f h o s p i t a l i s a t i o n . Thef i n d i n g sw er e m i x e d . G e n e r a l l y , i t a p p e a r e d t h a t s u p p o r t e d a c c o m m o -
d a t i o n wasa s s o c i a t e d w i t h a r e d u c t i o n i n d a y s s p e n t i n h o s p i t a l [78,8 1,8 2,8 9,9 0],a n d d u r a t i o n o f hospitals t a y s [96],o v e r t i m e . O n e s t u d y d e m o n s t r a t e d a s i g n i f i -
c an t reductioninmeannumberofhospitalandcrisis
centrea d m i s s i o n s f r o m p r e -
e n t r y i n t o a r e s i d e n t i a l p r o - g r a m t o o n e - y e a r post-
discharge[89].S i m i l a r l y , a n o t h e r m o d e r a t e qualit ystudydemonstratedasignificant re-
d u c t i o n i n m e a n n u m b e r o f d a y s i n h o s p i t a l f r o m b a s e - l i n e year(pre-
entry)tothefirstyearincommunitylivinga r r a n g e m e n t facilities[78].Inspiteoftheseposi tive f i n d i n g s , o t h e r s t u d i e s , i n c l u d i n g a s i n g l e h i g h q u a l i t y a r t i c l e [94],reportednocha ngeinthisoutcomeovert i m e [74,88].Onehighquality studyfoundthatsp ecial-
i s t casemanagement,whichwasreservedforSUswith ah i s t o r y ofrepeatedhospitalisations,wastheonlypre- d i c t o r offuturehospitalisations [92],whileanother mod-
e r a t e q u a l i t y s t u d y f o u n d t h a t s e v e r i t y o f s y m p t o m s p r e d i c t e d bothhospitalisationsanddurationof stay[77].
SymptomsNinep a p e r s a s s e s s e d c h a n g e s i n s y m p t o m s o v e r time(twohighquality[94,95]andse venmoderateq u a l i t y s t u d i e s [74,7 6,8 0,8 2,8 4,8 6,8 8].Therew a s m i x e d evidenceforanassociationb etweensupportedac-
c o m m o d a t i o n a n d sy m p t o m s i n g en er al S M I p o p u l a -
t i o n s . A l t h o u g h s o m e m o d e r a t e q u a l i t y p a p e r s d em o n st r a t e d significantimprovementsinsymp tomso v e r time[82,84,95],anumber,includingasingle highq u al it y stu dy, r e p o r t e d n o ch an g e[86,9 4],o r a w o r s e n -
i n g o f s y m p t o m s [74,8 0]a m o n g s t t h i s g r o u p . I n e x a m -
i n i n g c h a n g e o v e r t i m e , o n e m o d e r a t e q u a l i t y s t u d y sh owe d asignificantimprovementinsymptomsfor as m a l l s u b -
g r o u p o f p a r t i c i p a n t s w h o h a d b e e n d i s - c h a r g e d fromaresidentialfacility,butnochangeforth o s e p a r t i c i p a n t s w h o h a d r e m a i n e d i n p l a c e [76].
O n e s t u d y demonstratedimprovementindepressionan da n x i e t y overtime,howeverthiswasassessedusingas c a l e a s s e s s i n g s o c i al b e h a v i o u r s aso p p o s ed t o a sy m p - t o m inventory[88].
Socialf u n c t i o n i n g Int o t a l , 1 2 g e n e r a l S M I s t u d i e s e x a m i n e d t h e a s s o c i a t i o n b e t w e e n s u p p o r t e d a c c o m m o -
d a t i o n andsocialfunctioning,including onehighq uality[94]andeleven m od era te qualit y p ap er s [74–
76,79,82,8 3,8 5–
88,9 6].A g a i n , t h e f i n d i n g s r e l a t e d t o t h i s out- c o m e are b estd es cr ib ed asmix ed.S omem o d er a t e q ual -
i t y s t u d i e s d e m o n s t r a t e d s i g n i f i c a n t i m p r o v e m e n t s i n s o c i a l integration[82]andcommunityp articipation[96],i n c r e a s e s infriendshipsandsupp ortiverelationships [82,8 3]
andreductionsinsocialdisabilityovertime[79].However,th
emajorityofstudiesfoundnochangeinkeys o c i a l vari ablesovertime,suchassocialfunctioning[74,7 6,82],soc ialnetworks[74,75,82]andsatisfactionwiths o c i a l s u p p o r t [94].O n e s t u d y , e x a m i n i n g t h e e f f e c t i v e - n e s s o f o u t r e a c h s u p p o r t , f o u n d a s i g n i f i c a n t r e d u c t i o n i n t h e s i z e o f s o c i a l n e t w o r k s o v e r t i m e [88].A n o t h e r s t u d y r e p o r t e d a r e d u c t i o n i n i n d e p e n d e n t socialf u n c -
t i o n i n g andanincreaseinassistedsocialfunctioningo v e r time[86].Incontrast,asinglemoderatequality
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studyf o u n d t h a t S U s r e c e i v i n g h o m e c a r e r e p o r t e d s i g -
n i f i c a n t l y higherlevelsofsocialactivitycomparedtoS U s r e s i d i n g i n h a l f -
w a y h o u s e [87].S e v e r i t y o f s y m p -
t o m s a n d n u m b e r o f h o s p i t a l i s a t i o n s w a s f o u n d , i n o n e s t u d y , t o n e g a t i v e l y i n f l u e n c e t h e q u a l i t y o f s o c i a l net-w o r k s [85].
Qualityo f l i f e S i x m o d e r a t e q u a l i t y p a p e r s [74,7 9, 8 0,8 2,8 7,8 8]e x a m i n e d c h a n g e s i n Q o L w i t h t h e g e n e r a l S M Igroup.Thefindingsweremixed;halfrepo
rtedasig-n i f i c a n t improvement inQoL
overt i m e [79,82]ora n o n -
s i g n i f i ca n t t r e n d t o w a r d s i m p r o v e m e n t [88],a n d h a l f i n d i c a t e d n o c h a n g e [74,8 0,8 7],s u g g e s t i n g a l i m -
it ed, o r i n c o n s i s t e n t , r elationshipbetweensupporteda c c o m m o d a t i o n andthisoutcome.Inonestudy,QoLwaspos itivelyassociatedwithspecificlifeskills,in-
cludingbudgeting,self-
care,abilityt o goo u t ,andworkp e r f o r m a n c e [82].
Discussion
Thiss y s t em a t i c reviewattemptedtosynthesisethelitera- tureo n mentalhealthandpsychosocialoutcomesassoci- atedwithmentalhealthsupportedaccommodationservices.De spitetheinitialaimofcomparingandcon-
trastingoutcomesacrosssupportedaccommodationmodels,th ewidevariationinaccommodationservices,intermsofstructur e,staffingandrelatedvariables,requiredu s togroupourfindin gsbypopulationsub-groups.
Homeless
Thestrongeste vid en ce f o r su pp o rt ed ac co m m o d a t i o n c o m e s f r o m r e s e a r c h w i t h h o m e l e s s m e n t a l l y i l l p o p u l a -
t i o n s andthepermanentsupportedhousingmodel.S t u d i e s i n t h i s a r e a d e m o n s t r a t e c o n s i s t e n t e v i d e n c e f o r i m p r o v e m e n t s i n housingretentionandstability,andap -
propriateuseo f clinicalservicesovertime.Therei s alsosomein dicationthatthisformofsupportforthisgroupisassociatedwith improvementsinsymptoms,QoLandso-
cialfunctioning,butthisevidenceisinconsistent.Thema- jorityo f studiesreviewedfoundn o changeinsubstanceuseove rtime.AsstatedbyTsermberis[97],“HousingFirstandothersu pportivehousinginterventionsmayendhome-
lessnessbutdonotcurepsychiatric
disability,addiction,orpoverty”(p.52).Thesefindingsareinlin ewiththeconclu-sionsofarecentreviewofHF[98].
Althought h e p e r m a n e n t
s u p p o r t e d h o u s i n g a p p r o a c h h a s b e e n s h o
w n t o b e e f f e c t i v e
i n s o m e d o m a i n s , t h e i n t e r v e n ti o ns p ec i f i c al l y t a r g et s m e n t a l l y i l l h o m e l e ss p o p u l a t i o n s , andth echaracteristicsofthestudiedco-
h o r t s m a k e g e n e r a l i s i n g t o o t h e r m e n t a l h e a l
t h p o p u l a - t i o n s t r o u b l e s o m e . F i r s t , m a n y o f t h e s a m p l e s u s e d
i n t h e s e studies h av e relativelyl o w ratesof seriousp sy chi -
a tri c i l l n e s s . I n t h e c u r r e n t r e v i e w , w e u t i l i s e d a >50%w i t h psychiatricdiagnosiscut-
offpointtoensurewe
McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:1
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includedappropriatestudies.However,evenwiththisa p p r o a c h , itremainsdifficulttoconfidentlyapplythes y n t h e s i s e d findingstoothergroupsofpeoplewithmen- t a l h e a l t h p r o b l e m s . S e c o n d , t h e p r e s e n c e o f l o n g t e r m h o m e l e s s n e s s a m on g st t h e t ar get po p ul at i o n c o n f l a t es t h e f i n d i n g s w h e n c o n s i d e r i n g t h e a p p l i c a b i l i t y t o g e n -
e r a l SMIpopulations.Itremainsdifficulttoestablishw h e t h e r positivechangesinp sychosocialo u t comesa r e a t t r i b u t a b l e tointerventioncomponentsthatimpacto n homelessness(suchashousing),ormentalhealth(suchasm edicationmanagement)orboth.Third,p articipantsinthep ermanentsupportedhousings t u d i est ypicallyp r e sentwit hh igherr atesofd r u g andalcoholuset h an comparable,n on -
ho melesssamples.T h e r e isd angerthat ,d uetoth elar geandgrowingevidencebasefortheseservices,policymake rswilla t t e m p t a wholesaleimporto ft h e p e r m a n e n t sup-
p o r t edh o u singm o d elforu sewithpsychiatricp o p u l a - tions,withouta r eliableevidenceb ase.
Deinstitutionalisation
Researcho n o u t c o m e s i n s u p p o r t e d a c c o m m o d a t i o n f o r d e i n s t i t u t i o n a l i s e d populationsprovided goodevidencef o r improvementornon-
deteriorationinpsychiatricsy m p t o m s , s o c i a l f u n c t i o n i n g a n d r a t e s o f r e h o s p i t a l i s a -
t i o n . Therewaslimitedevidenceforimprovementin Q o L a n d employment.Notably, anumberofstu dies h i g h l i g h t e d aconsistentassociationbetweenmorer e-
s t r i c t i v e settingsandpooreroutcomes,acrosspsych i-
a t r i c , s o c i a l a n d Q o L o u t c o m e s , f o r t h i s g r o u p . A l t h o u g h , t h e s e f i n d i n g s a r e s o m e w h a t i n c o n s i s t e n t , t h e t h r e s h o l d of‘success’fort hi spo p ula tio ni sr ad ic all y dif-
f e r e n t th anf o ro th er gro ups.D uet o thesev erity o fc li n-
i c a l p r e s e n t a t i o n s a n d d u r a t i o n o f i n s t i t u t i o n a l i s e d c a r e , m o s t r e s e a r c h e r s a n d c l i n i c i a n s c o n s i d e r t h e a b s e n c e o f d et er i o r a t i o n a s i n d i c a t i v e o f s u c c e s s f u l t r a n s i t i o n t o c o m m u n i t y c a r e . I n d e e d , o n e o f t h e g r e a t e s t c h a l l e n g e s o f t h e d e i n s t i t u t i o n a l i s a t i o n p r o c e s s w a s t o a d d r e s s t h e c h r o n i c psychiatric,socialandbeh aviouraldifficulties ofp a t i en t s , w h i l e
s i m u l t a n e o u s l y m a i n t a i n i n g t h e i r t e n u r e i n thecommunity[1].Supportedacco mmodationser-
v i c e s a p p e a r t o h a v e c o n t r i b u t e d t o t h e a c h i e v e m e n t o f t h e s e go als;the r ep ort ed fin dings,w hi leno tconsistent ly d e m o n s t r a t i n g i m p r o v e m e n t s a c r o s s d o m a i n s d o , f o r t h e m o s t part,highlightsta bility.
Inreality,thedeinstitutionalisation‘story’h a s alreadybee ntold;i n mostEuropeanandnorthAmericancoun-
tries,thedeinstitutionalisationprocesscommencedthelate19 80sandearly1990sand,a s such,themajorityofthestudiescite dinthisreviewareold,orreportonlonger-termfollow-
ups.Itisgenerallyacceptedthatcom-
munitybasedsettingsaremorehumaneandofferabetterQoLth anlongtermhospitalisation[99].Thetransitionofpeoplefromlo ng-staywardstocommunity-basedcare
McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:1
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hasbeensuccessful,andtheevidencesuggeststhatthisgroup,for themostpart,canbemaintainedincommunitysettingswithouta nysignificantdeterioration[100].Thisisa n importantandwell establishedfindingbutdoeslittletoguideu s i n thedevelopmen tandimplementationofcon-
temporarysupportedaccommodationservices.
GeneralSMI
Ther e v i e w e d p a p e r s i n t h i s g r o u p p r e s e n t e d l e s s c l e a r e v i d e n c e betweensupportedaccommod ationandpsy-
c h o s o c i a l o u t c o m e s f o r g e n e r a l S M I p o p u l a t i o n s . W h i l e t h e r e w as a tr en d t o w a r d r ed uct ions i n r at es o f h o s p i t a l -
i s a t i o n o v e r t i m e , t h e e v i d e n c e w a s m i x e d w i t h r e g a r d s t o s y m p t o m s , s o c i a l f u n c t i o n i n g a n d QoL,w i t h s t u d i e s v a r i o u s l y demonstratingimpro vement,no-change,orde-
t e r i o r a t i o n i n t h e s e o u t c o m e s o v e r t i m e . Thesef i n d i n g s m a y reflectthehet erogen eousnatureo fthe li ter atu re.
Thissub-grouphadthefewestnumberofstudiesover- a l l , thefewestnumberofhigh-qualitypapersandthelar- g e s t n u m b e r o f o m i t t e d l o w -
q u a l i t y s t u d i e s , y e t t h i s p o p u l a t i o n isgrowingrap idly,reflectingthebroadadop-
t i o n o f t h e s u p p o r t e d a c c o m m o d a t i o n m o d e l , c u r r e n t a p p r o a c h e s tocommunity-
basedrehabilitationandther e j e c t i o n o f l o n g - t e r m h o s p i t a l i s a t i o n a s a f o r m o f treat-
m e n t . . Thisobservationhighlightsanurgentneedfor in-
c r e a s e d r e s ea r ch i n t hi sa r ea . A s m e nti on ed above, th er e i s a g e n u i n e d a n g e r t h a t d u e t o t h e g r o w i n g evidenceb a se , t h e H F m o d e l i s a p p l i e d t o t h i s g r o u p d e s p i t e t h e p r o b l e m s ingeneralisingth eresearchfindings.
Strengthsandlimitations
Thec u r r e n t r e v i e w h a d a n u m b e r o f s t r e n g t h s . W e a p -
p l i e d a t h o r o u g h s e a r c h s t r a t e g y , u t i l i s i n g a b r o a d d a t e r a n g e , a n d i n c l u d e d a r a n g e o f p s y c h o s o c i a l o u t c o m e s an d avarietyofquantitativ edesignsbeyondRCTs.Thesem e t h o d o l o g i c a l d e c i s i o n s e n a b l e d u s t o b e c o m p r e h e n -
s i v e inourreviewandconfidentincapturingallkeyout- c o m e studies.
Asthe r ev i ew ed s t u d i e s r e l a t et o su ppo rte d a c c o m m o -
d a t i o n only,itmustbeacknowledgedthat,byexamini ngt h e o u t c o m e s i n r e l a t i o n t o s u b g r o u p s , b r o a d e r f i n d i n g s r e l a t e d t o t h e s e g r o u p s m a y h a v e b e e n o v e r l o o k e d . F o r e x a m p l e , m a n y o f t h e Teamf o r t h e A s s e s s m e n t o f Psy-
c h i a t r i c S e r v i c e s (TAPS)s t u d i e s , a n d o t h e r p r o g r a m m e s o f researchinvestigatingoutcomesfordeinsti tutionalisedg r o u p s , w ere not in clu d edi nth i s r e v i e
w as t h e yd i d not e x p l i c i t l y c o n s i d e r s u p p o r t e d h o u s i n g , h o w e v e r d a t a fromthesestudieswouldhav eexpandedandcontex-
tualisedt h e r e p o r t e d findingsast heyr elatet o t h e deinstit utionalisationsub-group.Thepopulation-
basedconclusions,therefore,mustbeconsideredstrictlyinrela tiontosupportedaccommodation.
Aswewereunabletoexaminedifferencesinoutcomesa c r o s s m o d e l s , t h e
c u r r e n t r e v i e w c a n n o t c o m m e n t o n
McPhersonetal.BMCPsychiatry( 2 0 1 8 ) 18:1
28 Page12of15
theirr e l a t i v e m er i t s in r el a t i o n t o ou t com e s . A s d e - s c r i b e d , thereisalargevariationinhousingmodels;w i t h i n e a c h o f t h e p o p u l a t i o n s u b -
g r o u p s c o n s i d e r e d ab o v e , servicem o d e l s r a n g e d f r o m i n d e p e n d e n t t e n a n -
c i e s withoutreachsupporttohigh-
staffed,congregater e s i d e n t i a l settings.Inevitably,t hecharacteristicsofas er v i ce , s u c h a s t h e p h y s i c a l s t r u c t u r e , s t a f f i n g a r r a n g e -
m e n t s,l e v e l s o f s u p p o r t , r e c o v e r y f o c u s , a n d d i s c h a r g e a n d m o v e -
o n p o l i c i e s , w i l l i m p a c t o n serviceu s e r out- c o m e s , possiblybeyondtheinfluenceofpopulationch ar-
a ct e r i st i c s . Asaresult,thisreviewislimitedinitsabili tyt o f u l l y c o n s i d e r t h e e f f e c t i v e n e s s o f m e n t a l h e a l t h s u p - p o r t e d ac co m m o d a ti o n s e r v i c e s .
Bycomparingservicesfromdifferentnationalcon- t e x t s,weaimedtoenhanceourunderstandingofthec r i t i c al com p on ent s o f t h e s ei n t e r v e n t i o n s a n d h o w c o n -
t e x t u a l factorsimpactoutcomes.However,duetothea f o r e m e n t i o n e d v a r i a t i o n i n servicem o d e l s ( e v i d e n t e v e n withincountries),it wasdifficulttodi scerntheim-
pa ct ofnationallevelfactors,suchaslegislation,fundi ngb a r r i e r s orstatutoryresponsibilities. Theinter nationalf o c u s ofthisrev iewmakesi tchallenging t oprovide anys p e c i f i c recommendationsforlocalpolic ymakersandc o m m i s s i o n e r s . Am o r et argetedstudy,f ocusingo n o n e countryo r region,wouldbeb ettersuitedf o r t hisp u r p o s e . I n l i n e witht h e r e coverya p p r o a
c h , however,i t islikelythatany high-
qualitysupportedaccommo-
d a t i o n provisionwillcompriseofarangeofaccom- m o d ationoptions,witht h e d eliveryo f flexible,p e r sona lisedsupport.
Finally,a s w e h a v e consideredevidencefromnon- RCTdesigns,t h e d a t a p r e s e n t e d h erein,evenfroms t u d i esratedas‘highquality’,shouldbeinterpretedwithcautio n.
Conclusion
Them i x e d r e s u l t s o f t h i s s t u d y h i g h l i g h t t h e h e t e r o g e n -
e i t y o ft h e supp o rt ed ac co m m od a t i on li t er at ur e, i n term s o f researchquality,experimentaldesign,po pulation,ser-
v i c e t y p e s a n d o u t c o m e s a s s e s s e d . T h e r e i s s o m e e v i -
d e n ce t h a t s u p p o r t e d a c c o m m o d a t i o n i s e f f e c t i v e a c r o s s a r a n g e o f p s y c h o s o c i a l o u t c o m e s , w i t h t h e m o s t r o b u s t e v i d e n c e s h ow i n gt h ee f f ec t i v e n ess o f th eH F m o d e l f o rh o m e l e s s S M I a n d f o r o t h e r f o r m s o f s u p p o r t e d a c c o m -
m o d a t i o n f o r d e i n s t i t u t i o n a l i s e d p o p u l a t i o n s i n r e d u c i n g h o s p i t al i s a t i o n rates
andi m p r o v i n g a p p r o p r i a t e s e r v i c e u s e . Th ee v i d e n c e b a s e f o r g e n e r a l S M I p o p u l a t i o n s i s l e s s d e v e l o p e d , a n d r e q u i r e s f u r t h e r r e s e a r c h . U n f o r t u -
n a t e l y , thesebroadobservationsreinforcetheconclu -
s i o n s o f C h i l v e r s a n d c o l l e a g u e s [5]i n t h e i r r e c e n t C o c h r a n e r e v i e w : “ Int h e a b s e n c e o f e v i d e n c e o f t h e i r r e l a t i v e efficacy,decisionsontheprovisi onofalternativef o r m s o f a c c o m m o d a t i o n a n d c o n t i n u e d s u p p o r t f o r p e o p l e w i t h m e n t a l i l l n e s s c a n o n l y b e b a s e d o n a
Final Search Strategy. The search strategy used for the systematic review, organised according to database. (DOCX 28 kb) Summary table: All included studies. Summary of extracted data from all studies included in the final synthesis. (DOCX 60 kb)
combinationofprofessionaljudgement,patientpreferencea n d a vailability”(p.6).
Thei n t e n t i o n o f t h e currentr e v i e w w a s t o
c o m p a r e a n d c o n t r a s t t h e e f f e c t i v e n e ss o f v a r i o u s m o d e l s o f s u p -
p o r t e d a c c o m m o d a t i o n , a c r o s s a r a n g e o f p s y c h o s o c i a l o u t c o m e s . However,a s n o t e d , t h i s a t t e m p t wass t y m i e d b y thelargevariationin service models,thelackofdef-
i n i t i o n a l c o n s i s t e n c y a n d , a t t i m e s , p o o r r e p o r t i n g p r a c -
t i c e s i n t h e l i t e r a t u r e . I n o r d e r t o m a k e a s s e r t i o n s r e g a r d i n g theeffectivenessofvariousmodels ofsup-
p o r t e d a c c o m m o d a t i o n , i t i s c l e a r t h a t a s i m p l e m e t h o d o f servicec a t e g o r i s a t i o n , b a s e d o n c u r r e n t r e p o r t i n g p r a c t i c e s , i s r e q u i r e d . A t a x o n o m y t h a t c a n b e a p p l i e d r e t r o s p e c t i v e l y toexist ingresearch,andutilisedinfutures t u d i e s , wouldallo weffectivesynthesisofoutcomedata,f a c i l i t a t e a n e x a m i n a t i o n o f e f f i c a c y
a n d e f f e c t i v e n e s s , a n d s t r e n g t h e n f o l l o w -
u p / r e p l i c a t i o n studies[101].W h i l e so m ea t t e m p t s h a v e b ee n m ad e t o d e v e l op a s u p -
p o r t e d accommodationtaxonomy[102,103],thesem o d e l s a r e c o m p l e x a n d h a v e n o t b e e n w i d e l y u t i l i s e d . R ec en t l y , anew,
simpleclassificationsystemforsup-
p o r t e d a c c o m m o d a t i o n serviceshas
beend e v e l o p e d (TheS i m p l e Taxonomyf o r S u p p o r t e d Accommodation[STAX-SA]
[104]).Future research sh oul dconsider u ti-
li si n g t h i s t o o l t o s y n t h e s i s e t h e a v a i l a b l e e f f e c t i v e n e s s e v i d e n c e, c o m p a r i n g serviceu s e r o u t c o m e s a c r o s s ser-v i c e models.
Mentalhealthsupportedaccommodationservicesarewidelyi mplemented,however,currentlywehavenoclearresearchbas earticulatingwhatworksandforwhom.Therei s a clearneedfo rhighqualityeffectivenessre-
search,improvedreportingstandardsandconsistentandmeanin gfuldescriptionsofsupportedaccommodationser-
vicesi n theliterature.Researchersmustprioritiseexperi- mentalstudiesthatcompareoutcomesacrossdifferentservicem odels.Thesedevelopmentsshouldinformandimprovementalh ealthcommissioningandservicedevel-
opmentdecisionsinthefuture.
Additional files
Abbreviations
HF:HousingFirst;HUD-VASH:DepartmentofHousingandUrbanD e v e l o p m e n t - VeteransAffairsSupportiveHousingProgram;NIHR:NationalInstituteofHealthResearch;
QATQS:QualityAssessmentToolforQuantitativeS t u d i e s ; QoL:Qualityoflife;QuEST:Quality andeffectivenessofsupportedt e n a n c i e s f o r people
withmentalhealthproblems;RCT:Randomisedc o n t r o l l e d trial;SMI:Severementalilln ess;TAU:Treatmentasusual
Acknowledgements
WewouldliketoacknowledgecurrentandpastmembersoftheQualityandE f f e c t i v e n e s s ofSupportedTenancies(QuEST)researchgroupatUCL/QMUL
