Katherine Koh, MD, MSc of the Department of Psychiatry at Mass General Brigham, is the lead author of a new article in Psychiatric Services: Street Psychiatry: A Clinical Approach. Eileen C. Reilly, MD, of Beth Isreal Deaconess Medical Center is the co-author.
Both Koh and Reilly are part of the street team with the Boston Health Care for the Homeless Program (BHCHP), working to provide psychiatric care to unhoused individuals across Boston.
The approach to street psychiatry described in the article is based on their experience working with an interdisciplinary team, including case managers, medical providers, nurses, a therapist and a recovery coach, through the BHCHP.
The psychiatric burden of the homeless population is staggering—3/4 of unhoused individuals have a mental illness, and the prevalence of mental illness is particularly high among those who sleep on the street rather than in shelters.
In 2024, the number of homeless individuals in the US reached a record high.
Street psychiatry is a specialized component of street medicine that is designed to bring mental health care to unsheltered people where they reside.
While it incorporates the same core principles of traditional psychiatry, street psychiatry includes unique principles such as identifying individuals in need outside of a clinical setting, substantial time spent building trust, addressing frequent medication non-adherence, and working closely with other care team members and social service partners.
Identifying and engaging with patients is a key component of street psychiatry and often starts with addressing the immediate needs of a homeless person, such as offering socks or snacks; assisting the individual in obtaining wound care or accessing a detox program; and/or securing an ID card.
Some individuals may not initially engage with efforts by street psychiatrists to provide care, and trust between patients and providers is often built over months through regular check-ins on the street.
Frequent challenges in the practice of street psychiatry can include:
• High rates of co-occurring medical conditions, traumatic brain injuries, a chaotic social environment, trauma, and existential despair, which may complicate diagnostic clarity
• Patients that are more likely to be in acute crisis, which can require the use of deescalation skills and/or involuntary commitment, which should be carefully considered weighing risks and benefits and a plan for ongoing care in the aftermath of the commitment
• Medication non-adherence and/or medication theft, which can be addressed by using shorter prescription periods (one week at a time, for example), minimizing the use of medications with significant withdrawal symptoms, and prescribing injectable medicines with longer-lasting effects when possible
While there are legitimate critiques of street psychiatry, the authors write, “the benefits of giving individuals the opportunity of receiving treatment outweigh the risks that an individual languishes without receipt of mental health care and dies a premature death."
“The evidence thus far shows that street programs for people with mental illness show promise for improving psychiatric symptoms, treatment retention and quality of life in this vulnerable population.”
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