- Research
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Youth experiencing homelessness at risk for suicide: psychosocial risk factors and service use patterns
樱花视频 volume听25, Article听number:听444 (2025)
Abstract
Objective
Young adults experiencing homelessness often suffer from adverse mental health outcomes and suicide is a leading cause of death. The objective of this study is to examine service use and psychosocial risk factors for suicide, in relation to suicide risk assessment, to inform strategies for engaging youth in suicide prevention services.
Methods
A cross-sectional analysis of youth enrolled in a supportive housing randomized clinical trial. We categorized suicide risk into three groups (low-, moderate-, and high-risk) based on suicidal ideation and past-year suicide attempt. The service use patterns across these groups are described, as well as other psychosocial risk factors (psychiatric comorbidity, depressive symptoms, substance use, and sleep impairment).
Results
Among 193 enrolled youth, 126 (65.3%), 32 (16.6%), and 35 (18.1%) were categorized as low-risk, moderate-risk, and high-risk for suicide, respectively. A high proportion of youth reported ever having been diagnosed with a psychiatric disorder (57.5%) and cannabis was the most heavily used substance. However, only a minority of youth received medical care or mental health services in the past 3 months, 40% and 34%, respectively. Even fewer youth received mental/emotional health services in the past 3 months (15%), though use was highest among the high-risk group (34%).
Conclusion
Understanding the needs of youth experiencing homelessness who are at risk for suicide is critical to developing interventions to alleviate their risk for suicide. Given that the use of medical and mental health care is low among this population, more active outreach strategies may be warranted to deliver prevention interventions.
Introduction
Young adults experiencing homelessness (YEH) between the ages of 18鈥24 years suffer from adverse mental health and substance use outcomes [1], including suicidal ideation and drug overdose [2, 3]. Suicide and drug overdose are leading causes of death for YEH based on prior longitudinal epidemiologic studies [4, 5]. Further, suicidal ideation and prior suicide attempts are strong predictors of future suicide attempt [6], and suicidal ideation also predicts non-fatal drug overdose among YEH [3]. Youth who are unhoused experience suicidal behaviors to a greater extent than the general population, with prior studies estimating rates of past-year suicidal ideation and attempts among YEH more than double that of their housed counterparts [7]. Conditions of homelessness, stigma, and social exclusion perpetuate and reinforce poor mental health and risk behaviors for YEH and complicate access to treatment [8].
Several known psychosocial risk factors for suicide are prevalent among YEH. Substance misuse often co-occurs with suicidal ideation [9, 10], and is often involved in suicide deaths. Depressive symptoms are a strong independent predictor of suicidal behaviors, even after controlling for other psychosocial risk factors [11]. In addition, growing literature suggests that sleep has a strong relationship with suicidal ideation [12]. The high burden of depressive symptoms [13], substance misuse [14], and poor sleep [15] among YEH could exacerbate risk for suicide and, additionally, pose as a barrier for exiting homelessness [16]. Understanding the prevalence of these co-occurring psychosocial risk factors among YEH in relation to suicide risk assessments is critical for developing interventions to address the multifaceted needs of this population. Importantly, these risk factors are modifiable and may reduce risk for suicide if addressed.
Yet, unhoused youth often face significant barriers to accessing health care, mental health or substance use treatment, and social services, which further complicate intervention delivery [17]. Although these service settings provide opportunities to identify youth suffering from suicidal thoughts, YEH face obstacles to receiving these services ranging from lack of transportation, difficulty navigating where or how to access services, or general apprehension towards help-seeking given prior adverse experiences with service providers [17, 18]. As a result, suicidal ideation may go undetected, and youth may continue to suffer poor mental health and be at higher risk for suicide without receiving interventions.
Few studies have described service use and psychosocial risk factors for suicide among YEH with suicidal ideation or behaviors [19,20,21]. In context of a prior suicide prevention intervention trial among YEH, initial or sustained suicidal ideation was associated with higher levels of engagement with the intervention (e.g., number of treatment sessions) [19, 21]. However, only youth with suicidal ideation were eligible for that trial, and analyses could not capture baseline service engagement for youth not experiencing suicidal ideation at the time of enrollment. Similarly, suicidal ideation was predictive of SUD treatment engagement in another previous treatment trial [20]. However, this study only included those with substance use disorder (SUD) and could not characterize service use among YEH not meeting SUD criteria. The increased service use observed in these studies could indicate heightened mental health symptoms for those with suicidal ideation and greater motivation for help-seeking at higher levels of mental health acuity [22]. Greater understanding of service use patterns as well as other psychosocial risk factors for suicide is needed to inform future prevention program planning to address the high rates of suicide and premature mortality among YEH.
The present study details baseline suicidal ideation and behaviors, as well as psychosocial risk factors and service use among YEH enrolled in a randomized controlled trial. The main objective of the study was to describe the psychosocial risk factors for suicide and service use patterns to inform our understanding of service access and needs among YEH across a range of suicide risk categories. Although universal screening for suicide risk is increasing in health care settings, these programs may miss YEH at risk for suicide if they are not accessing those services. Thus, a greater understanding of the characteristics and needs of YEH with elevated risk for suicide is needed and can also inform opportunities to address needs through targeting potential touch points and services these youth access.
Methods
Study setting and sample
The present study uses baseline measures from a randomized controlled trial of housing and support services for young adults experiencing homelessness in a large Midwestern city in the U.S. Youth were eligible for the 鈥淗ousing, Opportunities, Motivation and Engagement (HOME)鈥 trial if they were experiencing homelessness, age 18 to 24 years, and did not meet DSM-5 criteria for Opioid Use Disorder (OUD), given the trial鈥檚 primary focus on OUD prevention. Briefly, youth were recruited through a drop-in shelter serving youth experiencing homelessness or through community outreach between June 2020 and September 2023. Youth were approached by trained research staff at youth drop-in center or other community settings to gauge their interest in participating in the study. If youth were interested and met eligibility criteria, they were consented and enrolled in the trial, and guided through baseline assessments by research staff. Youth were randomized at baseline to receive either supportive housing and risk preventive services (n鈥=鈥120) or risk preventive services alone (n鈥=鈥120). Youth in both arms of the study received advocacy over a 6-month period, which also included strengths-based outreach and advocacy, HIV prevention, and motivational interviewing. When suicidal ideation was expressed at any point during the study, youth were further evaluated for imminent risk based on, (1) whether there was a plan in place, (2) whether there were means to carry out the plan, and (3) whether there was intent to carry out the plan. A safety protocol was followed for those at imminent risk including hand-off to emergency services when indicated. The study was reviewed and approved by the Institutional Review Board at the Ohio State University and informed consent was obtained from all study participants. Not all youth enrolled in the parent study completed all baseline suicide risk measures because the measure of suicidal ideation (Scale for Suicidal Ideation Worst Point, described below) was added to the baseline survey after recruitment had already started. In the present study, youth who did not complete this suicidal ideation measure (n鈥=鈥47) were excluded because they had not been asked to complete this measure at baseline.
Measures
Suicide risk
Youth were categorized into three mutually exclusive suicide risk groups (low-, moderate-, and high-risk) based on suicide risk measures (suicidal ideation and past-year suicide attempts). Suicidal ideation was measured with the Scale for Suicidal Ideation, Worst Point (SSI-W), a 19-item measure that evaluates the intensity of suicidal ideation in the past 90 days (0鈥38 points) [23, 24]. The instrument is interviewer-administered, and respondents are instructed to recall their thoughts of and desire to die by suicide at the 鈥渨orst point,鈥 and higher scores reflect higher severity of suicidal ideation. Youth who reported no suicidal ideation (SSI-W score 0 points) and who had no past-year suicide attempt were considered 鈥渓ow risk.鈥 Youth were considered 鈥渕oderate risk鈥 if they reported suicidal ideation but no past-year suicide attempts (SSI-W scores 1鈥9 points). Finally, youth were considered 鈥渉igh risk鈥 if they reported higher SSI-W scores (SSI-W scores 10鈥38 points) or any past-year suicide attempt. We use a lower cut-point (SSI-W 鈮 10 points) than that used in prior research (SSI-W 鈮 16 points) [23] due to the inherent elevated risk for suicide among YEH relative to the general population [5, 25].
Psychosocial risk factors for suicide
Several measures of psychosocial factors with known associations to suicidal behaviors were collected during the baseline interview, including psychiatric comorbidity, depressive symptoms [6], substance use patterns [26], and sleep impairment [27].
Psychiatric comorbidity was assessed by asking participants whether they had 鈥渆ver received a psychiatric diagnosis from a mental health professional鈥 and, if so, youth indicating specific diagnoses (e.g., schizophrenia, major depressive disorder, bipolar disorder, personality disorder, generalized anxiety disorder, and/or post-traumatic stress disorder (PTSD)) (see Appendix 1 for survey questions).
The Beck Depression Inventory-II (BDI-II) was collected to assess severity of depressive symptoms, which includes 21 items for a total score ranging from 0 to 63 points [28]. The BDI-II individual scores were categorized into depressive symptom severity (e.g., 0鈥13, 鈥渕inimal;鈥 14鈥19, 鈥渕ild;鈥 20鈥28 鈥渕oderate;鈥 and 29鈥63, 鈥渟evere鈥).
The Form-90 was used to collect information on substance use frequency over the past 90 days [29, 30]. The percent of days with substance use, excluding tobacco, is calculated for the 90-day period from baseline for specific substance types (any substance, alcohol, cannabis, or opioid).
Finally, the PROMIS sleep impairment measure (PROMIS Short Form v1.0鈥擲leep-Related Impairment 8a) was used to assess level of sleep impairment, and scores were calculated according to PROMIS scoring manual with computed T-scores categorized into four groups (e.g., within normal limits, mild, moderate, and severe) [31].
Service use
Youth responded to self-report interview questions regarding their lifetime use of inpatient or outpatient treatment for mental health or substance use disorders. In addition, youth reported their use of shelter services, medical care, alcohol/drug services, or mental health services over the past 3 months (Appendix 1).
Other demographic measures
Demographic characteristics were collected on a baseline demographic questionnaire, and we report the following characteristics for the sample: age, race/ethnicity [Non-Hispanic White, Non-Hispanic Black, Hispanic, Non-Hispanic Multiracial, Other, Unknown (missing)], gender (male, female, nonbinary, or transgender), education (Completed high school or GED; currently enrolled in education/training program), and currently employed (Appendix 1). In addition, youth responded to questions on current experiences of homelessness, including length of current period of homelessness, longest period of homelessness, as well as age of first experiencing homelessness.
Analyses
Descriptive statistics were used to characterize the sample overall and by suicide risk categories. We compare the psychosocial risk factors for the high- and moderate-risk group, relative to low-risk group, using Chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. To limit the number of statistical comparisons for measures of psychiatric comorbidity and substance use frequency, we performed statistical comparisons only for the overall measures (e.g., any psychiatric diagnosis, or percent days with any substance use). Analyses were conducted in SAS 9.4, and we used a statistical significance threshold of 伪鈥=鈥0.05.
Results
Among a sample of 193 youth enrolled in the HOME trial who completed baseline suicide risk measures, 126 (65.3%), 32 (16.6%), and 35 (18.1%) were categorized as low-risk, moderate-risk, and high-risk for suicide, respectively (Table听1). Overall, 38.5% in the total sample reported any suicide attempt during their lifetime, ranging from 20% for low risk to 89% for the high-risk groups. The average age of first suicide attempt was 13.8 years (SD鈥=鈥3.6) and multiple attempts were common among those with a prior suicide attempt (mean鈥=鈥6.0, SD鈥=鈥9.7). Among the high-risk group, 62.9% reported a past-year suicide attempt. Whereas 56.4% of youth identified as male in the low-risk group, 34.3% identified as male in the high-risk group. A high proportion of the low-risk group identified as non-Hispanic Black (62.7%), but a little less than half of the high-risk group identified as non-Hispanic Black (45.7%). Meanwhile, 17.5% of youth identified as non-Hispanic White in the low-risk group, but 31.4% of those in the high-risk group identified as non-Hispanic White. Most youth reported a current period of homelessness of more than one month and the average age of first being unhoused was approximately 16 years. Youth who did not complete the baseline SSI-W and were excluded (n鈥=鈥47) were similar demographically and in terms of suicide risk to the larger sample included in the present study (n鈥=鈥193). For example, among those excluded, average age was 21.4 years (SD鈥=鈥1.9), 51.1% were male, 55.3% were non-Hispanic Black, 12.8% had a past-year suicide attempt, and the average number of lifetime attempts was 4.3 (SD鈥=鈥4.6), which were comparable to what was observed in the study sample (Table听1).
Psychosocial risk factors for suicide were common among youth with some variation across suicide risk groups. The prevalence of any psychiatric diagnosis was significantly higher among the high-risk group (74.3%), relative to the low-risk group (53.2%) (蠂2鈥=鈥5.0, p鈥=鈥0.03) (Table听2). However, there was no difference in the prevalence of any psychiatric diagnosis for the moderate- relative to the low-risk group. Overall, the most prevalent disorders were major depressive disorder, bipolar disorder, and generalized anxiety disorder for all groups. The mean score on the BDI-II was significantly higher for the high-risk group (mean鈥=鈥28.2, SD鈥=鈥12.8) relative to the low-risk group (mean鈥=鈥11.3, SD鈥=鈥10.1) (W鈥=鈥4,180, z鈥=鈥6.25, p鈥<鈥0.0001), as well as for the moderate-risk (mean鈥=鈥22.9, SD鈥=鈥11.7) relative to the low-risk group (W鈥=鈥3591, z鈥=鈥4.74, p鈥<鈥0.0001). A high proportion of youth in the high-risk group indicated severe depressive symptoms based on BDI-II Score (45.7%), while only 5.6% of the low-risk group had severe depressive symptoms. The mean percent of days with any substance use over the prior 90 days was 45.7 (SD鈥=鈥42.5) overall and did not differ significantly across suicide risk groups. There were also no significant differences in mean age of first substance use by suicide risk group. However, there was variation in the PROMIS sleep measure across suicide risk groups, such that the proportion of youth within normal limits of sleep impairment was significantly lower for the high-risk (22.9%) relative to the low-risk group (60.3%) (蠂2鈥=鈥4.53, p鈥=鈥0.0001), as well as the moderate-risk (31.3%) relative to the low-risk group (蠂2鈥=鈥8.69, p鈥=鈥0.003).
In the total sample, 54.4% of youth reported lifetime outpatient treatment for mental health and 40.4% reported any lifetime inpatient mental health treatment (Table听3). Lifetime inpatient or outpatient mental health service use was highest in the high-risk group. However, receipt of outpatient or inpatient alcohol or drug use services was low for all groups with only a small minority reporting ever having received treatment in inpatient or outpatient settings for substance use, 9.3% and 5.2%, respectively. In the past 3 months, medical care was the most frequently used service for all groups, while a smaller proportion reported mental health services (15%). Only a small minority of youth reported using a shelter (8.6%) in the past three months or receiving substance use treatment services (3.1%), which was also low across all groups.
Discussion
Among YEH enrolled in a prospective randomized controlled trial of a supportive housing intervention, a high proportion of youth were identified as moderate to high risk for suicide at baseline. These youth also reported a high prevalence of psychosocial risk factors for suicide, including prior diagnoses of psychiatric conditions, substance use, depressive symptoms, and sleep impairment. Yet, few youths were currently receiving mental health services, with only 15% overall receiving mental health counseling in the past 3 months and only 34% of those in the highest risk category for suicide. The results of this study underscore the need to engage youth at high risk for suicide outside of traditional health care or mental health service settings.
Consistent with prior research, suicidal behaviors and psychiatric comorbidity were common among YEH in this study. This was true across all categories of suicide risk, but particularly those in the highest risk category. Over half (56%) of YEH in moderate risk group and 88.6% of those in the highest risk category had a lifetime suicide attempt. Yet, these experiences were common overall as well, with 40% of youth in our sample reported at least one lifetime suicide attempt, similar to that reported in prior studies of YEH (37-46%) [20, 32, 33]. We also observed that many youth reported multiple lifetime suicide attempts, similar to another prior study that found that a majority of surveyed youth (72%) who had attempted suicide at least once in their lifetime had multiple attempts [32]. Increased chronicity of homelessness among youth results in increased exposures to violence and victimization, and is associated with increased substance use and adverse mental health outcomes [34]. However, in the present study, suicide risk did not appear to vary by length of current or lifetime periods of homelessness. While this is somewhat surprising, it could reflect the fact that the prevalence of extended periods of homelessness was high in our sample, with nearly half of all YEH experiencing homelessness for more than a year at the time they were enrolled. The growing U.S. housing crisis, which is making affordable rental units increasingly difficult to obtain, could further complicate exits from homelessness for all youth, regardless of mental health comorbidity. The need for evidence-based supportive housing programs that serve YEH and support them in their exit from homelessness has perhaps never been greater.
Youth in moderate or high-risk categories for suicide also reported many psychosocial risk factors, which may continue to elevate their risks for suicidal ideation or behaviors when left unaddressed. Depressive symptoms were high in this sample, particularly for those in the highest risk category, which is a strong predictor of both suicidal ideation and attempts [6]. Poor sleep quality was also common in the sample and varied by suicide risk category, with those in the moderate- and high-risk categories being significantly less likely to have sleep impairment within normal limits. Given the strong relationship between sleep and suicidal ideation and behaviors, improving sleep quality offers a promising modifiable target for suicide prevention [12, 27, 35]. However, the lack of a safe sleep environment for YEH is particularly challenging and could both exacerbate poor sleep quality and worsen mental health symptoms, further increasing suicide risk. As such, prevention efforts that target suicide risk among YEH may need to consider the competing psychosocial risk factors that may complicate symptom improvements and find ways to address them.
YEH experience numerous barriers to care, which likely contributed to our finding that few youths in our sample at higher risk for suicide were engaged in mental health services, despite many of these youth having been diagnosed with psychiatric conditions previously. Given these findings, it is likely necessary for future studies of suicide prevention interventions to focus on outreach and settings beyond health care systems or community mental health services. Youth drop-in centers are critical to serving youths鈥 immediate needs but could also offer avenues to engage them in prevention. Drop-in centers are preferred to shelters for many YEH [36], and offer resources such as on-site counseling or case management that allow youth to receive much needed mental health services. However, given exposure to discrimination during periods of homelessness or prior negative experiences with services [37, 38], youth may be reluctant to engage in mental health care, and it may take time to earn trust, particularly for addressing sensitive topics such as suicidal ideation. A previous study tested the effectiveness of offering suicide prevention through a youth drop-in center, with promising results [39]. Youth in the intervention arm had a faster decline in suicidal ideation relative to those in the control arm who received services as usual. Future studies examining strategies for implementing suicide prevention and other services in drop-in centers have the potential to improve the reach and benefit of interventions to YEH. Yet, these services can only be offered to the youth attending drop-in centers, and more research is needed to understand ways of delivering suicide prevention to youth who are not service-connected.
There are some limitations to the present study. First, we do not know whether these results would generalize to youth who would not consent to participate in a housing research study. Moreover, this sample was from a single metropolitan area of the Midwest, so we do not know whether our findings would generalize to YEH in other geographic areas. Yet, the descriptive findings regarding the prevalence of suicidal behaviors and psychosocial risk factors were in line with those reported previously. Second, these are cross-sectional associations, and the timing of risk factors with respect to current suicidal ideation or recent behaviors is unknown. However, our objectives for this study were descriptive in nature. Finally, some youths were excluded from the present study due to missing SSI-W at baseline. We do not believe that this introduced bias to our analysis because the reason for missingness was due to delays in incorporating this measure into the baseline survey, rather than differential nonresponse. Moreover, youth who did not have these baseline data appeared comparable in their demographic characteristics and other available suicide risk measures (e.g., any prior suicide attempts or number of prior suicide attempts). Further research is needed to explore changes in suicidal ideation with respect to modifications in housing status or psychosocial risk factors.
Conclusions
Understanding the needs of YEH at risk for suicide is critical to developing interventions and identifying optimal settings for implementing them. Our findings suggest that youth have many psychosocial risk factors for suicide in addition to suicidal ideation or behaviors, which merit consideration in prevention efforts. Yet, recent use of services in traditional service settings was low in our sample, across all suicide risk groups, with only a minority of youth receiving medical care or mental health services in the past 3 months. More active outreach may be needed to ensure delivery of suicide prevention strategies to this marginalized group.
Data availability
Data is available upon request.
Abbreviations
- YEH:
-
Youth Experiencing Homelessness
- SUD:
-
Substance Use Disorder
- OUD:
-
Opioid Use Disorder
- SSI-W:
-
Scale for Suicidal Ideation, Worst Point
- BDI-II:
-
The Beck Depression Inventory-II
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This research was supported by the National Institutes of Health through the NIH HEAL Initiative under award number 3UH3DA050174-02S1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or its NIH HEAL Initiative.
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LC drafted the manuscript. JH performed statistical analyses. LC, KK, AB, XF, MF, JF, AM, AS, TY, AP, JH, MD, and NS made substantial contributions to the conception and design of the study and critically revised the manuscript. LC, KK, AB, XF, MF, JF, AM, AS, TY, AP, JH, MD, and NS have approved the final submitted version. LC, KK, AB, XF, MF, JF, AM, AS, TY, AP, JH, MD, and NS agreed to be personally accountable for their contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which they were not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. No professional writers were used.
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Chavez, L.J., Kelleher, K.J., Bunger, A. et al. Youth experiencing homelessness at risk for suicide: psychosocial risk factors and service use patterns. 樱花视频 25, 444 (2025). https://doi.org/10.1186/s12889-024-21212-2
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DOI: https://doi.org/10.1186/s12889-024-21212-2