1131247

review-article2022
ISP0010.1177/00207640221131247International Journal of Social PsychiatrySpranger Forte et al.

E CAMDEN SCHIZOPH

Review

International Journal of

Schizoaffective disorder in homeless Social Psychiatry

2023, Vol. 69(2) 243­–252
© The Author(s) 2022
patients: A systematic review
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https://doi.org/10.1177/00207640221131247
DOI: 10.1177/00207640221131247
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Alexandre Spranger Forte1, António Bento2
and João Gama Marques1,2

Abstract
Background: Schizoaffective psychosis is a severe and chronic psychiatric disorder defined by the presence of mood
symptoms, like mania and/or depression and schizophrenia, such as hallucinations and/or delusions.
Aims: We aim to find out whether there is a correlation between schizoaffective psychosis and being homeless.
Method: To do so, a literature search was carried out in the PubMed platform in April 2022, using the keywords
‘schizoaffective’ and ‘homeless’.
Results: In this review, 28 articles from this search were included. Intrinsic characteristics, rates of psychiatric
readmission, prediction of homelessness, medication noncompliance, and substance use were explored, as they were
the main themes of the results.
Conclusions: The homeless population suffers from great diagnostic variability and the diagnosis schizoaffective
psychosis is still evolving contributing to such diagnostic and treatment difficulties. Their frequent visits to the healthcare
services, especially emergency room leads to consequent interaction with multiple healthcare professionals, resulting in
a myriad of diagnoses, with clinical remission and therapeutic goals not being attained. More studies are necessary for a
better evaluation of this super difficult population.

Keywords
Schizoaffective, homeless, psychosis

Introduction (ICD-9), defined schizoaffective disorder as being a sub-

type of schizophrenia (coded as 295.7). It was considered
The schizoaffective disorder a psychosis of mixed and cyclic nature (schizophrenic and
The first description and characterization of schizoaffec- affective). Full autonomy as an independent disorder came
tive psychosis was made in 1933. Jacob Kasanin with the10th Edition of the ICD (WHO, 1992). It was
described a group of nine cases where he found a blend- described as a set of episodic disorders in which both
ing between schizophrenic and affective symptoms. He affective and schizophrenic symptoms were prominent,
described the psychosis as marked by a sudden onset in a but which did not justify a diagnosis of either schizophre-
setting of emotional turmoil with a distortion of the out- nia or depressive or manic episodes. The ailment gained a
side world alongside the presence of false sensory code of its own (F25) and was subtyped into the manic,
impressions. The psychosis lasted a few weeks or months depressive, and mixed types. The ICD-11 (WHO, 2018), is
and was followed by recovery. He noted that a history of the most recent classification and only changed the code
a previous attack was usually present; the patients were given to schizoaffective disorder (6A21).
in their 20s or 30s and in good physical health. Kasanin The American Psychiatric Association’s (APA, 1952,
(1933) called it the acute schizoaffective psychosis. He 1968) Diagnostic and Statistical Manual of Mental
associated the diagnosis with better premorbid function-
ing, less severe symptomatology and overall, less severe 1
 línica Universitária de Psiquiatria e Psicologia Médica, Faculdade de
C
symptomatology. However, this psychosis had many Medicina, Universidade de Lisboa, Portugal, Europe
2
Serviço de Psiquiatria Geral e Transcultural, Hospital Júlio de Matos,
more similarities to the reactive psychoses of
Centro Hospitalar Psiquiátrico de Lisboa, Portugal, Europe
Scandinavian psychiatry, to bouffée délirante of French
psychiatry, or to schizophrenia-like emotion psychoses of Corresponding author:
João Gama Marques, Consulta de Esquizofrenia Resistente, Hospital
German psychiatry (Marneros, 2003a, 2003b). Júlio de Matos, Centro Hospitalar Psiquiátrico de Lisboa, Avenida do
The ninth edition of the World Health Organization’s Brasil, 53, Lisboa 1749-002, Portugal, Europe.
(WHO, 1972) International Classification of Diseases Email: [email protected]
244 International Journal of Social Psychiatry 69(2)

Disorders (DSM) is the recognized authority for psychiat- the schizophrenia spectrum, while others believed it was
ric diagnosis, taxonomy, and treatment options in North part of the bipolar spectrum. More recently, a third posi-
America. In the first and second editions, published in tion has been assumed by some clinicians and researchers,
1952 and 1968, respectively, the term schizoaffective was who look at schizoaffective psychosis and its related disor-
used to define a subtype of schizophrenia. In the DSM-III, ders, as more of an independent spectrum of its own, rather
the term schizoaffective was separated from schizophrenia than a group of individual and easily differentiable enti-
and retained without specific diagnostic criteria under the ties. This spectrum would include a range of disorders with
category of ‘psychotic disorder not otherwise classified’. It emotional and/or psychotic features that are not part of the
indicated that the diagnosis schizoaffective disorder should bipolar, but also not part of the schizophrenia spectra. That
be made whenever the clinician was unable to make a dif- spectrum would include entities such as borderline person-
ferential diagnosis between schizophrenia and affective ality, cycloid psychosis, and schizoaffective disorder. The
disorder (APA, 1980). The DSM-III-TR introduced the schizoaffective spectrum would be, therefore, somewhere
first operationalized diagnostic criteria for schizoaffective in between the bipolar spectrum and the schizophrenia
disorder, which required the persistence of psychotic spectrum (Gama Marques & Ouakinin, 2021). Table 1 pre-
symptoms in the absence of significant affective illness for sents a resume for the epistemological evolution of the
at least 2 weeks (APA, 1987; Wilson et al., 2014). In schizoaffective disorder.
DSM-IV and DSM-IV-TR the disorder has been retained
as a separate diagnostic entity with the diagnostic criteria
The homeless
remaining virtually unchanged (APA, 1994, 2000, 2013).
The DSM-5 and the DSM-5-TR defines schizoaffective The attempt to classify and distinguish types of homeless-
disorder as a combination of psychotic symptoms, and ness is no novelty. Leach (1979) classified two types of
mood disorder symptoms such as mania and/or depression. homelessness: intrinsic, homeless due to mental or physi-
The diagnostic criteria are as follows: An uninterrupted cal disability; and extrinsic, homeless due to situational
period of illness during which there is a major mood epi- factors.
sode (major depressive or manic) concurrent with the first Arce and Vergare (1984) subdivided them into chroni-
criteria of schizophrenia: delusions or hallucinations for cally homeless: predominantly older, and mentally ill peo-
two or more weeks, in the absence of a major mood epi- ple; episodically homeless: younger people who alternate
sode (depressive or manic), during the lifetime duration of between housing and institutional care and life on the
the illness. The disturbance is not attributable to the effects streets; and transiently homeless: people without an identi-
of a substance (drug or medication) or another medical fied major mental illness that became homeless due to an
condition. Additionally, the DSM-5-TR suggests further acute situational.
specification in different categories regarding subtype, Those who become homeless are commonly exposed to
course, and severity (APA, 2022). severe psychological stress, and approximately one third
The present definitions of schizoaffective disorder of homeless people live with severe mental illness (Tessler
given can be considered insufficient to define the group, & Dennis, 1989). This is particularly true in high-income
and certainly not definitive (Marneros, 2003a, 2003b). The countries. On the other hand, people living in middle-
main problem with the ICD and DSM classifications is the income and low-income countries experience homeless
statically transverse nature attributed to the schizoaffective not only due to mental illness and substance abuse
disorder, but longitudinal findings have suggested two (Vázquez et al., 2019), but also due to poverty, eviction,
courses of schizoaffective disorders beyond the ICD-11 or war, civil unrest, and climate change. In low-income and
DSM-5 definitions: the concurrent type, which is charac- middle-income countries, lone, single, male, rural workers
terized by the coincidence of schizophrenia and bipolar typically flock to the cities to work and send remittances
episodes; and the sequential type, which is characterized home (Tipple & Speak, 2009).
by the longitudinal change from schizophrenia to bipolar According to the United Nations Survey from 2005, an
episodes and/or vice versa. Indeed, the research data pub- estimated 100 million people were homeless worldwide and
lished by Marneros and colleagues that followed patients 1 billion were housed inappropriately (Koothari, 2005).
with schizoaffective disorder for decades, suggests that Also in 2005, the European Typology of Homelessness and
patients with schizoaffective disorder have polymorphous House Exclusion (ETHOS) was created by the Fédération
episodes (Marneros et al., 1991a, 1991b, 2003a, 2003b). Européenne d'Associations Nationales Travaillant avec les
Schizoaffective disorders seem to be very unstable, hav- Sans-Abri (FEANTSA, 2005, 2017). It was developed as a
ing, during longitudinal course, schizoaffective episodes, transnational framework definition for policy and practice
but also pure mood episodes reminiscent of classic bipolar purposes. The goal was not to harmonize the national defini-
disorder and pure psychotic episodes, similar to those con- tions of homelessness in Europe, but rather to facilitate
sidered typical in schizophrenia. Therefore, there were communication, improve understanding, and measure
authors classifying the schizoaffective disorder as part of homelessness. According to the ETHOS there are four main
Spranger Forte et al. 245

Table 1. Epistemological evolution of the schizoaffective disorder.

Author (year) Schizoaffective disorder definition

Kasanin (1933) Psychosis in emotional turmoil with false sensory impressions.
Lasted from weeks to months.
Good outcome.
Marneros (2003a, 2003b) Polymorphous nature: episodes of different types.
Longitude is given more importance: the diagnostic value of the sequential
Schizoaffective symptomatology is equal to that of the concurrent symptomatology.
WHO (2018) ICD-11 Episodic disorder in which the diagnostic requirements of schizophrenia and a manic, mixed, or severe
depressive episode are met within the same episode of illness, either simultaneously or within a few
days of each other.
Psychomotor disturbances, including catatonia, may be present.
Symptoms must have persisted for at least 1 month.
The symptoms are not a manifestation of another medical condition and are not due to the effect of a
substance or medication on the central nervous system, including withdrawal.
A diagnosis of schizoaffective disorder should be made only when the symptom criteria of
schizophrenia and of a moderate or severe mood episode are fulfilled simultaneously or within a few
days of each other.
APA (2022) DSM-5-TR An uninterrupted duration of illness during which there is a major mood episode (manic or depressive)
in addition to the first criteria for schizophrenia.
Hallucinations and delusions for two or more weeks in the absence of a major mood episode (manic
or depressive) during the entire lifetime duration of the illness.
Symptoms that meet the criteria for a major mood episode are present for most of the total duration
of both the active and residual portions of the illness.
The disturbance is not the result of the effects of a substance or another underlying medical condition.

Note. APA = American Psychiatry Association; DSM-5-TR = Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Revised Text;
WHO = World Health Organization; ICD = international Classification of Diseases.

categories included in the homelessness definition: the roof- Methods

less, the houseless, those with insecure housing and those
with inadequate housing. Table 2 presents the categories of Research pertaining to schizoaffective disorder, specifically
homelessness according to the ETHOS (FEANTSA, 2017). in homeless patients is virtually non-existent. No restric-
tions were imposed in regard to the type of study, interven-
tion, and outcomes. Most articles cited, and their results
The schizoaffective disorder in the homeless derive from studies where patients with schizoaffective dis-
order and schizophrenia were grouped together. Only
The present review was inspired by the Bellevue Homeless
English articles were considered. The search was carried out
Psychiatric Unit work, where North American researchers
with the terms ‘homeless’ and ‘schizoaffective disorder’ on
found out that admitted patients were sub-diagnosed with
PubMed (search details: (homeless*[Title/Abstract]) AND
schizoaffective disorder. Out of 377 patients, only 5% at
(schizoaffective [Title/Abstract]). On the 12th of April 2022,
admission were already diagnosed with schizoaffective
31 articles showed up using the above-mentioned search
disorder, whereas at discharge this number rose more than
words. Out of the 31 articles, 3 of them were excluded
five-fold, to a staggering 28%. At that time, authors sug-
because they were irrelevant or had little to do with the
gested that further studies were needed for a better under-
review goal. Figure 1 presents the selection of articles for
standing of schizoaffective disorder among the homeless
this review.
population (Nardacci et al., 1993). In more recent European
studies, of 500 homeless people, the prevalence of schiz-
oaffective disorder was 11% (Monteiro Fernandes et al., Results
2021), and the homeless with schizoaffective disorder had Characteristics of schizoaffective disorder
a statistically significant longer follow-ups, a higher
median of psychiatric hospitalizations, and a higher
patients living homeless
median duration of total psychiatric hospitalizations Ries and Comtois (1997) studied the psychiatric disorder
(Ayano et al., 2019). Therefore, following the scarce exist- severity and treatment services in dually diagnosed
ence of literature regarding the topic (Fazel et al., 2008), severely mentally ill outpatients. In this study dual diag-
the authors propose to do a review aiming to study the rela- nosis was considered whenever a patient had both a men-
tion between schizoaffective disorder and homelessness. tal disorder and a drug or alcohol problem. Illness severity
246 International Journal of Social Psychiatry 69(2)

Table 2. Categories of homelessness.

Conceptual category Operational category Living situation

Roofless People living rough Public or external space
People in emergency accommodation Overnight shelters
Houseless People in accommodation for the homeless Homeless hostels
Women’s shelters
Temporary accommodation
Transitional accommodation
Refugee accommodation
People living in institutions Health care institutions
Penal institutions
Inadequate housing People living in non-conventional dwellings Mobile homes
Non-conventional buildings
Temporary structures
Insecure housing Homeless people living temporarily in Conventional housing, but not the usual
conventional housing with family and friends place of residence

Source. Adapted from ETHOS (FEANTSA, 2017).

Note. ETHOS = European Typology of Homelessness and House Exclusion; FEANTSA = Fédération Européenne d'Associations Nationales Travaillant
avec les Sans-Abri.

outpatient services (17.8 vs. 11.7 appointments/month,

p < .01). Participants with a high TSI received twice the
number of appointments (20.7 vs. 12.3) per month. A
higher TSI was related to schizoaffective disorder or
schizophrenia being in a lower phase of treatment. They
went further by comparing patients with a schizoaffective
disorder or schizophrenia diagnosis to those without this
diagnosis.
Homelessness is famous for motivating many visits to
the emergency department (Padgett et al., 1995). A retro-
spective review of 1,285 patients who visited the emer-
gency room more than once in a period of 6 years was
carried out in 2011. Patients with six or more visits were
compared to patients with between two to five visits (317
and 968 patients, respectively). The study found out that
the former group was significantly more likely to be home-
less, have a substance use disorder and to have more diag-
nostic variability. A total of 177 patients were found to have
Figure 1. Selection of articles for the review regarding diagnostic variability between schizophrenia, schizoaffec-
schizoaffective disorder in the homeless. tive disorder, and bipolar disorder, suggesting a diagnosis
of schizoaffective disorder. In the univariate analysis, three
was assessed using the Psychiatric Symptom Assessment sociodemographic characteristics were significantly asso-
Scale (PSAS; Bigelow & Berthot, 1989). Furthermore, ciated with being a frequent visitor: younger age (p = .015),
drug use intensity as well as dysfunction intensity was single marital status (p < .001), and homelessness (p < .001;
scaled via questionnaires, added to the Psychiatric Boyer et al., 2011).
Symptom Assessment Scale, thus forming the Total
Severity Index (TSI). Patients with higher severity of ill-
ness were more likely to be male, to have schizoaffective Psychiatric readmission in schizoaffective
disorder or schizophrenia as a diagnosis, to be more non-
homeless patients
compliant with treatment, to be homeless, to have been
psychiatrically hospitalized in the last 6 months, to be in A retrospective study (Lorine et al., 2015) followed 207
the protective payee program, to be in the pre phase level patients that had been hospitalized due to acute psychiatric
of treatment, receiving twice as much case management illnesses, being that 50% of them had schizoaffective dis-
services, more day treatment, and significantly more total order or schizophrenia diagnosis. Of the 207 patients
Spranger Forte et al. 247

included in the study 47 (24%) were homeless. They were the non-compliant group was significantly more likely to
then followed consecutively to analyze readmission pat- have a history of medication noncompliance, substance
terns. Three groups were created. Group 1 (readmitted abuse or dependence, and difficulty recognizing their own
within 15 days), group 2 (readmitted within 3–6 months), symptoms. Patients who became medication noncompliant
and group 3 (not readmitted for at least 12 months post- were significantly less likely to have formed a good thera-
discharge). The study found that 68% of the total number peutic alliance during hospitalization as measured by in-
of patients readmitted just after 15 days of discharge had patient staff reports and were more likely to have family
schizoaffective disorder or schizophrenia diagnosis. In members who refused to become involved in their treat-
group 2, schizoaffective disorder or schizophrenia ment. Within 72 hours before hospital discharge, patients
accounted for half of the patients admitted between 3 and completed a structured assessment spanning clinical symp-
6 months. In group 3 it accounted for 27%. When it comes toms, substance use disorders, insight into illness, and
to homelessness, 36% of the patients in group 1 had no aspects of their medication management. At that time,
living arrangements, 23% were admitted between 3 and structured assessments were also conducted with the clini-
6 months, and 13% of those who managed not to be read- cal staff to assess the therapeutic alliance, family involve-
mitted in the period of 12 months. The authors went even ment in treatment, and medication management. Insight
further by calculating the Odds Ratio (OR) between home- into illness was assessed with two probes. Positive
lessness and having schizoaffective disorder or schizo- responses were followed with an item to determine whether
phrenia, and how this led to either readmission at 15 days the patient believed he or she had schizoaffective disorder
or no readmission (group 3). They determined that given a or schizophrenia. Therapeutic alliance was measured with
diagnosis of schizoaffective disorder or schizophrenia the the 6-item Active Engagement Scale (AES) completed by
chances of being in group 1 rather than group 3 increased inpatient clinicians at the time of discharge. Family involve-
17.8 times. For homelessness it increased 29.4 times. ment was evaluated by asking staff whether patients had
Therefore, a diagnosis of schizoaffective disorder or schiz- any family members, whether family members visited the
ophrenia in the homeless was found to be a significant risk patient in the hospital, whether they agreed or refused to
factor for early readmission. become involved during the admission, whether they met
with staff, and whether they received family therapy.
Prediction of homelessness in schizoaffective Noncompliance was not taking antipsychotics for 1 week or
more. Missing or stopping antipsychotic medication was
patients
strongly associated with several untoward outcomes,
In a study of 1999 (Rosca et al., 2006), 263 patients with including homelessness, symptom exacerbation, and non-
schizophrenia or schizoaffective disorder were evaluated compliance with outpatient treatment, emergency room
at discharge and 3 months later. Homelessness during this visits, and rehospitalization. Substance use disorders
period was reported by 20 patients (7.6%). Drug use disor- emerged as the strongest predictor of medication noncom-
der, total score of above 40 in the Brief Psychiatric Rating pliance. Patients whose families refused to participate in
Scale (BPRS; Thompson et al., 1994) and scores under 43 treatment were at high risk for stopping their medications.
in the Global Assessment Scores (GAF; Endicott et al., To sum-up, patients with schizoaffective disorder or schiz-
1976) all led to increased likelihood of experiencing home- ophrenia and comorbid substance use disorders, a history
lessness. Therefore, the risk of becoming homeless follow- of medication noncompliance, a poor alliance with inpa-
ing hospital discharge seems to be increased in patients tient staff, difficulty recognizing their own symptoms, and
with schizoaffective disorder or schizophrenia (El Hayek families who refuse to become involved in treatment are at
et al., 2022). increased risk of stopping their medications after hospital
discharge (Olfson et al., 2000).
Medication noncompliance in schizoaffective
disorder homeless patients Substance use in schizoaffective disorder
Medication non-compliance poses one of the most difficult homeless patients
challenges in managing major psychiatric disorders. Olfson A study analyzed the 3-year outcomes of 152 patients
et al. (2000) studied a population of 213 adults with either with schizophrenia or schizoaffective disorder and con-
schizophrenia or schizoaffective disorder, to whom oral comitant substance use (dual diagnosis). The 3-year out-
antipsychotics were prescribed. Then, 3 months later, all comes for patients with dual-diagnosis receiving
patients were re-evaluated to assess medication compli- integrated dual disorder treatments were clearly positive
ance. A 19.2% were found to be non-compliant (Olfson for a large proportion. Despite severe and prolonged dis-
et al., 2000). These patients were at increased risk of home- ability, many of these individuals were able to achieve
lessness, symptom exacerbation, emergency room visits, control of both disorders, to reduce episodes of hospitali-
and rehospitalization. Compared with the compliant group, zation and homelessness, to achieve success in some
248 International Journal of Social Psychiatry 69(2)

aspects of community functioning, and to attain what they patients with remitting alcohol use disorders were com-
perceived as a better quality of life. Overall, the data pared to those with active disorders and found little hous-
showed that nearly all participants were rapidly engaged ing instability. The findings indicated that the schizophrenic
in mental health services and that homelessness was and schizoaffective patients who have housing instability
reduced over time as patients increased their usage of out- problems have more psychosocial issues, have less sup-
patient services (Lieberman & Bowers, 1990). port, and exhibit dangerous behaviors such as hospitaliza-
A study compared 608 patients with a diagnosis of tion, alcohol abuse, and therapeutic noncompliance. All
schizoaffective disorder or schizophrenia treated on hospi- these factors summed up together contribute to the rise in
tal units with integrated dual diagnosis treatment. Patients homelessness. Institutionalization and homelessness can
with no history of substance abuse were then compared, be avoided if housing options are available, desirably alco-
using t-tests, chi-square tests, and analysis of variance, to hol-free, to increase the likelihood of success in maintain-
those who had a substance abuse disorder. Those who did ing constant housing (Xie et al., 2005).
have a substance abuse problem stayed 30% shorter than
those who didn’t. Additionally, they also showed greater
symptomatic improvement and no increase in 18-month Pharmacogenetic testing in schizoaffective
readmission rates. On admission, dually diagnosed patients disorder homeless patients
were more likely to be homeless, younger, male, and a
greater danger to self and others. On discharge, they were A recent case report (Gama Marques, 2019b) in a home-
on average less psychotic. A possible hypothesis suggested less patient with schizoaffective disorder used the power
by these results is that, although substance use amplifies of pharmacogenetics. The patient had already experienced
psychotic symptoms, when patients are admitted and stop 85 admissions in 25 years, taken a combination of benzodi-
abusing substances, they stabilize faster (Ries et al., 2000). azepines, antidepressants, mood stabilizers and antipsy-
A study tracked 43,724 patients from three ethnicities, chotics, and undergone electroconvulsive therapy. By
all with either schizophrenia or schizoaffective disorder using Neuropharmagen® (Espadaler et al., 2017), a higher
diagnosed. The main goal was to find out whether there probability of positive response to treatment with haloperi-
were variations between ethnicities (Caucasian, Black, and dol (favorable NEF3 (NEuroFilament-medium 3) gene
Latino) pertaining to substance abuse in patients with polymorphism) and lithium (favorable polymorphism to
schizoaffective disorder or schizophrenia. Homeless CACNG2 (CAlcium voltage-gated Channel auxiliary sub-
patients with schizoaffective disorder or schizophrenia unit Gamma 2) were found, while there appeared to be a
were more than two times likely to have a substance abuse normal pattern response to both clonazepam and clozap-
disorder. Those living with someone had half the chance to ine. The patient had been treated many times with some
abuse drugs in comparison to those who lived alone. To drugs that were not the best option, as he presented fast
sum up, homelessness seems to be more associated with metabolism of olanzapine (unfavorable polymorphism in
drug abuse regardless of ethnicity (Montross et al., 2005). CYP1A2 (a member of the cytochrome P450 superfam-
Substance abuse is often a source of problems for housing ily), carbamazepine (unfavorable polymorphism in
stability. In a study of 75 outpatients from rural and urban EPHX1 (microsomal Epoxide Hydrolase 1)), and loraze-
settings, with schizoaffective disorder or schizophrenia pam (unfavorable polymorphism in Uridine 5′-diphos-
who were followed for 1 year, 10.7% had schizoaffective phate-Glucuronosyl Transferase 2B15 (UGT2B15)). After
disorder (eight patients). Living arrangements in the past getting these results, his medication was changed and total
6 months were scored on a 5 points scale from highly sup- remission of symptoms was achieved in 4 weeks, and oral
portive (1) to highly stressful (5). Points 4 and 5 were con- haloperidol was then substituted by a monthly long-acting
sidered unstable housing. Only 4 had point 5 while 15 had injectable formulation of haloperidol decanoate 300 mg, in
4. Nineteen subjects had unstable housing (25.3%). order to guarantee maximum therapeutic adherence.
Housing problems were mostly related to alcohol abuse Finally, after a quarter of century years of erratic wander-
and medication noncompliance which led to tensions ing between the urban homeless life and the psychiatric
between the patients and landlords or relatives. Both rural asylum environment, the patient got transferred to a rural
and urban patients appeared similarly in psychosocial charity community residence, where he has been without
problems such as alcohol and medication noncompliance. further psychiatric readmissions.
Findings suggested that alcohol abuse led to housing insta-
bility and not the other way around, all subjects indicated
Discussion
that they developed an alcohol problem before they were
met with housing instability; the case managers reported Limitations of studies are an important part of scientific
that the patients’ landlords and families indicated displease research. The greatest limitation of this work was the fact
with behaviors related to alcohol, consequently jeopardiz- that patients with schizophrenia and schizoaffective disor-
ing housing arrangements. To prove this even further, der were often grouped together in the articles cited. This
Spranger Forte et al. 249

makes the drawing of conclusions and results difficult contributors to housing instability and psychiatric stability
because the sample is not pure. Also, some works included remain one of the most difficult challenges to mental
in this systematic review did not state clearly whether healthcare workers (Carnot & Gama Marques, 2018).
organic causes for psychosis had been excluded, as we did Healthcare-patient relationship bonds remain key in deal-
in a particular case report of ours (Gama Marques, 2022b). ing with discharged mental patients. A good relation can
Secondary psychosis is very common in clinical practice increase the likelihood that patients take their medication
and often undiagnosed (Gama Marques, 2019a, 2020). and don’t miss appointments, increasing therapeutic suc-
Many imitators affecting the central nervous system can cess and diminishing the probability of a decompensation
mimic schizophrenia or schizoaffective disorder (Gama (Frank & Gunderson, 1990; Olfson et al., 2000).
Marques, 2019a, 2020). Therefore, all causes of what was Medication noncompliance places patients with schizoaf-
previously so-called organic psychosis should always be fective disorder at risk of homelessness, and interruptions
discarded before assuming the diagnosis of primary or idi- in the continuity of outpatient care. Last but not least,
opathic psychosis (Gama Marques, 2021a, 2022c). pharmacogenetics. Pharmacogenetics has been anecdo-
Clinicians should be aware of schizophrenia as the great tally used in patients with schizoaffective disorder living
imitated in clinical neuroscience (Gama Marques & Bento, homeless. No one can deny its importance in guiding clini-
2020c). The ICD-11 and DSM-5-TR are clear on stating cian’s choice of antipsychotic treatment for less iatrogenic
that the disturbance must not be attributable to the effects and better theranostic. Its cost, however, remains an obsta-
of a medical condition or substance use (drug or medica- cle to daily clinical use. One can also entertain the possi-
tion) and we believe that use of substances among patients bility of investing in pharmacogenetics testing in these
with schizoffective disorder could be especially trouble- small yet costly populations. These are patients that utilize
some (Morrens et al., 2011) and even worse in homeless many expensive resources. Likely, with pharmacogenetics
patients that live with very high comorbidity (Gama testing (Gama Marques, 2022b; Huang et al., 2016), medi-
Marques, 2022a; Gama Marques & Bento, 2020). cation plans could be tailored and optimal from the start,
Homeless patients suffer not only from mental disease, which can save money in the long run.
but also from various medical organic conditions (Gama
Marques & Bento, 2020) and social ailment phenomenon
Conclusion
such as mortification, as inpatients in hospitals or shelteri-
zation, as outpatients in the community shelters (Gama Schizoaffective disorder is still evolving in the way we
Marques, 2022a). Among the homeless population, define it. Even though this evolution contributes to greater
patients with schizoaffective disorder, undergoing psychi- diagnostic variability, with unclear and polarizing criteria,
atric treatment, are particularly difficult to follow. steps are being taken and research is being carried out to
Another important limitation of the present review is standardize the way we diagnose and treat the disorder.
intrinsically related with the low quantity and low quality Healthcare professionals struggle with unclear instruc-
of the published articles. Unfortunately, it was not possible tions in the diagnostic criteria. This increases the diffi-
to fulfill the Preferred Reporting Items for Systematic culty of the already hard diagnosis. The homeless
Reviews and Meta-Analyses (PRISMA; Page et al., 2020). population with schizoaffective disorder, undergoing psy-
And it was also very difficult to follow the instructions for chiatric treatment, is a particularly difficult population to
the making of scoping reviews, as recommended by the follow. Compliance with outpatient visits and medication
Joanna Briggs Institute (JBI; Peters et al., 2020). The pro- is still a challenge. Homeless people with schizoaffective
tocol for the present review was also not registered nor disorder must contend with competing priorities, such as
published, unfortunately. Therefore, other authors inter- securing food and shelter. This frequently takes prece-
ested in the relation between schizoaffective disorder and dence over healthcare. They may also avoid care due to a
homelessness shall prepare in the future, enhanced proto- lack of trust of the healthcare system and previous experi-
cols for better reviews than the one that is present here. ences of discrimination from providers. Thus, when com-
Nevertheless, this is the first one ever made, at least, to our bining a difficult diagnosis with a super-difficult patient
limited knowledge of scientific literature. population (Gama Marques, 2021b), the result is what we
Compliance with outpatient visits and medication is found in the literature. Patients who are sub-diagnosed
still a challenge, as homeless people with schizoaffective and therefore, psychiatrically unstable, experiencing fre-
disorder must contend with competing priorities, such as quent psychiatric readmission, the revolving door phe-
securing food (Luder et al., 1989). This frequently takes nomenon (Botha et al., 2010; Haywood et al., 1995). This
precedence over healthcare. They may also avoid care due will not only cut costs in the long run, since psychiatric
to a lack of trust of the healthcare system and previous admissions are known to be lengthy, but also improve the
experiences of discrimination from providers. quality of life of this downtrodden population. More
Substance abuse and medication noncompliance remain research regarding schizoaffective disorder among the
the foes of psychiatric improvement. These two-factors as homeless is of paramount importance. This is real fourth
250 International Journal of Social Psychiatry 69(2)

world population (Raps & Kemelman, 1994), deserving El Hayek, S., Ghida, K., Kassir, G., Charara, R., El Hayek, S.,
the health care of a new speciality: Marontology (Gama Genadry, F., & El-Khoury, J. (2022). Correlates of unscheduled
Marques & Bento, 2020b, Gama Marques, 2021b). and emergency clinical contact in a cohort of patients treated for
psychosis. Psychiatry Research Communications, 2(1), 100024.
Endicott, J., Spitzer, R., Fleiss, J., & Cohen, J. (1976). The
Funding
global assessment scale. A procedure for measuring over-
The author(s) received no financial support for the research, all severity of psychiatric disturbance. Archives of General
authorship, and/or publication of this article. Psychiatry, 33(6), 766–771.
Espadaler, J., Tuson, M., Lopez-Ibor, J., Lopez-Ibor, F., &
ORCID iD Lopez-Ibor, M. (2017). Pharmacogenetic testing for the
João Gama Marques https://orcid.org/0000-0003-0662-5178 guidance of psychiatric treatment: A multicenter retrospec-
tive analysis. CNS Spectrums, 22(4), 315–324.
Fazel, S., Khosla, V., Doll, H., & Geddes, J. (2008). The preva-
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