Feodor Nilsson Sandra, Laursen Thomas Munk, Ranning Anne, Thorup Anne A E, Nordentoft Merete, Fazel Seena
Copenhagen Research Center for Mental Health (CORE), Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark.
The National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark.
Lancet Reg Health Eur. 2025 Jul 22;56:101381. doi: 10.1016/j.lanepe.2025.101381. eCollection 2025 Sep.
Family adversity and childhood abuse have been associated with an increased risk of homelessness in adulthood. However, to our knowledge, no population-based longitudinal studies have examined the association between out-of-home placement and subsequent homelessness, while accounting for psychiatric disorders and parental background. Thus, we aimed to investigate the association between out-of-home placement and psychiatric disorders during childhood or adolescence and homelessness later in life.
We used data from a nationwide, register-based birth cohort in Denmark from 1 January 1983 to 31 December 2003, who were alive at any point from 1 January 2001 to 31 December 2021. Children and adolescents (aged 0-17) were followed up from their 18th birthday for risk of homelessness. We investigated associations using national registers with information on homelessness and psychiatric disorders. We examined individuals with any out-of-home placement history with and without psychiatric disorders diagnosed up to age 18 according to the first episode of homelessness after age 18, defined as first contact with a shelter. We estimated the cumulative incidence function using an Aalen-Johansen estimator. Hazard ratios (HRs) for the association between out-of-home placement, psychiatric disorder, and homelessness were estimated by sex using Cox proportional-hazard regression analyses, adjusted for birth year, parental sociodemographic factors and psychiatric disorders. Additionally, we employed a stratified Cox model (stratified by mother) to examine the contribution of within-family covariates.
The study cohort included 1,226,130 Danish residents aged 18-39 years. Of these, 53,281 individuals (4·3%) had experienced out-of-home placement during childhood or adolescence. By age 39, 12·2% (95% CI 11·6-12·7) of males and 6·3% (95% CI 5·9-6·7) of females with a history of out-of-home placement experienced homelessness. This corresponds to a substantially increased risk compared to people without such a history, with adjusted HRs of 7·1 (95% CI 6·7-7·5) for males and 9·0 (8·2-9·8) for females. In sibling analyses restricted to 955,287 individuals and adjusted for birth year, out-of-home placement was associated with a 3-fold increased risk of homelessness compared to siblings without such a history (aHR 2·8 (95% CI 2·4-3·3) for males and aHR 3·2 (2·4-4·1) for females). Homelessness risk was even higher for individuals with a history of both out-of-home placement and psychiatric disorder, particularly when psychiatric diagnosis occurred after the first placement. In the full cohort, adjusted HRs were 11·8 (95% CI 10·8-13·0) for males and 19·3 (16·9-21·9) for females, compared to individuals with neither out-of-home placement nor psychiatric disorder.
Individuals with a history of out-of-home placement are at higher risk of experiencing homelessness, particularly those with co-occurring psychiatric disorders. These findings highlight the need for targeted interventions and coordinated efforts across medical and social services to prevent homelessness.
Funded by a grant from the Lundbeck Foundation to SFN, F-61171-23-50 and the Independent Research Fund to SFN 10.46540/3162-00051B.
家庭困境和童年期受虐与成年后无家可归风险增加有关。然而，据我们所知，尚无基于人群的纵向研究在考虑精神疾病和父母背景的情况下，探讨家庭外安置与随后的无家可归之间的关联。因此，我们旨在调查童年或青少年期的家庭外安置与精神疾病以及晚年无家可归之间的关联。
我们使用了丹麦一个基于全国登记的出生队列的数据，该队列涵盖1983年1月1日至2003年12月31日出生的人群，且在2001年1月1日至2021年12月31日的任何时间点仍在世。儿童和青少年（0至17岁）从18岁生日开始随访无家可归风险。我们利用有关无家可归和精神疾病信息的国家登记册调查关联。我们根据18岁后首次无家可归事件（定义为首次与收容所接触），检查有和没有在18岁前被诊断出精神疾病的任何家庭外安置史的个体。我们使用Aalen-Johansen估计量估计累积发病率函数。通过Cox比例风险回归分析按性别估计家庭外安置、精神疾病和无家可归之间关联的风险比（HRs），并对出生年份、父母社会人口学因素和精神疾病进行调整。此外，我们采用分层Cox模型（按母亲分层）来检查家庭内协变量的作用。
研究队列包括1,226,130名18至39岁丹麦居民。其中，53,281人（4.3%）在童年或青少年期经历过家庭外安置。到39岁时，有家庭外安置史的男性中有12.2%（95%CI 11.6 - 12.7）、女性中有6.3%（95%CI 5.9 - 6.7）经历过无家可归。与没有这种经历的人相比，这相当于风险大幅增加，男性调整后的HRs为7.1（95%CI 6.7 - 7.5），女性为9.0（8.2 - 9.8）。在限于955,287人的同胞分析中，并对出生年份进行调整后，与没有这种经历的同胞相比，家庭外安置与无家可归风险增加3倍相关（男性aHR 2.8（95%CI 2.4 - 3.3），女性aHR 3.2（2.4 - 4.1））。有家庭外安置和精神疾病史的个体无家可归风险更高，特别是当精神疾病诊断发生在首次安置之后。在整个队列中，与既无家庭外安置也无精神疾病的个体相比，男性调整后的HRs为11.8（95%CI 10.8 - 13.0），女性为19.3（16.9 - 21.9）。
有家庭外安置史的个体经历无家可归的风险更高，特别是那些同时患有精神疾病的个体。这些发现凸显了有针对性的干预措施以及医疗和社会服务之间协调努力以预防无家可归的必要性。
由伦贝克基金会授予SFN的一项赠款（F - 61171 - 23 - 50）以及独立研究基金授予SFN的10.46540/3162 - 00051B资助。
