“Jan” became a patient of ours, not in a hospital, but on a muddy back road of East Atlanta. This was her new home, after she had just been evicted from her apartment, without the dignity of collecting any of her belongings. Not even her psychiatric prescriptions.
Without them, her depression deepened, and at the time of our streetside intake, she expressed both suicidal and homicidal ideation. Jan was in an unequivocal psychiatric emergency warranting immediate admission to a nearby crisis center. And yet, we had no safe disposition plan, no stable housing to discharge her to after this temporary solution.
Jan’s story is not unusual. We encounter this pattern constantly in Atlanta: people whose psychiatric conditions are failing not because of poor medicine, but because of deficient housing policies.
As healthcare students, we learn the vast spectrum of medicines used to treat psychiatric conditions. But on the streets of Atlanta, where we provide care to people experiencing homelessness (PEH), that knowledge is insufficient. We can stabilize someone on a sidewalk, prescribe the right treatments, and even connect them with a case manager, but what we cannot do is substitute the stability of housing that makes recovery sustainable.
The Clinical Reality
Studies consistently show that housing instability is a significant risk factor for the development and exacerbation of mental health disorders. A recent review found a current mental health disorder prevalence of 67% among PEH, compared with population-based estimates of roughly 14% in the general population. On the streets, our patients struggle to safely store medications, attend follow-up care, and are burdened with relentless threats to their well-being. Some may resort to substance use to stay alert for safety or manage trauma, a tactic that worsens their psychiatric health, but is ultimately a means of survival.
Georgia compounds these realities. The state ranks 46th in access to mental health services and is one of only ten states that has not expanded Medicaid eligibility, maintaining nearly twice the uninsured rate of expansion states. Georgia’s failure to provide consistent, accessible, preventative care perpetuates cycles of instability and crisis.
As a result, the majority of healthcare delivery for PEH occurs through the most expensive systems we have: repeated psychiatric hospitalizations, emergency departments (EDs), and jails.
Georgia’s methods of healthcare delivery for PEH are not only ineffective but also costly. Compared to housed patients, psychiatric admissions for PEH cost over $1,000 more per stay than for housed patients, and they are twice as likely to be readmitted within 30 days. Meanwhile, jails have become America’s de facto psychiatric facilities, despite being neither designed nor funded to provide adequate mental health care. PEH are 11 times more likely to be arrested, and nearly 40% of incarcerated people have a history of mental illness, roughly double the general population rate, which can be largely attributed to survival behaviors and lack of access to care.
Megan Blasberg, co-author and medical student, witnessed this cycle firsthand while working as an assistant researcher at an Atlanta Hospital Psychiatric Unit and as a jail EMT. She observed how consistent, reliable access to psychiatric medication and care is essential for stabilization and sustained recovery. Yet outside of controlled environments, access to treatment often disappears. Patients were often discharged with only a few days of medication and left with a list of resources that were nearly impossible to navigate without access to transportation, insurance, or a safe place to live.
Without a stable environment to store medications, maintain routines, or follow up with care, adherence becomes unrealistic. As a result, many patients cycled back, and I saw familiar faces return to the hospital and jail – not because treatment is ineffective, but because the conditions required for treatment to succeed are absent.
Housing is one of those conditions. It is what makes consistent access to medication, adherence, and continuity of care possible. Without it, even the most effective psychiatric treatments struggle to succeed.
A Better Alternative
A better model already exists, and it has been rigorously tested. Housing First (HF) is an evidence-based model that provides immediate, permanent housing to PEH without requiring sobriety or psychiatric treatment as a prerequisite. Rather than treating housing as something to be earned, the model recognizes residential stability as the foundation upon which psychiatric recovery becomes possible.
Critics argue individuals must demonstrate “housing readiness” first, but the evidence shows the opposite: stable housing produces a 41% increase in housing stability over traditional approaches. It not only more than doubled the retention rate in methadone maintenance programs, but it also facilitated declines in alcohol use, averaging 7% every three months, even without abstinence mandates. This outperforms “Treatment First” models, demonstrating how safe, private housing alleviates the “survival mentality,” improves adherence to complex regimens, and provides the essential foundation for clinical engagement.
The clinical outcomes are striking. The Moore Place program in Charlotte reported a 79% reduction in inpatient psychiatric days. In scattered-site programs, participants took their antipsychotic medications nearly 80% of the time, approaching therapeutic levels that are impossible to sustain on the streets. In Denver, the Supportive Housing Social Impact Bond (SIB) Initiative, a city-backed HF intervention, found that housing help allows patients to seek sustainable care, disrupting the cycle of unhoused patients having to choose between either criminalization or the revolving door of ERs in the face of worsening mental health.
Co-author Hridith Sudev, attests to what he saw happen when that cycle was interrupted: “People stopped rotating through EDs and jails, and started showing up to scheduled psychiatric appointments instead. The difference was astounding. And the city was saving money.” Sudev is an onco-epidemiologist and doctoral student at Mercer University, who was formerly an SIB Initiative provider in Denver.
The data supports his observation. Evaluating the SIB Initiative using a randomized controlled trial found that within two years, participants had six fewer ED visits and eight more office-based psychiatric visits; and within three years, participants with frequent arrests and ED use experienced a 30% reduction in jail stays and 38 fewer days incarcerated. The annual per-person cost of emergency services was nearly $7,000 less than the control group, offsetting roughly half the program’s total cost. Supportive housing runs $12,000 to $15,500 per person annually, a figure that is dwarfed by the status quo.
The patients we have the privilege of caring for remind us that housing is not a luxury but a critical part of physical and emotional health. Georgia must implement permanent supportive housing and expand Housing First programs to transform psychiatric care from reactive crisis management into sustained, preventative treatment.
