Unmet Subsistence and Mental Health Needs in Women Experiencing Homelessness: Rethinking Care Models for Improved Outcomes.

Abstract

Women experiencing homelessness or unstable housing (WEH) exhibit disproportionately high rates of depression and anxiety. While existing research links unmet subsistence needs (e.g., housing and food insecurity) to mental health (MH), the intersection of these unmet needs with health and social factors on MH disparities remains underexplored. We examined associations between unmet subsistence needs and MH symptoms among WEH, focusing on interactions with health and social-related factors, including sleep disturbances, pain, and HIV status. Cross-sectional analysis using baseline data from the PULSE cohort study. 245 women recruited from shelters, free meal programs, and street encampments. We measured anxiety with the Generalized Anxiety Disorder 7-item (GAD-7) and depression with the Patient Health Questionnaire (PHQ-9). Unmet subsistence needs included insufficient access to shelter, food, clothing, and hygiene resources. Nearly half (49%) of WEH had moderate to severe depression, 36% had moderate to severe anxiety, and nearly 40% had at least one unmet subsistence need. WEH with ≥ 2 unmet needs had almost four times the odds of depression (AOR = 3.96, 95% CI = 1.84, 8.51) and nearly three times the odds of anxiety (AOR = 2.83, 95% CI = 1.39, 5.77) than those without unmet needs. Sleep disturbance and pain were also associated with higher odds of depression (AOR = 4.46, 95% CI = 2.28, 8.71; AOR = 7.01, 95% CI: 3.40, 14.44) and anxiety (AOR = 5.01, 95% CI = 2.70, 9.31; AOR = 3.60, 95% CI = 1.73, 7.50). HIV modified the effect of unmet needs, with seven times higher odds of anxiety among women with HIV who also had ≥ 2 unmet needs (AOR = 7.11, 95% CI = 1.06, 48.00). Unmet subsistence needs, sleep disturbances, and pain contribute to depression and anxiety among WEH, particularly those living with HIV. Low-barrier care models that address social needs alongside medical care may improve MH outcomes in WEH.