May 17, 2019
4 min read

A look at homelessness in San Francisco and its link to mental health

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This year, the American Psychiatry Association is hosting its annual meeting, the premier psychiatry event of the year, in San Francisco, a city with a large population of people experiencing homelessness. With the meeting almost here, Healio Psychiatry sought to learn more about the nation’s homeless population and the link between homelessness and mental health.

In 2018, about 553,000 people experienced homelessness in the United States on a given night, according to the 2018 Annual Homeless Assessment Report (AHAR) to Congress.

Data from the 2018 AHAR showed that about 35% of people experiencing homelessness were staying in unsheltered locations. California had one of the largest numbers of people experiencing homelessness and highest rates of homelessness in 2018. The state accounted for nearly half (47%) of all unsheltered people experiencing homelessness in the country, and 69% of these 89,543 people were found in unsheltered locations, according to 2018 AHAR data.

Homelessness in San Francisco

Many people experiencing homelessness in California reside in San Francisco, a city undergoing a “homelessness crisis,” London Breed, mayor of the City and County of San Francisco, wrote in a 2018 article published on

According to the 2017 City and County of San Francisco Point-in-Time Count, the homeless population was 7,499, which is slightly lower than in 2015 (n = 7,539). Among this population, 58% stayed in unsheltered locations, 41% reported drug or alcohol abuse, 39% reported psychiatric or emotional conditions and 29% reported PTSD.

Image of homeless man 
Source: Adobe Stock

In the article, Breed wrote that San Francisco spends about $250 million on homeless services each year, including for supportive housing, preventing eviction and rental subsidies. Although San Francisco helps approximately 2,000 people out of homelessness each year, the homeless population remains steady, she wrote.

One of Breed’s plans as mayor is to improve mental health and addiction treatment. She suggested opening safe IV injection facilities for people to inject drugs under the supervision of health care professionals.

“The rampant drug use, dirty needles, human and animal excrement, garbage, tents, and aggressive behavior on our streets are totally unacceptable,” she wrote. “It is inhumane for the people enduring mental health and addiction issues, and unhealthy, even unsafe, for those passing by.”

In a San Francisco Chronicle article, one reporter called San Francisco’s behavioral health care system “a tangled web of complex and expensive services.” Because of this, Breed has appointed Anton Nigusse Bland, MD, medical director for Psychiatric Emergency Services at San Francisco General Hospital, to a newly created position in the health department to review the mental health system and recommend changes.


According to the article, San Francisco has 133 crisis beds, but more are needed. San Francisco recently received a $415 million windfall from a county education fund, a portion of which Breed announced in December will be used for homelessness and housing initiatives, such as adding extra beds.

Another San Francisco Chronicle article published in February reported that the city received a $3 million state grant to expand needed mental health and substance abuse services for people experiencing homeless within the next year and a half. This grant will include more than $950,000 to pay for six case managers to help chronically ill people identified through the city’s Healthy Streets Operation Center and two social workers at the San Francisco General Hospital emergency psychiatric ward.

The HCP’s role

With such a large proportion of San Francisco’s homeless population reporting mental health issues, health care professionals can play an important role in addressing homelessness.

In my experience, I’ve found health professionals to be the most effective at addressing homelessness when they practice in nontraditional ways,” Megan Smith, MSW, clinical social worker, teaching associate with the section of medical education at Alpert Medical School of Brown University and doctoral candidate at Boston University School of Social Work, told Healio Psychiatry.

Smith, who has been doing street outreach for more than a decade, has worked with a psychiatrist for the past 5 years. She explained that the psychiatrist was able to connect with individuals who he would not work with in a traditional practice setting.

“Particularly because so many people who are experiencing homelessness have had traumatic encounters with providers (or encounters with providers are reminiscent of past trauma), having health professionals engage on the turf and terms of the people who are experiencing homelessness is key,” she said.

In addition, Smith explained that it’s important for providers to share what they see in clinical practice at the policy level.

“Providers can both act as co-organizers with patients and use their privilege to help elevate those voices in conversations about policy and organizational decisions that impact access to and quality of care,” she told Healio Psychiatry. – by Savannah Demko

References: A Bold Approach to Homelessness. Accessed on May 1, 2019.

San Francisco Chronicle. Fixing San Francisco’s behavioral health system is complicated — here’s why. Accessed on May 1, 2019.

San Francisco Chronicle. SF gets $3 million state grant for mental health, drug abuse services for homeless. Accessed on May 1, 2019.

San Francisco Chronicle. Spending SF’s $181 million windfall: Breed breaks down how she’d do it. Accessed on May 1, 2019.

San Francisco Homeless Point-In-Time 2017 Count and Survey. Accessed on May 1, 2019.

The U.S. Department of Housing and Urban Development. The 2018 Annual Homeless Assessment Report (AHAR) to Congress. Accessed on May 1, 2019.

Disclosure: Smith reports no relevant financial disclosures.