The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness
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The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness.

Kirst M., Zerger S., Misir V. et al.
Drug and Alcohol Dependence: 2015, 146, p. 24–29.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kirst at You could also try this alternative source.

This intervention based on housing first led to significantly greater reductions in drinking problems after 14 months, but not in problems with other substances.

Summary Housing first interventions provide immediate and stable accommodation for homeless people with mental health and substance use problems, and provide additional support (if wanted) for their wider needs, as opposed to treatment first interventions which require treatment entry or treatment success before housing is provided. Housing first is associated with improvements in quality of life and housing stability, but little is known about its impact on substance use outcomes.

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Key points
From summary and commentary

Housing first interventions are associated with improvements in housing stability and quality of life among homeless people with mental illness and substance use problems.

This study sought to investigate the impact of housing first on substance use outcomes over 24 months in Toronto, Canada.

The researchers found that housing first contributed to reductions in drinking problems over time, but did not have an impact on drug use problems.

This study examined the effect of scatter-site housing first compared with treatment-as-usual for a population of homeless adults with mental illness in Toronto, Canada. The 97 participants with high service needs were allocated at random to an intervention group (housing plus assertive community treatment), 204 were randomised to an intervention group designed for those with moderate service needs (housing plus intensive case management), and 274 were randomised to receive treatment-as-usual, which involved no specialist services, but information materials about services available in the community.

Typically the sample were homeless, unemployed single men aged around 40 with multiple chronic health problems, and nearly half were from minority ethnic groups and/or had been born outside Canada.

All participants were interviewed at the start of the study, and then every three months up to 24 months. 80% of participants were followed-up at 24 months. The researchers looked for changes in mental health, substance use, social functioning, community integration, and criminal justice system involvement. Substance use outcomes included reported drinking, drinking to intoxication, use of drugs (including the type of drug), and drinking or drug use problems in the past 30 days.

The researchers presumed that they would see greater reductions in drinking and drug use problems over time among participants receiving housing first, compared with treatment-as-usual.

Main findings

Substance use problems fell across all participants in the study, but at the 12-month follow-up had fallen to a significantly greater degree among those allocated to housing first interventions – a result not maintained at later follow-ups.

After 24 months, participants allocated to housing first had significantly greater reductions in the number of days on which they experienced drink-related problems and amount of money spent on alcohol than participants in the treatment-as-usual group. However, no differences were found between housing first and treatment-as-usual for drug problems or in spending on drugs.

The authors’ conclusions

These findings suggest that a housing first intervention can contribute to reductions in drinking problems over time. The lack of an effect on drug use problems suggests that individuals experiencing homelessness, mental illness, and drug problems may need to have additional support alongside a housing first intervention.

Findings logo commentary Housing first interventions offer housing stability without conditions: there are no requirements to enter or remain in treatment or prove sobriety; housing is viewed as a right, rather than something earned as an “end product of rehabilitative success”. Much of the evidence relating to the effectiveness of housing first focuses on people whose primary treatment need is considered to be mental illness. Relatively little is known about the outcomes for people with “severe and active substance misuse”. Traditional treatment first programmes (in contrast to housing first programmes) have shown reductions in the severity of addiction for this subgroup, but have had less success with long-term housing. Research cannot point with confidence to an optimal housing and treatment approach for people who are homeless, with coexisting mental illness and substance use dependence issues.

A recent evaluation of housing first services in England found small reductions in drinking and drug use among a small sample of service users. The services assessed provided housing-related support, emotional support, and help with education, work, and social integration. They used “intensive forms of case management” and engaged with external services including specialist drug and alcohol services, and community mental health services. 60 service users were asked about their substance use a year before housing first: 69% reported drinking alcohol on the street, 71% drinking until they felt drunk, and 66% taking illegal drugs, proportions which fell to 47%, 56%, and 53% respectively while receiving housing first. Positive changes observed on substance use outcomes were smaller than those on physical and mental health.

The evidence base for housing first is smaller in the United Kingdom than in the United States, the country where housing first was developed. There are various models of housing first, and more research will be needed to identify which models suit which client groups.

Try these Effectiveness Bank searches to read more about substance use interventions relating to housing and homelessness, and housing as an element of reintegration in treatment.

Last revised 27 April 2016. First uploaded 15 April 2016

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