Housing First or Treatment First Interventions for Mental Illness and Substance Abuse Disorders Among the Chronically Homeless? A Review of the Randomized Controlled Trial Evidence Base

The longstanding U.S. approach for treating chronically homeless people with mental illness and/or substance use disorders has been Housing First (HF): providing permanent supportive housing with wrap-around services, with no requirements on participants to engage in behavioral health support. The Trump Administration has recently reversed course, adopting an alternative strategy: Treatment First (TF). This research note addresses the question of which approach is more effective for treating mental illness and substance use disorders. My review of results from randomized controlled trials conducted in the United States demonstrates that neither HF nor TF approaches represent panaceas in helping the chronically homeless improve their mental health or free themselves from addiction. Results imply that we should adopt a more heterodox strategy that can better tailor treatments to individual circumstances—and build the requisite human, housing, and institutional resources in the public health domain to support such—if we are to fight the symbiotic challenges of chronic homelessness, mental illness, and substance use disorders successfully.