High Rates Of Substance Abuse Research Articles

Substance abuse in bipolar disorder

Background: High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized. Methods: Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted. Results: Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations. Conclusions: Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.

Substance abuse in bipolar disorder

High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized. Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted. Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations. Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.

Inuit Dreams, Inuit Realities: Shattering the Bonds of Dependency

The Inuit--The People-of Canada have long dreamed of creating their own territory out of the former Northwest Territories. With the birth of Nunavut--Our Land--on 1 April 1999, that dream has come true. Proposed since 1974, Nunavut was approved by Native constituents in 1979. The tentative agreement was signed in December of 1991 and was ratified by the people of the Northwest Territories, Native groups, and the Canadian government in late 1992, but the new territory is very much a creature of the twentieth century that attempts to undo some of the mistakes of the past. Nunavut Territory lies in Canada's Central and Eastern Arctic, roughly north and east of the tree line, and along the boundaries of traditional Inuit and Dene Indian usage (see Nixon 1991; Burns 1991). Iqaluit, with over five thousand inhabitants and the largest town in Nunavut, has been designated its capital. As a third Canadian territory, Nunavut emerged from the collective efforts of many Inuit leaders and organizations. Elsewhere, I have referred to three main periods of Inuit history from a mainstream point of view. For thousands of years during the Free Reign period, the Inuit eked out a nomadic, hunting and gathering subsistence, living in what amounts to approximately one-fifth of Canada's land mass. After that, the Contact with an infusion of explorers, traders, whalers, and missionaries during the sixteenth through the nineteenth centuries, brought Anglo-and Franco-European material and nonmaterial culture into Inuit lives. This was followed in the mid-twentieth century by the which dramatically transformed Inuit lifestyles and culture, dreams and realities. The government moved the Inuit off the land into settlements when many issues converged: a tuberculosis epidemic, a canine encephalitis epidemic, the government's interest in centralizing health and welfare services, government pressure on families to send their children to school, and concerns about Canadian sovereignty in the Ar ctic (Billson 1990). Although widespread starvation and tuberculosis were controlled, resettlement succeeded in creating a structurally and culturally marginalized people (Billson 1988).Camps out on the land averaged forty to fifty people, compared to the settlements that range from 250 to a few thousand people. When the government placed the Inuit into settlements over thirty years ago, the people became almost completely reliant on government policies and support. A rash of social problems emerged from the dramatic changes in lifestyles and livelihood. The ramifications of moving from very small, isolated groups to larger communities include changes in family structure and parent-child relationships; rising levels of education and diversity of occupation; and disconcerting rates of alcoholism, suicide, drug abuse, domestic violence, and unemployment. Many Inuit believe that role reversal and male loss of the provider role have led to higher rates of substance abuse, depression, and violence among males (Skinner 1989). The Inuit provide us with an excellent case study of the ways in which domination of an aboriginal people has created both far-reaching opportunities and a perplexing social, economic, and cultural crisis for an indigenous population. The surge toward autonomy among the Inuit stems from long-standing domination by southern, Euro-Canadian government and business interests. Their situation also suggests the complex ramifications of the government-enforced massive resettlement of Inuit off the land into newly created settlements (Billson 1990). Nunavut can be understood only within the context of this dramatic shift from the land to village life. The concept of Nunavut emerged from the Resettlement Period as a political and spiritual quest for freedom and independence, but in a modern form designed to fit into Canadian realities of Confederation. On the other hand, the Resettlement Period, marked by central government control, paternalism, and economic support, leaves a complicated and stubborn legacy of dependency. …

Book: Review/Commentary: Addictions and Native Americans

Addictions and Native Americans, by Laurence Armand French (Westport, CT: Praeger, 2000), 192 pp., $59.95 (cloth only). Substance abuse is among the most serious public health problems facing Native Americans. Compared with the general population, rates of alcoholism among Native Americans are higher, death rates due to alcohol-related causes are eight times higher, and Native Americans as a group tend to die younger, often from alcohol and alcohol-aggravated conditions (Green, 1999, p. 233). Although the phenomenon of Native Americans' problem drinking has been studied for many decades, there is still an incomplete understanding of the etiology of the problem and a lack of effective prevention and treatment programs. Addictions and Native Americans presents a review of the current state of knowledge on the prevalence, nature, causes, and treatment of addictions (primarily alcohol abuse, with limited reference to inhalant abuse and gambling addiction) among Native Americans in the United States. The problem of substance abuse is first examined from a historical perspective and then from within its current sociocultural context. The author makes a good case for the significance of historical events in the evolution of problem drinking among Native Americans-e.g., the manner and purpose of introduction of alcohol to aboriginal groups as well as the federal policy on prohibition, which promoted a pattern of rapid intoxication. In addition, he cites such varied federal policies as forced removal to reservations and assimilation in the 19th century and termination of federal protection and responsibility in the 1950s, with relocation off reservations to cities, as contributing to the disintegration of native cultures and to their current marginality. With the loss of cultural cohesiveness, native groups could not establish or reestablish aboriginal proscriptive or prescriptive drinking norms that might have controlled drinking behaviors. While current systemic factors such as poverty and inadequate housing, diet, and health care are noted, the author, a psychologist, emphasizes psychocultural marginality as an etiological factor in the high rate of substance abuse among Native Americans. He does not discuss the alienation, despair, and hopelessness that stem from economic marginality, denial of land, hunting, and fishing rights, racism, and increasingly prevalent violence. The focus at the microlevel of analysis in this book results in a tendency to make Native Americans' problem drinking too much a special case that is explainable primarily in psychocultural terms and therefore requires primarily psychocultural solutions. Consequently insights into causation that could be gained from an examination of the association of colonialism with high rates of substance abuse in aboriginal groups worldwide are overlooked, as are studies that indicate that economic and community development have been associated with declines in substance-abuse rates. The author provides a good summary of the native culture-- centric treatment programs that have been developed to replace or augment existing substance-abuse treatment approaches found to be ineffective. …

Health Care Needs of Detained Youth

The purpose of this article is to define the health care services required by detained youth. Study population consisted of 901 youth detained at the Milwaukee County Juvenile Detention Center with the following distributions: 21% females and 79% males, 70% African-American, 19% Caucasian, 9% Hispanic, 2% other. Data collection used each subject's medical record. Findings compare the prevalence of health risk behaviors across various demographics. Other studies of similar adolescent populations provide greater clarity to these findings. Detained adolescents have high rates of substance abuse and sexual activity. Many have no health care provider (HCP) and multiple unmet health care needs. Centers need to provide comprehensive medical services and link youth with a HCP when discharged.

Assessment and classification of patients with psychiatric and substance abuse syndromes. 1989.

Patients with both mental illness and substance abuse pose a major clinical challenge to mental health and substance abuse clinicians. The literature seems to support the hypothesis that mental illness and substance abuse occur together more frequently than chance would predict. Assessment and classification of these patients should be guided by clinicians' needs to make meaningful therapeutic judgments and to communicate effectively with each other in coordinating treatment. Different phases of treatment require different approaches to assessment and classification. In initial classification, the clinician should recognize the problem of dual diagnosis and resist premature assumptions about which diagnosis is primary. Long-term treatment and rehabilitation may require systematic evaluation of alternative clinical by potbeses about why a patient exhibits both disorders. This approach eventually may lead to better ways to assess, classify, and treat these difficult patients.

The lives of incarcerated women: violence, substance abuse, and at risk for HIV.

High rates of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs) are seen in women prisoners. These high rates may be related to the nature of their lives, which may include violence, substance abuse, promiscuity, prostitution, and exchange of sex for drugs--all of which increase their risk for acquiring HIV. The purpose of this study was to examine the HIV-related risk behaviors and protective practices of women prisoners in a rural southern state and factors related to these behaviors. The sample included 57 women incarcerated in a medium-to-maximum security prison. Key findings included high rates of substance abuse, extensive past and current violent experiences including sexual abuse, high percentage of multiple partners, and low use of condoms. Additionally, women in this sample did not perceive themselves to be at risk for HIV infection. Practical suggestions for reducing the HIV risks of incarcerated women are offered.

Schizophrenia, substance use, and brain morphology

The high rate of comorbid substance abuse in schizophrenia and the consistently poor outcome of this comorbidity are well established findings in the research literature. However, the reasons for the high rate of comorbidity are not adequately understood, and the question of why some patients with schizophrenia abuse substances and others do not remains unanswered. There is widespread agreement about the clinical heterogeneity of schizophrenia, and there is some evidence suggesting that the heterogeneous clinical presentation may reflect a parallel underlying heterogeneity of brain morphology. We were interested in examining the possibility that the high rate of substance abuse and the characteristically poor outcome may be associated with the underlying brain morphology. Our hypothesis was that study subjects with schizophrenia and substance abuse would have higher rates of gross brain abnormalities than subjects with only schizophrenia. In an attempt to explore this possibility, we looked at qualitative differences in magnetic resonance imaging scans for a large sample ( n=176) of schizophrenia patients. In the group of patients who abused both alcohol and drugs, we found the rate of gross brain abnormalities to be slightly less than half the rate found among the patients with no history of alcohol or substance abuse (8 vs. 19). Although these results are not statistically significant, they reflect a trend that is compatible with previous findings, suggesting that substance abuse history may be accompanied by less impairment in certain areas, which in turn may be reflected in a better premorbid adjustment. However, our findings are not compatible with previous findings that show substance abuse to be associated with more severe symptoms and a poorer outcome in schizophrenia.

Who brings patients to the psychiatric emergency room?: Psychosocial and psychiatric correlates

In a sample of 311 consecutive psychiatric emergency room patients, 133 (43%) were accompanied by relatives, friends, or others, 113 (36%) came with the police, and 65 (21%) came by themselves. There were more males in the group brought in by police or who came by themselves than in the group accompanied by family or others. Aggression was the presenting problem in about 40% of police referrals. Half the aggressive patients who were brought in by the police were diagnosed with psychotic disorders. Poor social functioning was found in patients who came with police and by themselves, this finding was more pronounced in males. High rates of substance abuse, as suggested by positive toxicology, were found in police referrals and patients who came by themselves. This was mostly due to alcohol in males and cocaine in females. Findings indicate that gender, diagnosis, and psychosocial status contribute independently to who brings patients to the psychiatric emergency room. It is suggested that this information is clinically useful for diagnostic assessment and management. Clinical and research implications are discussed.

Patterns of current and lifetime substance use in schizophrenia.

A structured interview and standardized rating scales were used to assess a sample of 194 outpatients with schizophrenia in a regional Australian mental health service for substance use, abuse, and dependence. Case manager assessments and urine drug screens were also used to determine substance use. Additional measurements included demographic information, history of criminal charges, symptom self-reports, personal hopefulness, and social support. The sample was predominantly male and showed relative instability in accommodations, and almost half had a history of criminal offenses, most frequently drug or alcohol related. The 6-month and lifetime prevalence of substance abuse or dependence was 26.8 and 59.8 percent, respectively, with alcohol, cannabis, and amphetamines being the most commonly abused substances. Current users of alcohol comprised 77.3 percent and current users of other nonprescribed substances (excluding tobacco and caffeine) comprised 29.9 percent of the sample. Rates of tobacco and caffeine consumption were high. There was a moderate degree of concordance between case manager determinations of a substance-use problem and research diagnoses. Subjects with current or lifetime diagnoses of substance abuse/dependence were predominantly young, single males with higher rates of criminal charges; however, there was no evidence of increased rates of suicide attempts, hospital admissions, or daily doses of antipsychotic drugs in these groups compared with subjects with no past or current diagnosis of substance abuse or dependence. Subjects with a current diagnosis of substance use were younger at first treatment and currently more symptomatic than those with no past or current substance use diagnosis. The picture emerging from this study replicates the high rate of substance abuse in persons with schizophrenia reported in North American studies but differs from the latter in finding a slightly different pattern of substances abused (i.e., absence of cocaine), reflecting relative differences in the availability of certain drugs.

Issues in the psychiatric care of Hispanics.

Factors affecting the mental health care of ethnic minority groups in the United States deserve serious consideration. Hispanics, the second largest of these groups, face problems of access to care, high rates of substance abuse and HIV, and shortages of Hispanic psychiatric professionals. Recommendations for improving psychiatric care for Hispanics include changes in the areas of health insurance, research funding, affirmative action, and psychiatric training.

Psychiatric implications of medications used in human immunodeficiency virus disease

Between four and seven percent of patients admitted to psychiatric hospitals are infected with Human Immunodeficiency Virus (HIV). Psychiatric patients are at a higher risk for developing HIV because they are more likely to engage in high-risk sexual behaviors, have higher rates of substance abuse than other populations, and are less knowledgeable about AIDS. HIV positive patients are at increased risk for adverse drug reactions; therefore, psychiatrists need to be aware of potential neurologic and psychiatric adverse effects of medications commonly used for HIV. For example, many of the common adverse effects associated with agents used in the treatment of HIV mimic signs and symptoms of depression. Also, antiretroviral therapy is rapidly changing and several new agents have become available. It is imperative for psychiatrists to be aware of drug interactions between psychotropic agents and antiretrovirals, particularly the protease inhibitors. The potential for drug interactions is significant because more than half of the psychotropic agents available today as well as five of the eleven HIV agents described in this article are metabolized by or affect drug metabolism through the Cytochrome P450 system. Collaboration with the patients' other prescribers or pharmacists and knowledge of all concurrent medications the patients are taking are the key to preventing adverse events because of drug interactions.

Screening for Drug Abuse Among Adolescents in Clinical and Correctional Settings Using the Problem-Oriented Screening Instrument for Teenagers

Recent research has indicated high rates of substance abuse among adolescents with emotional and behavioral disorders. Moreover, adolescents in clinical and correctional settings found to have comorbid disorders involving substance abuse experience higher morbidity and mortality rates when compared to adolescents having one or no condition. The present study examines the ability of the Problem-Oriented Screening Instrument for Teenagers (POSIT) to identify DSM-III-R-defined psychoactive substance use disorders among 342 adolescents aged 12–19 years. Participants were sampled from school, clinical, and correctional settings. Optimal-scale cut scores for drug abuse diagnosis classification were derived by a minimum loss function method that minimized false classifications. When using the optimal cut score of two for the total sample, the standard POSIT substance use/abuse scale obtained a drug abuse diagnosis classification accuracy of 84% with sensitivity and specificity ratios of 95% and 79%, respectively. The internal validity of the standard 17-item substance use/abuse scale was subsequently examined by principle component analysis, item analysis, and coefficient alpha. The internal validity analyses were conducted to determine if a shortened scale could be developed and yet retain acceptable classification accuracy. When using the optimal cut score of two for the total sample, the revised 11-item scale obtained a drug abuse diagnosis classification accuracy of 85% with sensitivity and specificity ratios of 91% and 82%, respectively. The results suggest that the POSIT can serve as a useful first-gate instrument to identify adolescents in need of further drug abuse assessment.

Prevalence of psychiatric disorders among incarcerated women. II. Convicted felons entering prison.

No unbiased estimates of the rates of psychiatric disorder among women prison inmates are available. Nonetheless, available data suggest that some psychiatric disorders are prevalent in this population. The objective of the study was to determine the rates, risk factors, and outcomes of specific psychiatric disorders among women prison inmates. A virtual census of women felons (N = 805) entering prison in North Carolina was assessed using in-person interviews. Assessments were conducted for 8 disorders, using the Composite International Diagnostic Interview as the primary assessment measure. For validation purposes, one quarter of the inmates were reassessed for 2 of these disorders, using structured clinical interviews. Inmates were found to have high rates of substance abuse and dependence and antisocial and border-line personality disorders compared with women in community epidemiologic studies. Rates among inmates were also somewhat elevated for mood disorders but not for anxiety disorders. The rate of reports of lifetime exposure to traumatic events was also high. Rates of disorder tended to be higher among white than among African American women. High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.

Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders.

This study compared sexuality, reproduction, and childrearing characteristics of women with schizophrenia-spectrum disorders with those of women without serious mental illness. A semistructured interview was given to 46 women meeting Research Diagnostic Criteria for schizophrenia or schizoaffective disorder and to 50 control subjects without major mental illness who were matched for age, race, education, employment status, and religion. Compared with the control subjects, the women with schizophrenic disorders had more lifetime sexual partners, were less likely to have a current partner, and were more likely to have been raped and to have engaged in prostitution. Despite being at high risk for HIV infection, as a group they were less likely to have been tested for HIV. They reported wanting sex less often than did control subjects and rated their physical and emotional satisfaction with sex lower. They had fewer planned pregnancies, more unwanted pregnancies, and more abortions and were more often victims of violence during pregnancy. They were more likely to have lost custody of children and to report that they were unable to meet their children's basic needs and less likely to have another caregiver helping them raise their children. Both groups reported high rates of substance abuse during pregnancy. Health care delivery systems could better meet the needs of women with severe mental illness by providing social skills training, family planning, and more consistent screening for pregnancy, HIV, and battering. In addition, barriers to care for pregnant women with severe mental illness and substance abuse should be reduced, and parenting training should be incorporated into psychosocial rehabilitation programs for mentally ill parents.

Characteristics of Substance-Abusing Veterans Attempting Suicide: A National Study

Demographic, diagnostic, and service utilization characteristics of veterans diagnosed with suicide attempt, substance dependence, both, or neither at discharge from Department of Veterans Affairs (DVA) hospitals in fiscal year 1994 (FY94) were compared using the DVA's discharge abstract database. Four groups of veterans were studied: (1) substance-abusing suicidal inpatients (n = 1,459), (2) substance-abusing nonsuicidal inpatients (n = 123,808), (3) nonsubstance-abusing suicidal inpatients (n = 632), and (4) nonsubstance-abusing nonsuicidal inpatients (n = 402,906). Substance-abusing suicidal veterans had higher rates of substance abuse than substance-abusing nonsuicidal veterans. Substance-abusing suicidal veterans had a higher mean number of inpatient treatment episodes and a larger proportion of discharges against medical advice than the other three inpatient groups. Psychiatric and substance use disorders are more prevalent among substance-abusing suicidal veterans than among veterans with only substance use disorders or suicidal conduct.

Long-term correlates of child sexual abuse: Theory and review of the empirical literature

Since Browne and Finkelhor's (1986) seminal review of the impact of child sexual abuse, there has been a dramatic increase in the child sexual abuse literature. Because of this tremendous growth in the literature, a more current review is warranted. The focus of this paper is a review of the long-term correlates of child sexual abuse published since 1987. Sexually abused subjects report higher levels of general psychological distress and higher rates of both major psychological disorders and personality disorders than nonabused subjects. In addition, child sexual abuse survivors report higher rates of substance abuse, binge eating, somatization, and suicidal behaviors than nonabused subjects. Adult survivors of child sexual abuse report poorer social and interpersonal relationship functioning, greater sexual dissatisfaction, dysfunction and maladjustment including high-risk sexual behavior, and a greater tendency toward revictimization through adult sexual assault and physical partner violence. The long-term correlates of child sexual abuse are conceptualized within a theoretical framework based on a theory of emotional avoidance. Although more recent empirical findings have demonstrated improved designs and methodology, these studies continue to be limited in their generalizability. Recommendations for future research are discussed.

Switching From 'Unipolar' to Bipolar II

Given the therapeutic and prognostic importance of the unipolar-bipolar dichotomy, predicting which patients will become bipolar subsequent to index diagnosis of major depressive disorder (MDD) is of paramount clinical significance. We sought to characterize the profile of patients with MDD who would convert to the more subtle bipolar subtype (known as BPII) on the basis of clinical and personality variables obtained during MDD episodes. A total of 559 patients, comprehensively evaluated with the Schedule of Affective Disorders and Schizophrenia and "unipolar" MDD at entry, were administered 17 self-report personality measures. Hypomanic and manic episodes were systematically recorded over a prospective observation period of up to 11 years. We compared 48 converters to BPII (8.6%) with 22 converters to bipolar I (BPI) (3.9%) and the remaining larger group of unipolar patients. Except for greater acuteness, severity, and psychotic symptomatology, BPI converters were essentially similar to MDD nonconverters. By contrast, BPII converters were robustly distinguished from those with MDD who remained unipolar on the basis of self-report measures along the newly derived factors of Mood Lability, Energy-Activity, and Daydreaming. This profile was associated with early age at onset of MDD and pleomorphic psychopathology beyond the usual affective realm, high rates of substance abuse, as well as educational, marital, and occupational disruption and minor antisocial acts prior to discrete hypomanic episodes. Overall, BPII switchers had a more protracted and tempestuous course with shorter well intervals. "Habitual self" descriptions of temperamental instability during MDD episodes provided useful clinical information for predicting which depressed patients will switch to BPII, attaining a sensitivity of 91% for all three factors combined (23 items); Mood Lability alone (nine items) was the most specific predictor (86%), though of lower sensitivity (42%). The BPII subtype is best understood by such lability intruding into, and possibly its accentuation during, depressive episodes, thereby creating an intimate interweaving of trait and state. Clinicians must note that the foregoing temperamental profile appears more fundamental in defining the affective dysregulation of the BPII subtype than hypomanic episodes emphasized in DSM-IV.

Psychological correlates of frequency and type of drug use among jail inmates

The comorbidity of drug abuse and various forms of psychopathology is pervasive and well documented. In particular, the incidence of depression, anxiety, and antisocial personality disorder is high among substance abusers relative to non-drug abusers. Offender populations have a high rate of substance abuse, and some studies suggest that the incidence of psychopathology may be even greater than in order drug using groups. In order to identify specific types of psychopathology as they relate to drug preferences and frequency of use among drug-using offenders, arrestees at the Baltimore City Detention Center were examined. During extensive interviews, drug-abusing arrestees provided information pertaining to their backgrounds, childhood histories, biological relatives, present behaviors, and criminal and drug histories. Additionally, several psychological inventories were administered to evaluate the presence of depression, anxiety, psychopathy, and impulsivity. Results indicate that the frequency with which subjects reported using specific drugs and drug of choice were significantly associated with particular measures of psychopathology. A composite measure of psychopathy was especially related to the frequency of alcohol, marijuana, and cocaine use. Subjects who reported using cocaine on a frequent basis scored high on measures of hostility and reported committing more property crimes, while violent crimes were more likely to be reported by subjects scoring high on the measure of psychopathy. Other noteworthy findings will be discussed along with the limitations of this study.

Mental Health Problems of the Edinburgh ‘Roofless’

The roofless have not been previously surveyed in detail looking specifically at their psychiatric status. All roofless people in a discrete area were interviewed in their 'skippers' using a semi-structured interview. Other roofless people helped in case finding and diagnostic validity was confirmed using a computerised case register. Sixty-five people were interviewed. High rates of substance abuse (n = 48, 75%), and very low rates of psychotic illness (n = 2, 3%) were found. High rates of serious physical morbidity, of imprisonment and of being the victim of a crime were found. The roofless have multiple severe medical, social, and psychiatric problems. These all must be addressed when considering the provision of services.