Hirrah Syed is a locum GP in Essex, working on both frontline and remote primary care, including a pilot project for homeless and marginalised populations at Sanctus.
R’s PHQ-9 dropped from 19 to 6 the week after receiving the keys to a new flat.* There had been no medication changes.
I work in a primary care pilot project for homeless and marginalised populations. My patients sleep in doorways and hostels, on friends’ sofas, or in tents by the bypass. Others have recently left prison, are on probation, or are seeking asylum. Some were evicted after rent arrears, some fled domestic violence, some fell between the cracks after relationship breakdowns. All share one thing: life is precarious.
When life is precarious, mental health struggles and substance use flourish.
When life is precarious, mental health struggles and substance use flourish. I see anxiety, depression, paranoia, self-harm, alcohol dependence, heroin, crack cocaine — often all in the same person. Our team includes social prescribers and mental health practitioners, and they do remarkable work. Yet in both research and my experience, housing and basic security appear to be pivotal: when these improve, mood symptoms ease, relapses become less frequent, and the draw of alcohol or drugs often lessens.
It’s not that therapy and medication are irrelevant. Far from it — but without stability, their effect is blunted. Antidepressants can help regulate mood, but they can’t insulate against the constant cortisol surge of sleeping rough or fearing eviction. Cognitive–behavioural therapy can reframe unhelpful thoughts, but it can’t stop the cold seeping through a hostel mattress or the dread of another night on the street.
Primary care often tries to treat the symptom without addressing the cause. We invite patients to complete PHQ-9 questionnaires, refer them for talking therapy, titrate antidepressants — all vital tools — yet the single most transformative intervention is often outside our direct remit: secure housing.
There is a quiet shift when someone moves from the chaos of the street or sofa-surfing into their own front door. They start attending appointments regularly. They answer phone calls. Their conversation becomes less about survival and more about the future. Alcohol units fall, not because of detox programmes alone, but because hopelessness eases when you can lock the door and call a place home.
In primary care, we are used to thinking in terms of care pathways: mental health → IAPT → review; substance misuse → recovery service → review. But for the populations I see, the first branch of that pathway is often housing. Social prescribers, housing liaison workers, and voluntary sector organisations are not optional extras — they deliver frontline mental health care.
This work also tests our own resilience. It is hard to keep offering help when the patient misses three appointments in a row, or relapses after months of sobriety. It can be tempting to see this as personal failure — theirs or ours. But instability makes recovery a moving target. Progress is often measured in smaller units: a week without drinking, a follow-up kept, an honest conversation about cravings.
We also have to recognise our role as advocates. Writing letters to housing departments or probation services may not feel like medicine, but it is — because each successful housing application is a mental health intervention, a relapse prevention tool, and a suicide risk reduction strategy rolled into one.
Social prescribers, housing liaison workers, and voluntary sector organisations are not optional extras — they deliver frontline mental health care.
There is a line I find myself repeating: “It’s not the antidepressants, it’s the keys.” That’s not to dismiss the value of treatment, but to acknowledge that in some lives, the most potent prescription we can help facilitate isn’t 20 mg of citalopram — it’s a tenancy agreement.
If primary care truly wants to reduce the mental health and substance misuse burden in homeless and marginalised populations, we need to bring housing into the heart of the care model. Commissioning decisions should integrate health and housing, funding multidisciplinary teams that include housing workers, and measuring success not only in PHQ-9 scores but in the number of people with a secure place to sleep.
Until that happens, we will keep adjusting doses, extending sick notes, and referring to therapy — while the real treatment remains out of reach for too many.
*Author’s note: R is not a specific individual patient, but represents a phenomenon I witness with patients in my work.
Featured Photo by Jakub Żerdzicki on Unsplash
