To the Editor We commend Barry and colleagues on their excellent systematic review,¹ which provides much-needed estimates of the prevalence of psychiatric comorbidities among people experiencing homelessness (PEH). This analysis is particularly timely given the escalating crisis of homelessness in the US.

We urge caution on the interpretation of the estimate that approximately one-fourth of PEH may have antisocial personality disorder (ASPD). Against the backdrop of structural racism, homelessness and mass incarceration are complex health equity problems that disproportionately impact Black and Hispanic people. The process of diagnosing ASPD and conduct disorder (CD)—via the assessment of whether patients violated societal norms—is potentially fraught with context-dependent value judgments that can contribute to misdiagnosis. For instance, impulsivity and failure to plan ahead—a criterion for ASPD—can be attributable to confounding diagnoses that were not included in the present analysis; this includes undertreated attention-deficit/hyperactivity disorder, which is prevalent in young adults with CD in our analyses of national data (2017-2023),² as well as cognitive disorders³ (ie, dementia, traumatic brain injury, cognitive impairment secondary to chronic untreated substance use) that are prevalent among PEH. Among PEH, competing needs (eg, for food or shelter) may impact the receipt of health services, which impacts symptom burden and overall functioning. Notably, repeatedly performing acts that are grounds for arrest, another criterion, runs the risk of pathologizing minor drug offenses, which is pertinent given the high prevalence of substance use disorders in the analyses by Barry et al¹ and the unjust criminalization of drug use in the US,¹ and may reflect the criminalization of homelessness (for acts of living, eg, anticamping ordinances, public urination charges).