Background <p>Women with disorders due to psychoactive substance use (PSU) are at an&#xa0;increased risk for liver disease; however, liver fibrosis is rarely assessed in psychiatric settings. This study aimed at&#xa0;assessing the prevalence of liver fibrosis using non-invasive indices among women hospitalized for PSU dependence, evaluate hepatology referral patterns and explore association between fibrosis severity and socio-economic indicators.</p> Methods <p>We conducted a retrospective analysis of liver fibrosis using the Fibrosis-4 Index (FIB-4) and aspartate aminotransferase (AST) to platelet ratio index (APRI) in women hospitalized for PSU dependence in two separate years, 2019 and 2024. Standard cut-offs were applied. Demographic, psychiatric and biochemical data was reviewed and hepatology referral rates were analyzed. Association between fibrosis severity and socio-economic factors was also explored.</p> Results <p>Total 199 women were included (median age 50.1&#xa0;years, interquartile range [IQR] 39.8–59.5); 91.5% had documented alcohol dependence. Psychiatric comorbidities were frequent, including personality, anxiety and stress-related and adjustment disorders. Based on FIB-4, 43 patients (21.6%) were at intermediate risk and 14% (7.0%) at high risk of fibrosis and only 12.3% were referred to hepatology. APRI identified 20 patients with significant fibrosis or probable cirrhosis, with a referral rate of 15%. FIB-4 scores differed significantly across education levels (<i>p</i> = 0.004), showing a bimodal distribution.</p> Conclusions <p>Despite the availability of simple non-invasive tools, many women at risk for liver disease were not referred for specialty care. Raising awareness and integrating fibrosis screening into psychiatric care are keys to identifying liver disease early and addressing social vulnerability in at-risk patients.</p> Graphical abstract <p>An overview of study design, key findings and implications</p> <p></p>