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Researchers and advocates have argued that people living with severe mental illnesses are a vulnerable group and should be prioritized for COVID-19 vaccines. People living with severe mental illnesses, including substance use disorders, bear an elevated burden of intersecting risk factors related to the social determinants of health and medical comorbidities leading to greater COVID-19 morbidity and mortality. Tis increased risk is based on several intersecting factors, including the likelihood of living in unstable and crowded living conditions such as shelters, group homes, or institutions; unsafe working conditions; high rate of comorbidities; and marginalization and stigmatization. Nonetheless, many of the initial iterations of vaccine allocation frameworks internationally did not prioritize people living with severe mental illnesses. Moreover, people with severe mental illness who are long-stay inpatients in psychiatric institutions were left off of vaccine priority setting lists that included long-term care facilities and other congregate settings. In this commentary, we question why people living with severe mental illnesses – particularly those who are institutionalized – were not initially considered a priority for vaccine access given the supposed vulnerability. We describe how people are made vulnerable by intersecting aspects of systematic disadvantage such as stigma, poverty, and racism. We suggest that the lack of attention given to intersectional factors in vaccine prioritization compromises health equity for people living with mental health and substance use disorders. We end the commentary by suggesting how vaccine distribution and allocation could be more equitable by including people with lived experience of mental illness in designing and implementing vaccination strategies. Understanding how people with mental illnesses have experienced structural vulnerability and intersecting risk factors throughout the pandemic can help inform the creation of effective and ethical vaccine-related responses to the COVID-19 pandemic.