By Frank Spinelli, M D
Originally published on Advocate.com September 15 2010 3:00 AM ET
Depression affects six million men in the United States. Although it has been noted that men are less likely to be affected by depression than women, studies suggest that men are less inclined to complain about it to their doctors. Several large surveys suggest a higher prevalence of psychiatric disorders among gay men. Conversely, the suicide rates in men are four times higher than in women; however, women attempt it more often.
There is a debate concerning whether gay men on the whole suffer from depression more than their heterosexual counterparts. The fact is that gay teenagers are more likely to suffer from depression due to the stress of “coming out,” while others struggle with discovering their sexuality, knowing that they are “different” from their peers.
Adolescent gay men even have higher rates of suicide. Likewise, many adult gay men struggle with the complex issue of “coming out” and the apprehension over being a societal anomaly. In the HIV community, mental illness is a frequent issue, most often due to the debilitating nature of the disease, but also due to the battle in coming to grips with the diagnosis. Reports suggest that the rates of major depression, bipolar disorder, and obsessive compulsive behavior in HIV- positive patients can be as high as 54 percent. Other studies have shown that untreated depression can even increase the progression to AIDS in this population.
A recent report by the American Journal of Psychiatry found that there were indeed higher rates of depression in gay men than in the general population. As a result, gay men are more likely to engage in high-risk sexual behavior and to abuse alcohol and drugs with more frequency. Inadequate social support, internalized homophobia, shame over not meeting cultural standards, and cultural insensitivity were cited as some of the many reasons that gay men fall prey to depression.
The World Health Organization categorizes depression into typical, mild, moderate, or severe episodes. Patients with depression may suffer from low energy, decreased activity, and depressed mood. Often there is a diminished capacity for enjoyment and interests. Concentration is reduced, and there can be marked lethargy even in performing minimal tasks. Depressed men complain about disturbed sleep patterns in which they either sleep too much or suffer from insomnia. Appetite is usually affected in much the same way, with patients complaining that they eat too much or too little. Usually the depressed male expresses feelings of low self- worth, lack of self- esteem, and diminished self-confidence. Men with prolonged depression describe a sense of utter worthlessness and associated guilt. Moods can vary from one day to the next and are often accompanied by “somatic” complaints, such as body aches and pains. One of the most striking complaints for gay men is a loss of sexual interest and pronounced erectile dysfunction.
1. Major depression, which is characterized by symptoms that interfere with the ability to work, sleep, or eat, and persist for at least two weeks. These episodes may occur only once but usually crop up several times in a lifetime. Major depressive episodes without symptoms of mania have also been referred to as unipolar depression. The diagnosis of major depression excludes cases where the symptoms are a result of normal bereavement as in loss of a loved one, except when it persists for a period of over one year.
2. Dysthymia is characterized by a less severe form of depression. Symptoms are more chronic, lasting for at least two years with brief periods of improvement but for no more then two months. Patients are usually not disabled by their symptoms. In fact they usually carry on their normal daily functions; however, they are unable to perform to the best of their ability and are usually dissatisfied with their performance.
3. Bipolar disorder, also called manic- depressive illness, is characterized by episodes of mania followed by severe depression. Mania is described as an extreme change in mood that is often dramatic and energetic. During the manic phase the patient may appear overactive and talkative. Manic episodes affect a patient’s rational thinking and judgment. Commonly, they may go on expensive shopping sprees and proclaim to have grand schemes. Socially their behavior is inappropriate and can be embarrassing. Usually the manic person dresses wildly with vibrant colors. Untreated, the manic episode can worsen into a psychotic state. The transition from depression into mania can be rapid or gradual, but there is a marked change in mood. In the depressed phase, symptoms are consistent with major depression.
Signs and symptoms to look for that might lead you to believe that you or someone you know is depressed include:
1. Constant fatigue
2. Insomnia or sleeping throughout the day
3. Disinterest in normal activities
4. Increased use of recreational drugs or alcohol
5. Sad or irritable mood
6. Tearfulness and feelings of despair
7. Change in appetite with either weight loss or weight gain
Despite the different categories of depression, anxiety may often co- exist. The National Comorbidity Survey (U.S.) reports that 58 percent of those with major depression also suffer from episodes of anxiety. It is also evident that even mild symptoms of anxiety can have a major impact on the course of a depressed individual.
The National Institutes of Mental Health (NIMH) define generalized anxiety disorder (GAD) as chronic anxiety, exaggerated worry, and prolonged tension, even when there is little or nothing to provoke it. People with GAD are often preoccupied with their health, money, and family issues. Usually they find that even the least troublesome task can be thoroughly anxiety producing.
GAD is excessive worry that persists for at least six months. Most patients are even able to rationalize that their worry is unwarranted; however, they are still unable to find comfort or relax, even after discussing their fears openly. Most patients with GAD have an incredibly difficult time concentrating and suffer from erratic sleep patterns.
One patient, David, had a longstanding history of bipolar disorder and such severe anxiety that he suffered from an inability to swallow. This issue complicated his treatment because he had trouble taking medication. After a battery of tests that included an upper endoscopy, he was diagnosed with a narrowing of the esophagus. Despite multiple attempts at dilating the stricture, David still had a poor capacity to swallow and needed to crush all his medications.
Other common symptoms associated with anxiety include headaches, nausea, heart palpitations, and shortness of breath. In mild cases of GAD, most patients can function socially and maintain a job. In more severe cases, patients instinctively avoid situations that are considered anxiety provoking; in some instances, this can interfere with basic daily activities. Social phobias and post- traumatic stress disorder are other forms of anxiety.
In order to make the diagnosis of GAD, symptoms must persist for longer than six months and have to include at least three of the following:
• insomnia or excessive sleep
• muscle tension
• difficulty focusing
Like depression, GAD is treated with behavioral therapy and medication. For the most part, depression and anxiety are said to be 40 to 70 percent inheritable, according to the NIMH.
In addition to family history, gay men endure issues with low self- esteem and shame. Often the complex development of a gay man’s personality and learning how to cope with environmental stress are also major contributing factors toward mental illness. Traumatic experiences especially during childhood involving bereavement, neglect, or abuse can increase the likelihood of depression. Even certain chronic medical conditions like HIV, hepatitis, and hypothyroidism can contribute to depression. Particularly in some gay men, struggles with anabolic steroids, alcohol, benzodiazepines, and recreational drugs can complicate a patient’s battle with psychiatric problems.
With the current state of health care, primary-care providers are faced with the unwanted task of having to treat many common psychiatric illnesses like depression and anxiety. Many doctors increasingly have to attend to these conditions as the “gatekeeper” to all illnesses. Most clinicians agree that screening for depression and anxiety in the gay community is warranted.
Essentially, there are chemical changes or imbalances that affect how information is transmitted in the brain. These neurotransmitters affect mood. Decreased levels of certain ones, specifi cally serotonin and norepinephrine, can result in depression and anxiety. Medications that target these neurotransmitters are called selective serotonin re-uptake inhibitors, or SSRIs. This class of drugs includes such pop u lar brands as Prozac (fl uoxetine), Zoloft (sertraline), Paxil (paroxetine), and Lexapro (escitalopram oxalate). SSRIs work well to alleviate symptoms of depression and GAD but also help restore the brain’s chemical imbalances. Recent advances in psychopharmacology have produced another class of antidepressants that target both serotonin and norepinephrine, called serotonin norepinephrine re- uptake inhibitors (SNRIs). One example is Cymbalta (duloxetine HCL), which in addition to its antidepressant affects also treats such somatic complaints as bodily pain. Still another commonly used antidepressant medication, Wellbutrin (buproprion), works as a norepinephrine/dopamine re- uptake inhibitor. With all these different classes of drugs, making the appropriate choice can be a difficult decision, especially when you have to consider all the different side effects.
As a whole, the SSRIs are associated with sexual side effects, sleep disturbances, as well as weight gain. This can be alarming for some patients; however, it is my experience that they are well tolerated. Before you begin any drug regimen your doctor should discuss not only the potential side effects but also how the medication works and any drug interactions. Most antidepressants take effect after one or two weeks but require two to four weeks for full effect.
Another class of drugs called benzodiazepines, known for their sedating effect, were widely overused in the 1960s and 1970s to alleviate stress but were found to be highly addictive. Many patients to this day request these medications, which include Valium, Xanax, Ativan, and Klonopin because of their immediate onset of action. Unfortunately, they only provide temporary relief of symptoms and tolerance can soon develop. Benzodiazepines are not recommended for long- term treatment of anxiety or depression. They may be necessary for an acute breakthrough of anxiety, but caution needs to be exercised because of the addiction potential.
For the most part, patients usually require antidepressants to aid them through difficult periods in their lives, like the death of a loved one, the loss of a job, or a breakup. In these cases, antidepressants are prescribed for a specific period of time, usually six months to a year. In many cases, especially in complicated circumstances, therapy is also called for.
Traditional psychotherapy can be an essential outlet for most patients experiencing depression or anxiety. It allows some people the ability to express their underlying fears and concerns, while for others it affords the chance to explore more deeply rooted issues. In addition to traditional one- on-one therapy, there is also group therapy. This is a form of psychotherapy in which one or several therapists treat a small group of patients. Sometimes this is essential because of the cost- effectiveness compared to one- on- one counseling. In a group, the members organize around related issues and try to resolve them as a system. This gives the members the opportunity to explore personal issues within a social context.
Feelings of prolonged depression and anxiety should be brought to your health- care provider’s attention. There are many treatment options available, and no one should have to suffer.
Other psychosocial concerns that affect gay men include addiction, especially to alcohol, tobacco, and drugs. Questions regarding eating disorders, especially bulimia and anorexia, should be addressed as well during the initial assessment. Finally, other complex issues that come up time and again for gay men include concerns with sexual compulsivity, domestic violence, and hate crimes.