A Brief Discussion on Mood Disorders in the LGBT Population

The LGBT community is a vulnerable population that faces higher rates of mood disorders, anxiety, alcohol, and substance use disorders (1). There is also a higher prevalence of suicide, with the rate of suicide attempts among LGBT youths being as high as four times that of a control heterosexual population in at least one study (2). Additionally, the LGBT population is at higher risk of being victims of aggression and physical and sexual abuse (3). Mood disorders comprise all types of depression and bipolar disorders, and when compared with the heterosexual population, one study found that “the risk for depression and anxiety disorders (over a period of 12 months or a lifetime) were at least 1.5 times higher in lesbian, gay and bisexual people” (4). However, a recent study reported higher odds of any lifetime mood disorder in sexual minority women who experienced discrimination compared with those who did not (3). The factors contributing to mood disorders in LGBT people may include a lack of acceptance by family and self that is reflected in internalized homophobia, shame, negative feelings about one’s own sexuality/gender, and uneasiness with one’s own appearance (5). LGBT youths typically disclose their sexual preference 2 years earlier than control peers and generally during a developmental period defined by strong peer influence and reactions, making them more susceptible to victimization with subsequent consequences, especially regarding mental health (6). The case report below demonstrates the importance of identification of the underlying problem when treating LGBT youths and young adults, in addition to formal assessment and evidence-based treatment of symptoms.

Case

“Mr. J,” a 21-year-old Caucasian man, was admitted to our inpatient psychiatric facility on a 24-hour emergency detention for suicidal behavior. On the day prior to admission, he had an argument with his mother and ran out on the highway in front of a tractor trailer that just missed hitting him; he then attempted to step in front of another truck that slammed on its brakes just in time. He ran into the woods and was eventually located by a police helicopter. He was taken to a nearby hospital for evaluation but refused to give any information. He ran away from the hospital, and the police found him by a river. The patient had an extensive history of psychiatric hospitalization, suicide attempts, self-injurious behavior, and substance use since his late teenage years. During the initial intake interview at our facility, he was hyperverbal but avoided most questions, although he expressed that he suffered from anxiety and panic attacks and that only benzodiazepines had helped him. When questioned about manic symptoms, he was vague and in general admitted to reckless behavior. When asked about the multiple linear scars on all his limbs, he stated that they occurred while he was sleeping and that he had no recollection or knowledge of them until after he woke up. Collateral information was obtained from his outpatient provider, who mentioned that the patient was known to be manipulative and impulsive and often engaged in risky behavior. He denied suicidal or homicidal ideations when first evaluated by the treatment team.

During the initial week of his hospital stay, the patient had several incidents of impulsive and provocative behavior that put him and others at risk, including staff members. He assaulted several staff members, and on each occasion he did not show any remorse or regret. He refused to speak with the therapist and expressed that nobody could understand what he was going through. He also maintained an air of superiority and talked down to other patients on the unit, often boasting of his many girlfriends. On day 8 of hospitalization, Mr. J was found crying in his room and appeared very upset; he described experiencing “unbearable pain” and “guilt,” wishing to die. He agreed to sit down and talk to one of the psychiatry residents to whom he expressed that he was gay but did not want other patients to know. He expressed that he wished he was straight and was ashamed of his sexuality and had been to a conversion therapy center at his mother’s insistence, but it did not work for him. He admitted that he often cuts himself, puts himself in risky situations, and self-medicates because he “does not know what else to do.” He also stated that he often hurts other people so that they think he is a “strong man.” He admitted to feeling hopeless and unsure about his future and often wanted to “end it all.” Per assessment, he met the DSM-5 criteria for major depressive disorder and borderline personality disorder. After additional inpatient treatment that consisted of regular individual therapy, dialectical-behavior therapy for self-harm and provocative behavior, as well as selective serotonin reuptake inhibitors, Mr. J was discharged from the psychiatric unit. At the time of discharge, he reported that he was looking forward to spending time with his friends and looking for a job but was still uncomfortable with his sexual preferences. His insight and judgment, however, had improved, and he expressed understanding of the fact that most of his actions stemmed from shame and negative feelings about his own sexuality.

Discussion

One of the most conspicuous facts while treating the above patient was that the treatment team was not aware of his sexual preference until a week after he was admitted. Initially, he was perceived to be prone to dramatics and provocative and risky behavior; however, after the team was made aware of the underlying issue, the approach and diagnosis were accordingly modified. This case highlights the complex challenges psychiatrists face when treating LGBT patients. In addition to a formal assessment and evidence-based treatment of symptoms, identification of the underlying problem is of utmost importance. The above case exemplifies the prevailing challenges, approach aspects, and underlying framework one can use while treating mood disorders in such patients.

As with the patient in the above case, LGBT youths experience higher rates of depression, especially when dealing with stigmatized identity and the stressors that accompany it. It has been shown that family acceptance and support is one of the most important protective factors when dealing with negative emotions in the LGBT population (7). However, as with our patient, LGBT youths often experience diminished social support, social rejection, and isolation within their social circles (8, 9). Although attitudes toward same-sex relationships have generally become more positive, any breach from socially accepted gender roles is still questioned and frowned upon. For youths who have little to no social support, access to social networks and support groups, along with appropriate psychological interventions, should be made available. As mentioned above, teenagers may often experience bullying when they openly identify as LGBT; however, a recent study reported the benefits of being “out” during adolescence, relating it as a crucial period in which individuals identify who they are, which is essential to their mental health (10). In light of these conflicting studies, it is important to stress that there is no simple answer, and the emotional maturity and social environment of the individual has to be taken into consideration while talking about disclosing an individual’s sexual preference. Promoting a positive self-image is an essential but long-term process, and treating risky and self-harm-inducing behavior should be the priority.

Key Points/Clinical Pearls