Depression Is Killing Gay Men

It’s well known to the point of stereotype that gay men experience higher rates of HIV, substance abuse, and suicide. But it’s less known, and hardly talked about, that we also have much higher rates of depression, especially those of us living with HIV, despite the causal relationship of depression and self-medicating and self-harming behavior.

You might call depression the big gray elephant in the room staring us in the face as we do our best to ignore it.

The 2013 fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) defines depression clinically as a depressive mood or loss of interest or pleasure in nearly all activities over a two-week period, along with four of these symptoms: “changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation or suicide plans or attempts.”

Although depression affects both men and women, men kill themselves at rates four times higher than women. Of the 41,149 suicides in the U.S. in 2013, nearly 80 percent were men.

Research suggests that depression in gay men often starts early in adolescence and continues into young adulthood. It’s not surprising to know that homophobia is a major contributor—or that homophobia-induced depression can lead to harmful outcomes.

A 2009 Pediatrics study found that young gay and lesbian people from families that rejected them were 8.4 times more likely to report attempting suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse.

An American study of gay men found that those who perceived increased homophobia and danger were more likely to report depressive symptoms. Feeling unaccepted and rejected by the gay community—as do too many gay and bisexual men of color and those living with HIV—were also found to increase the risk for depression.

A British survey of gay men found that 50 percent of those who experienced depression had contemplated suicide; 24 percent had already attempted to take their own lives. Of the 600 men who responded to the survey, 70 percent cited low self-esteem as the main reason for their depression, followed by relationship problems, isolation, and not feeling attractive. Twenty-seven percent said homophobic bullying was the main reason for their depression. Living with HIV was the most common reason for feeling suicidal or attempting suicide. Black gay and bisexual men were twice as likely to be depressed and five times more likely to have attempted suicide than their white counterparts. In fact 31 percent of the black men met the definition of depression and 10 percent had attempted suicide in the last year—far higher than 3 percent of white men.

Depression is the most common neuropsychiatric complication of HIV, estimated to affect 42 percent of those living with the virus. But HIV itself isn’t necessarily the catalyst per se, although its presence in the central nervous system and HIV medications, too, can affect mood. As a Canadian study showed, suicide among HIV-positive gay and bisexual men has been associated with a recent experience of HIV stigma such as rejection, harassment, and physical violence.

Of course the ideal solution to decrease gay men’s depression—and its consequences for our health—is to foster acceptance and support from families and in the broader society. While that prospect may seem remote in the current political climate, there are other concrete ways to address depression and its pernicious effects.

One obvious solution is to support our relationships. Researchers have found that cohabiting men were 50 percent less likely to suffer from depression compared to men living alone.

Health care providers working with gay men should first establish rapport and trust by displaying empathy and not making assumptions about an individual’s behavior and sexual choices based on generalizations about “all” gay men. They should ascertain the degree to which the man is “out” to his family and friends, and the extent of his social support network. They should assess substance overuse and its potential to be used to self-medicate depression and/or suicidality. Frequent follow-up consultations also are helpful to monitor and manage suicidality.

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Two simple questions can be very effective in recognizing depression: (1) During the past month, have you often been bothered by feeling down, depressed, or hopeless? and (2) During the past month, have you often been bothered by little interest or pleasure in doing things?

The good news for gay men—anyone, really—experiencing depression is that antidepressant medication can help cope with depression, whether they have HIV or not. Lifestyle changes, including regular exercise, sunlight, counseling, stress management, and improved sleeping habits also have been found to be effective in treating depression.

Life is too short and precious to spend it in depression or end it in suicide. Speaking openly and frankly about the disproportionate impact of depression on gay men, and prioritizing our mental health and well-being, we can chase that big gray elephant out of the room—and keep it from harming any more of us.