Medication Use Among Sexual-Minority Populations for Self-Reported Feelings of Depression and Anxiety
Abstract
Objective:
The purpose of this study was to compare, by sexual-minority status, the prevalence of feelings of depression and anxiety as well as use of medication for these feelings.
Methods:
Data on adults ages 18 years and older (N=79,542) came from the 2013–2017 National Health Interview Survey. The authors used descriptive statistics and multivariable logistic regression to compare, by sexual-minority status, the prevalence of depressive feelings, anxious feelings, and use of medication for these feelings.
Results:
Adults who identified as lesbian, gay, bisexual, or other sexual minority exhibited greater odds of having frequent (defined as weekly or daily) feelings of depression and anxiety compared with their heterosexual peers. On average, adults who identified as a sexual minority were more likely than their heterosexual peers to take medication for depressive and anxious feelings. Meanwhile, among adults living with frequent anxiety, gay and lesbian adults were more likely than heterosexual adults to take medication for their anxious feelings.
Conclusions:
Adults who identified as a sexual minority were more likely than heterosexual adults to self-report frequent feelings of depression and anxiety and to use medication for their symptoms. Public health initiatives should focus on mental health promotion and the prevention of depression and anxiety among sexual-minority populations, which may include establishing more welcoming and affirming environments. Mental health providers can also play critical roles in treating sexual-minority populations for depression and anxiety and in researching interventions that narrow mental health disparities related to sexual orientation.
HIGHLIGHTS
Gay, lesbian, and bisexual adults were more likely to report feelings of depression and anxiety compared with heterosexual adults in the United States.
Gay and lesbian adults were more likely than heterosexual adults to take medication for depressive and anxious feelings.
On average, approximately 45% of adults with frequent feelings of depression and 30% of adults with frequent feelings of anxiety take medication for their feelings.
A large body of evidence has documented mental health disparities among persons who self-identify as a sexual minority, including lesbians, gay men, bisexual individuals, and other non-heterosexual populations (1, 2). Numerous studies have shown that persons who self-identify as a sexual minority are at increased risk of suicidal ideation, serious mental illness, and mood disorders, including depression and anxiety (3–13). Sexual orientation–based disparities in mental health are partly a response to “minority stress,” which is defined as stress that stems from discrimination, stigma, and negative attitudes toward minority groups (13–18). Stigma-related stressors can be internalized and translated into emotional dysregulation and worsening of psychosocial outcomes (17). Other research has demonstrated that future expectations of rejection, internalized homophobia, and gender nonconformity may also mediate elevated rates of depression and anxiety within sexual-minority populations (19).
According to the 2015 National Survey on Drug Use and Health (NSDUH)—which recently added sexual orientation to its questionnaire—adults who self-identify as a sexual minority were more likely than heterosexual adults to have had any mental illness (37.4% versus 17.1%) and serious mental illness (13.1% versus 3.6%) in the past year (20). They were also more likely than heterosexual adults to have had a major depressive episode in the previous year (18.2% versus 6.2%) (20). Missing from the literature on mental health among persons who identify as a sexual minority is a robust body of population-based evidence about utilization of mental health services by sexual orientation, including information about type of care received and care received for specific mental health conditions.
Previous research on mental health services utilization among sexual-minority populations has sometimes relied on nonrepresentative community samples (21, 22). Some population-based studies have been confined to specific states, geographic regions, and unique populations (23–26). Of the available nationally representative studies, findings indicate that sexual-minority populations may actually be more likely to seek and receive mental health care compared with their heterosexual counterparts (27–30). According to the NSDUH, for instance, about 26.4% of adults who identify as a sexual minority received some form of mental health services, compared with 13.7% of heterosexual adults; services included counseling, prescription medication, and services in an inpatient or outpatient setting (20). Much more research is critically needed to document and confirm these patterns of mental health services utilization in order to monitor mental health care needs and treatment among persons in the United States who identify as a sexual minority. The purpose of this study was to use recently available, nationally representative data to compare the prevalence and patterns of medication use for feelings of depression and anxiety by sexual-minority status.
Methods
This study used data on adults ages 18 years and older from the 2013–2017 National Health Interview Survey (NHIS), a nationally representative health survey of the civilian, noninstitutionalized population. Conducted annually by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention, the NHIS provides timely and comprehensive data used to monitor the nation’s health (31). The family core questionnaire records basic demographic, health, and disability information for each household member. A single adult in each household is selected at random for a detailed interview on more specific health information that includes sexual-orientation identity, health conditions, and health services utilization. Participants are asked which of the following categories best represents how they think of themselves: lesbian or gay; straight, that is, not lesbian or gay; bisexual; something else; I don’t know the answer; or refuse.
Our study sample was drawn from the sample adult component of the 2013–2017 NHIS, which was accessed through the University of Minnesota’s Integrated Public Use Microdata Series Health Series, a harmonized and publicly available version of the NHIS (32). Beginning in 2013, approximately one-half of all adults in the sample were randomly selected to participate in the Adult Functioning and Disability (AFD) supplement, which is a multinational project designed to develop population-based measures of wellness, quality of life, and functioning (33). Adults receiving the AFD supplement were asked detailed questions about their activity limitations, cognitive disabilities, and mental health. More specifically, participants were asked, “How often [do you] feel worried, nervous, or anxious?” and “How often do you feel depressed?” Respondents could answer with the following options: daily, weekly, monthly, a few times a year, and never. First, we classified participants as having frequent feelings of depression if they said they felt depressed daily or weekly. Next, we classified participants as having frequent feelings of anxiety if they indicated feeling anxious daily or weekly. All respondents were also asked the following follow-up questions, “Do you take medication for depression?” and “Do you take medication for these [worried, nervous, or anxious] feelings?” Medication use was dichotomized as either yes or no.
We classified sexual orientation among AFD respondents as heterosexual (N=77,163), gay or lesbian (N=1,385), bisexual (N=737), or other (N=257). We excluded AFD respondents who did not know the answer (N=491), refused to answer the sexual-orientation question (N=492), or had incomplete data on activities of daily living (ADLs) (N=8).
We used descriptive statistics and chi-square tests to characterize the study sample by sexual orientation. We examined differences in the following sociodemographic variables: age category in years (18–24, 25–34, 35–44, 45–54, 55–64, ≥65), race-ethnicity (white, black, Hispanic, other or multiple races, missing data), citizenship (U.S. citizen or not, missing data), educational attainment (less than high school, high school graduate, some college, bachelor’s degree or higher, missing data), relationship status (married or living with a partner, formerly married, never married, missing data), children ages ≤18 in the household, family income relative to the federal poverty guidelines (FPG) (≤100%, 100%−199%, 200%−399%, ≥400%, missing data), current cigarette smoker (smoking more than 100 cigarettes in an individual’s lifetime and currently smoking every day or some days), self-rated health status (excellent/very good/good, poor/fair, missing data), needing help with ADLs or instrumental ADLs (IADLs), health insurance status (private, public, uninsured, missing data), office visit with a provider in the prior 12 months, and unmet medical care needs due to cost in the prior 12 months.
We estimated multivariable logistic regression models to compare the odds of self-reporting feelings of frequent depression or frequent anxiety by sexual orientation. Our fully adjusted models controlled for age, sex, race-ethnicity, relationship status, the presence of a child in the household, educational attainment, family income relative to FPG, current smoking status, self-rated health status, needing help with ADLs or IADLs, recent office visit with a provider, unmet medical care due to cost, U.S. Census region, and survey year. Finally, using fully adjusted logistic regression models, we compared the odds of taking medication for depression and anxiety—first for the entire sample (controlling for self-reported feelings of depression or anxiety) and then for the subset of individuals who indicated having frequent feelings of depression or frequent feelings of anxiety.
Results from the logistic regression models are presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). We conducted all analyses in Stata, version 14, using survey weights for the AFD supplement and the svy command to adjust standard errors for the complex survey design of the NHIS. Because data were collected from publicly available and deidentified sources, the Vanderbilt University Institutional Review Board deemed this analysis exempt from review.
Results
Table 1 presents sociodemographic and health characteristics of adults in the United States by sexual orientation. Adults who identified as gay, lesbian, bisexual, or other sexual orientation were more likely to be younger compared with heterosexual adults. The racial-ethnic composition of the sample was similar across sexual-orientation groups. Gay and lesbian adults were more likely than the other sexual-orientation groups to have a college degree and a family income equal to or above 400% of FPG. Adults who identified as gay, lesbian, bisexual, or other sexual orientation were less likely than heterosexual adults to be married or living with a partner and were more likely to be a current smoker and have unmet medical care needs due to cost.
Heterosexual (N=77,163) | Gay and lesbian (N=1,385) | Bisexual (N=737) | Other (N=257) | ||||||
---|---|---|---|---|---|---|---|---|---|
Characteristic | N | % | N | % | N | % | N | % | p |
Weighted distribution | 77,163 | 97.1 | 1,385 | 1.7 | 737 | .9 | 257 | .3 | |
Age (years) | <.001 | ||||||||
18–24 | 6,704 | 11.7 | 163 | 15.9 | 202 | 35.9 | 45 | 29.0 | |
25–34 | 12,900 | 17.9 | 268 | 20.1 | 227 | 28.7 | 50 | 21.6 | |
35–44 | 12,057 | 16.6 | 253 | 18.4 | 104 | 12.9 | 26 | 10.9 | |
45–54 | 12,463 | 17.6 | 300 | 21.8 | 86 | 9.8 | 32 | 9.1 | |
55–64 | 13,359 | 16.6 | 231 | 14.6 | 63 | 7.4 | 54 | 14.5 | |
≥65 | 19,680 | 19.7 | 170 | 9.1 | 55 | 5.3 | 50 | 14.9 | |
Race-ethnicity | .16 | ||||||||
White | 50,317 | 65.7 | 942 | 67.6 | 516 | 68.8 | 167 | 61.0 | |
Black | 9,993 | 11.9 | 183 | 13.9 | 78 | 9.7 | 37 | 11.8 | |
Hispanic | 11,513 | 15.6 | 181 | 13.1 | 94 | 14.6 | 28 | 16.0 | |
Other/multiple races | 5,107 | 6.6 | 75 | 5.2 | 47 | 6.8 | 24 | 11.4 | |
Missing data | 233 | .2 | 4 | .3 | 2 | 0 | 1 | .2 | |
Sex | |||||||||
Male | 42,465 | 48.4 | 633 | 53.0 | 516 | 31.6 | 131 | 52.8 | |
Female | 34,698 | 51.6 | 752 | 47.0 | 221 | 68.4 | 126 | 47.2 | |
U.S. citizenship | <.05 | ||||||||
Yes | 71,055 | 91.6 | 1,329 | 96.5 | 705 | 94.3 | 241 | 93.4 | |
No | 6,029 | 8.3 | 56 | 3.5 | 32 | 5.8 | 16 | 6.6 | |
Missing data | 79 | .1 | 0 | — | 0 | — | 0 | — | |
Educational attainment | <.001 | ||||||||
Less than high school | 10,462 | 12.6 | 92 | 6.8 | 219 | 13.0 | 39 | 17.4 | |
High school graduate | 19,495 | 25.1 | 247 | 18.0 | 77 | 22.7 | 58 | 23.7 | |
Some college | 15,072 | 19.4 | 301 | 22.6 | 152 | 27.6 | 55 | 21.9 | |
Bachelor's degree or higher | 22,968 | 31.2 | 605 | 42.3 | 216 | 29.3 | 71 | 27.1 | |
Missing data | 9,166 | 11.8 | 140 | 10.3 | 73 | 7.5 | 34 | 10.0 | |
Relationship status | <.001 | ||||||||
Married or living with a partner | 39,059 | 61.0 | 531 | 49.7 | 214 | 32.8 | 59 | 27.2 | |
Formerly married | 20,892 | 17.5 | 154 | 7.7 | 153 | 15.0 | 58 | 17.2 | |
Never married | 17,090 | 21.4 | 696 | 42.4 | 369 | 52.2 | 139 | 55.4 | |
Missing data | 122 | .1 | 4 | .2 | 1 | .1 | 1 | .2 | |
Child in household, age <18 | <.001 | ||||||||
No | 54,534 | 65.0 | 1,214 | 82.7 | 527 | 68.7 | 217 | 77.0 | |
Yes | 22,629 | 35.0 | 171 | 17.3 | 210 | 31.3 | 40 | 23.0 | |
Family income relative to federal poverty guidelines (FPG) | <.001 | ||||||||
≤100% of FPG | 11,524 | 11.7 | 194 | 11.5 | 215 | 21.9 | 63 | 18.2 | |
100%–199% of FPG | 14,529 | 17.0 | 215 | 14.0 | 151 | 19.0 | 57 | 25.0 | |
200%–399% of FPG | 20,506 | 26.8 | 340 | 25.9 | 168 | 25.4 | 67 | 29.2 | |
≥400% of FPG | 25,042 | 36.9 | 587 | 44.6 | 166 | 27.8 | 51 | 19.7 | |
Missing data | 5,562 | 7.6 | 49 | 4.1 | 37 | 6.1 | 19 | 7.9 | |
Current cigarette smoker | <.001 | ||||||||
No | 64,395 | 84.3 | 1,054 | 78.3 | 557 | 78.4 | 196 | 75.7 | |
Yes | 12,653 | 15.5 | 328 | 21.5 | 180 | 21.6 | 61 | 24.3 | |
Missing data | 115 | .2 | 3 | .2 | 0 | — | 0 | — | |
Health status | .81 | ||||||||
Excellent, very good, good | 65,933 | 87.3 | 1,199 | 88.6 | 617 | 86.4 | 204 | 85.4 | |
Poor, fair | 11,202 | 12.7 | 186 | 11.4 | 120 | 13.6 | 52 | 14.5 | |
Missing data | 28 | 0 | 0 | — | 0 | — | 1 | .04 | |
Needs help with ADLs/IADLsb | .62 | ||||||||
No | 72,414 | 95.2 | 1,312 | 95.5 | 690 | 95.5 | 233 | 93.3 | |
Yes | 4,749 | 4.8 | 73 | 4.5 | 47 | 4.5 | 24 | 6.7 | |
Health insurance status | <.001 | ||||||||
Private | 37,258 | 54.1 | 836 | 64.3 | 394 | 57.8 | 107 | 45.8 | |
Public | 30,531 | 33.5 | 386 | 23.8 | 232 | 26.9 | 116 | 38.0 | |
Uninsured | 9,107 | 11.9 | 155 | 11.2 | 110 | 15.2 | 30 | 12.4 | |
Missing data | 267 | .5 | 8 | 6.1 | 1 | .1 | 4 | 3.9 | |
Office visit in the prior 12 months | .16 | ||||||||
Yes | 63,882 | 82.0 | 1,159 | 83.5 | 608 | 81.0 | 202 | 74.6 | |
No | 13,034 | 17.7 | 220 | 16.0 | 127 | 18.9 | 55 | 25.4 | |
Missing data | 247 | .3 | 6 | .5 | 2 | .1 | 0 | — | |
Unmet medical care due to cost in prior 12 months | <.001 | ||||||||
Yes | 5,702 | 6.5 | 141 | 9.3 | 103 | 11.8 | 36 | 9.8 | |
No | 71,436 | 93.5 | 1,243 | 90.3 | 634 | 88.2 | 220 | 89.5 | |
Missing data | 25 | 0 | 1 | .4 | 0 | — | 1 | .7 |
TABLE 1. Sociodemographic and health characteristics of U.S. adults, by sexual orientationa
Table 2 presents the prevalence and AORs (from multivariable logistic regression models) for frequent feelings of depression and frequent feelings of anxiety by selected characteristics. Approximately 8.4% of all adults reported frequent feelings of depression, and 19.5% of all adults reported frequent feelings of anxiety (data not shown). After the analyses controlled for sociodemographic characteristics, adults who identified as gay and lesbian (OR=1.88, 95% CI=1.51–2.34), bisexual (OR=3.00, 95% CI=2.31–3.91), or other sexual orientation (OR=2.28, 95% CI=1.35–3.85) were more likely than heterosexual adults to report frequent feelings of depression. Other demographic characteristics (independent of sexual orientation) were associated with increased odds of depression. For instance, frequent feelings of depression were more likely to be reported by whites versus Hispanics, by females, by adults who were formerly married or never married versus adults who were currently married, by adults with incomes under 400% of FPG, and by current cigarette smokers, adults with public versus private health insurance, adults needing help with ADLs or IADLs, and adults with unmet medical care needs due to cost.
Depression (N=77,575) | Anxiety (N=77,637) | |||||||
---|---|---|---|---|---|---|---|---|
Characteristic | N | % | AORb | 95% CI | N | % | AORb | 95% CI |
Sexual orientation (reference: heterosexual) | ||||||||
Heterosexual | 75,244 | 8.1 | — | 75,303 | 19.0 | — | ||
Gay and lesbian | 1,363 | 14.4 | 1.88** | 1.51–2.34 | 1,362 | 30.9 | 1.69** | 1.43–1.98 |
Bisexual | 721 | 24.4 | 3.00** | 2.31–3.91 | 725 | 47.1 | 2.75** | 2.18–3.47 |
Other | 247 | 19.0 | 2.28* | 1.35–3.85 | 247 | 43.7 | 2.83** | 1.96–4.09 |
Age (years) (reference: 45–54) | ||||||||
18–24 | 7,004 | 8.0 | .93 | .80–1.08 | 7,014 | 22.8 | 1.26** | 1.13–1.41 |
25–34 | 13,176 | 7.6 | .98 | .86–1.12 | 13,181 | 21.9 | 1.27** | 1.17–1.39 |
35–44 | 12,153 | 7.9 | 1.04 | .91–1.18 | 12,156 | 20.5 | 1.17** | 1.07–1.27 |
45–54 | 12,547 | 9.6 | — | 12,559 | 20.6 | — | ||
55–64 | 13,352 | 10.1 | .87* | .77–.98 | 13,373 | 19.1 | .78** | .72–.85 |
≥65 | 19,343 | 7.4 | .40** | .34–.46 | 19,354 | 13.7 | .42** | .37–.46 |
Race-ethnicity (reference: Hispanic) | ||||||||
White | 50,673 | 8.9 | 1.27** | 1.12–1.44 | 50,717 | 21.7 | 1.51** | 1.38–1.66 |
Black | 9,986 | 7.8 | .68** | .58–.80 | 9,999 | 14.6 | .67** | .60–.76 |
Hispanic | 11,564 | 7.9 | — | 11,567 | 16.6 | — | ||
Other/multiple races | 5,114 | 5.6 | .84 | .70–1.02 | 5,116 | 14.0 | .88 | .76–1.01 |
Missing data | 238 | 10.3 | 1.36 | .80–2.30 | 238 | 12.8 | .64 | .35–1.16 |
Sex (reference: male) | ||||||||
Male | 34,990 | 7.0 | — | 35,024 | 16.1 | — | ||
Female | 42,585 | 9.7 | 1.29** | 1.19–1.39 | 42,613 | 22.7 | 1.47** | 1.40–1.55 |
U.S. citizenship (reference: yes) | ||||||||
Yes | 5,998 | 8.7 | — | 71,561 | 20.1 | — | ||
No | 71,502 | 5.8 | .76* | .64–.89 | 6,001 | 12.7 | .69** | .61–.79 |
Missing data | 75 | 4.1 | .64 | .18–2.28 | 75 | 14.1 | .87 | .42–1.83 |
Education (reference: high school graduate) | ||||||||
Less than high school | 10,365 | 13.2 | 1.07 | .96–1.20 | 10,382 | 21.3 | 1.06 | .97–1.16 |
High school graduate | 19,443 | 9.7 | — | 19,453 | 19.0 | — | ||
Some college | 15,275 | 9.3 | 1.01 | .90–1.13 | 15,298 | 21.7 | 1.13* | 1.05–1.22 |
Bachelor's degree or higher | 23,319 | 5.1 | .86* | .77–.97 | 23,330 | 18.0 | 1.21** | 1.12–1.31 |
Missing data | 9,173 | 8.1 | .92 | .81–1.04 | 9,174 | 19.2 | 1.03 | .94–1.13 |
Relationship status (reference: married or living with a partner) | ||||||||
Married or living with a partner | 38,949 | 6.5 | — | 38,978 | 17.5 | — | ||
Formerly married | 20,615 | 13.4 | 1.39** | 1.27–1.52 | 20,641 | 22.0 | 1.12* | 1.05–1.21 |
Never married | 17,889 | 9.7 | 1.24** | 1.10–1.39 | 17,895 | 23.2 | 1.14** | 1.06–1.23 |
Missing data | 122 | 10.9 | 1.43 | .71–2.87 | 123 | 22.4 | 1.37 | .58–3.23 |
Child <18 in the household (reference: no) | ||||||||
No | 55,030 | 8.9 | — | 55,080 | 19.4 | — | ||
Yes | 22,545 | 7.4 | .86* | .78–.95 | 22,557 | 19.7 | .93 | .87–1.00 |
Family income relative to federal poverty guidelines (FPG) (reference: ≥400% of FPG) | ||||||||
≤100% of FPG | 11,694 | 17.3 | 1.81** | 1.59–2.07 | 11,714 | 28.9 | 1.51** | 1.37–1.66 |
100%–199% of FPG | 14,596 | 12.4 | 1.54** | 1.35–1.76 | 14,609 | 22.9 | 1.29** | 1.18–1.41 |
200%–399% of FPG | 20,599 | 7.5 | 1.24** | 1.12–1.38 | 20,620 | 19.1 | 1.15** | 1.07–1.23 |
≥400% of FPG | 25,294 | 4.6 | — | 25,306 | 16.1 | — | ||
Missing data | 5,392 | 6.9 | 1.12 | .94–1.34 | 5,388 | 15.2 | .92 | .82–1.03 |
Current cigarette smoker (reference: no) | ||||||||
No | 64,577 | 6.9 | — | 64,625 | 17.7 | — | ||
Yes | 12,898 | 16.3 | 1.68** | 1.54–1.83 | 12,914 | 29.1 | 1.49** | 1.39–1.60 |
Missing data | 100 | 11.6 | 1.42 | .60–3.35 | 98 | 18.9 | 1.05 | .52–2.13 |
Health status (reference: excellent, very good, good) | ||||||||
Excellent, very good, good | 66,382 | 5.8 | — | 66,423 | 16.9 | — | ||
Poor, fair | 11,168 | 26.6 | 3.30** | 1.14–1.48 | 11,188 | 37.9 | 2.57** | 2.39–2.76 |
Missing data | 25 | 11.0 | 1.87 | .47–7.49 | 26 | 26.4 | 2.01 | .75–5.39 |
Needs help with ADLs/IADLs (reference: no) | ||||||||
No | 72,916 | 7.3 | — | 72,965 | 18.4 | — | ||
Yes | 4,659 | 30.3 | 2.06** | 1.82–2.32 | 4,672 | 41.5 | 1.97** | 1.78–2.19 |
Health insurance status (reference: private) | ||||||||
Private | 37,733 | 5.3 | — | 37,758 | 18.2 | — | ||
Public | 30,362 | 12.6 | 1.80** | 1.61–2.01 | 30,387 | 78.9 | 1.22** | 1.13–1.31 |
Uninsured | 9,217 | 10.9 | 1.30** | 1.14–1.48 | 9,229 | 78.7 | 1.01 | .92–1.11 |
Missing data | 263 | 6.9 | 1.12 | .62–2.03 | 263 | 21.0 | 1.23 | .75–2.03 |
Office visit in the prior 12 months (reference: yes) | ||||||||
Yes | 64,219 | 9.0 | — | 64,269 | 20.6 | — | ||
No | 13,147 | 5.7 | .62** | .55–.70 | 13,162 | 14.4 | .64** | .59–.70 |
Missing data | 209 | 19.9 | 1.76 | 1.06–2.90 | 206 | 22.8 | .96 | .59–1.55 |
Unmet medical care in prior 12 months due to cost (reference: no) | ||||||||
Yes | 5,828 | 24.5 | 2.30** | 2.05–2.58 | 71,775 | 40.8 | 2.23** | 2.04–2.45 |
No | 71,724 | 7.3 | — | 5,839 | 18.0 | — | ||
Missing data | 23 | 19.3 | 1.79 | .51–6.34 | 23 | 36.3 | 1.58 | .37–6.67 |
TABLE 2. Association between demographic and health characteristics and having frequent feelings of depression and anxiety among participants in the NHISa
Table 2 also presents logistic regression results for frequent feelings of anxiety. After the analyses controlled for sociodemographic variables, adults who identified as gay and lesbian (AOR=1.69, 95% CI=1.43–1.98), bisexual (AOR=2.75, 95% CI=2.18–3.47), or other sexual orientation (AOR=2.83, 95% CI=1.96–4.09) were more likely than heterosexual adults to report frequent feelings of anxiety. Other characteristics (independent of sexual orientation) that were associated with having frequent feelings of anxiety included being younger than 45, white versus Hispanic, female, having some college education or a college degree versus a high school education, being formerly married or never married versus currently married, low income (<400% of FPG), poor/fair versus excellent/very good/good health, needing help with ADLs or IADLs, and having unmet medical care needs due to cost.
Table 3 presents the prevalence and AORs of taking medication for depression and anxiety for all adults ages 18 and older. Overall, about 8.1% of all adults took medication for depressive feelings, and 8.7% of adults took medication for anxious feelings (data not shown). After the analyses adjusted for sociodemographic characteristics, gay and lesbian adults (AOR=2.07, 95% CI=1.64–2.62) and bisexual adults (AOR=1.56, 95% CI=1.11–2.18) exhibited greater odds of taking medication for feelings of depression compared with heterosexual adults. Having self-reported feelings of depression (AOR=11.21, 95% CI=10.26–12.25) was the strongest predictor of taking medication for depressive feelings. The odds of taking medication for depressive feelings were higher among white versus Hispanic adults, females, U.S. citizens, adults who were formerly married (e.g., separated, divorced, or widowed) versus currently married, adults with incomes between 200% and 399% of FPG versus <400% of FPG, current smokers, adults with poor/fair health versus excellent/very good/good health, and adults with public health insurance.
Taking medication for depressive feelings (N=77,530) | Taking medication for anxious feelings (N=77,597) | |||||||
---|---|---|---|---|---|---|---|---|
Characteristic | N | % | AORb | 95% CI | N | % | AORb | 95% CI |
Sexual orientation (reference: heterosexual) | ||||||||
Heterosexual | 75,200 | 7.9 | — | 75,266 | 8.5 | — | ||
Gay and lesbian | 1,363 | 15.9 | 2.07** | 1.64–2.62 | 1,360 | 16.6 | 1.85** | 1.46–2.34 |
Bisexual | 721 | 16.9 | 1.56* | 1.11–2.18 | 725 | 15.8 | 1.20 | .89–1.61 |
Other | 246 | 14.6 | 1.70 | .78–3.73 | 246 | 17.8 | 1.73 | .93–3.33 |
Age (years) (reference: 45–54) | ||||||||
18–24 | 7,003 | 3.9 | .38** | .31–.47 | 7,013 | 5.1 | .42** | .35–.52 |
25–34 | 13,172 | 5.9 | .68** | .59–.80 | 13,178 | 7.0 | .68** | .59–.78 |
35–44 | 12,144 | 7.4 | .89 | .78–1.01 | 12,154 | 7.8 | .96 | .85–1.08 |
45–54 | 12,542 | 10.3 | 1.00 | 12,555 | 10.8 | — | ||
55–64 | 13,348 | 11.6 | .94 | .84–1.06 | 13,363 | 11.2 | .90 | .80–1.01 |
≥65 | 19,321 | 8.6 | .44** | .38–.50 | 19,334 | 8.6 | .48** | .42–.55 |
Race-ethnicity (reference: Hispanic) | ||||||||
White | 50,640 | 10.0 | 1.73** | 1.51–1.97 | 50,688 | 10.6 | 1.59** | 1.40–1.80 |
Black | 9,979 | 5.4 | .70** | .59–.83 | 9,992 | 5.7 | .74** | .63–.87 |
Hispanic | 11,560 | 4.9 | — | 11,566 | 5.3 | — | ||
Other/multiple races | 5,113 | 2.8 | .55** | .42–.71 | 5,113 | 3.6 | .68* | .54–.86 |
Missing data | 238 | 4.6 | .63 | .28–1.41 | 238 | 5.1 | .91 | .38–2.18 |
Sex (reference: male) | ||||||||
Male | 34,973 | 5.6 | — | 35,008 | 5.9 | — | ||
Female | 42,557 | 10.6 | 1.84** | 1.69–1.99 | 42,589 | 11.4 | 1.70** | 1.58–1.84 |
U.S. citizenship (reference: yes) | ||||||||
Yes | 71,457 | 8.7 | — | 71,523 | 9.3 | — | ||
No | 5,998 | 2.4 | .53** | .42–.67 | 5,999 | 2.8 | .64** | .51–.79 |
Missing data | 75 | 1.7 | .49 | .05–4.58 | 75 | 2.6 | .62 | .14–2.76 |
Education (reference: high school graduate) | ||||||||
Less than high school | 10,360 | 8.8 | .92 | .81–1.05 | 10,375 | 9.1 | .94 | .83–1.07 |
High school graduate | 19,428 | 8.3 | — | 19,443 | 8.6 | — | ||
Some college | 15,269 | 8.9 | 1.17* | 1.04–1.31 | 15,288 | 9.9 | 1.19* | 1.07–1.32 |
Bachelor's degree or higher | 23,306 | 6.9 | 1.15* | 1.02–1.29 | 23,320 | 7.4 | .97 | .87–1.09 |
Missing data | 9,167 | 9.2 | 1.18* | 1.03–1.35 | 9,171 | 10.2 | 1.20* | 1.06–1.36 |
Relationship status (reference: married or living with a partner) | ||||||||
Married or living with a partner | 38,931 | 7.2 | — | 38,964 | 7.9 | — | ||
Formerly married | 20,594 | 13.1 | 1.17* | 1.07–1.29 | 20,621 | 12.7 | 1.13* | 1.04–1.24 |
Never married | 17,885 | 6.9 | 1.10 | .98–1.23 | 17,889 | 7.9 | 1.14* | 1.02–1.27 |
Missing data | 120 | 5.8 | .57 | .19–1.72 | 123 | 6.1 | .56 | .19–1.64 |
Child <18 in the household (reference: no) | ||||||||
No | 54,994 | 9.0 | — | 55,043 | 9.4 | — | ||
Yes | 22,536 | 6.4 | .84* | .74–.94 | 22,554 | 7.5 | .86* | .77–.96 |
Family income relative to federal poverty guidelines (FPG) (reference: ≥400% of FPG) | ||||||||
≤100% of FPG | 11,686 | 12.1 | 1.05 | .89–1.24 | 11,703 | 12.6 | 1.03 | .89–1.19 |
100%–199% of FPG | 14,590 | 9.7 | 1.05 | .92–1.21 | 14,605 | 10.0 | .98 | .86–1.11 |
200%–399% of FPG | 20,586 | 8.2 | 1.16* | 1.04–1.29 | 20,612 | 8.7 | 1.04 | .94–1.15 |
≥400% of FPG | 25,285 | 6.5 | — | 25,298 | 7.5 | — | ||
Missing data | 5,383 | 5.9 | .74* | .61–.90 | 5,379 | 6.0 | .68** | .57–.82 |
Current cigarette smoker (reference: no) | ||||||||
No | 64,542 | 7.2 | — | 64,593 | 7.8 | — | ||
Yes | 12,890 | 13.0 | 1.26** | 1.15–1.39 | 12,908 | 14.0 | 1.37** | 1.25–1.50 |
Missing data | 98 | 4.4 | .32* | .11–.95 | 96 | 5.7 | .55 | .20–1.57 |
Health status (reference: excellent, very good, good) | ||||||||
Excellent, very good, good | 66,354 | 6.0 | — | 66,404 | 6.7 | — | ||
Poor, fair | 11,151 | 22.7 | 1.92** | 1.71–2.15 | 11,167 | 22.7 | 1.97** | 1.77–2.20 |
Missing data | 25 | 11.9 | 1.75 | .57–5.40 | 26 | 17.5 | 2.64 | .90–7.73 |
Needs help with ADLs/IADLs (reference: no) | ||||||||
No | 72,886 | 7.2 | — | 72,943 | 7.8 | — | ||
Yes | 4,644 | 27.9 | 1.54** | 1.33–1.78 | 4,654 | 27.7 | 1.57** | 1.39–1.78 |
Health insurance status (reference: private) | ||||||||
Private | 37,719 | 6.2 | — | 37,749 | 7.2 | — | ||
Public | 30,333 | 12.6 | 1.73** | 1.54–1.93 | 30,358 | 12.6 | 1.70** | 1.53–1.90 |
Uninsured | 9,215 | 4.5 | .74* | .59–.93 | 9,227 | 4.9 | .76* | .62–.93 |
Missing data | 263 | 7.7 | 2.21 | .89–5.45 | 263 | 7.7 | 1.63 | .62–4.26 |
Office visit in the prior 12 months (reference: yes) | ||||||||
Yes | 64,182 | 9.6 | — | 64,236 | 10.3 | — | ||
No | 13,145 | 1.4 | .20** | .16–.24 | 13,160 | 1.5 | .20** | .16–.24 |
Missing data | 203 | 9.5 | .51 | .27–.98 | 201 | 15.6 | 1.48 | .88–2.51 |
Unmet medical care due to cost in prior 12 months (reference: no) | ||||||||
Yes | 5,824 | 14.5 | .99 | .86–1.15 | 5,836 | 15.0 | .99 | .86–1.13 |
No | 71,683 | 7.7 | — | 71,738 | 8.3 | — | ||
Missing data | 23 | 17.2 | 1.16 | .26–5.08 | 23 | 17.1 | 1.43 | .45–4.57 |
Self-reported feelings of depression (reference: no) | ||||||||
Yes | 7,233 | 44 | 11.21** | 10.26–12.25 | — | — | — | — |
No | 70,297 | 4.84 | — | — | — | — | — | |
Self-reported feelings of anxiety (reference: no) | ||||||||
Yes | — | — | — | — | 15,616 | 3.9 | 7.43** | 6.88–8.03 |
No | — | — | — | — | 61,981 | 28.5 | — |
TABLE 3. Association between demographic and health characteristics and taking medication for feelings of depression and anxiety among participants in the NHISa
Table 3 also presents the logistic-regression results for taking medication for anxious feelings. Gay and lesbian adults (AOR=1.85, 95% CI=1.46–2.34) were more likely than heterosexual adults to take medication for frequent feelings of anxiety. Self-reporting frequent feelings of anxiety was the strongest predictor of taking medication for anxious feelings (AOR=7.43, 95% CI=6.88–8.03). The odds of taking medication for frequent feelings of anxiety were higher among white versus Hispanic adults, females, adults who were formerly married or never married versus currently married, current cigarette smokers, adults with poor/fair health versus excellent/very good/good health, adults needing help with ADLs or IADLs, and adults with public health insurance.
Table 4 presents the prevalence and AORs of taking medication for depression and anxiety among the subset of respondents with frequent feelings of depression and anxiety, respectively. Approximately 44% of adults with frequent feelings of depression took medication for depression, and 28.4% of adults with frequent feelings of anxiety took medication for anxiety (data not shown). After the analyses controlled for sociodemographic characteristics, there were no statistically significant differences in taking medication for depression between the sexual-minority and heterosexual adults who reported frequent feelings of depression. Among all adults with frequent feelings of depression, the likelihood of taking medication for depression was greater among females, adults with college degrees versus a high school education, adults with poor/fair health versus excellent/very good/good health, adults needing help with ADLs or IADLs, and adults with public health insurance.
Taking medication for depressive feelings (N=7,227) | Taking medication for anxious feelings (N=15,616) | |||||||
---|---|---|---|---|---|---|---|---|
Characteristic | N | % | AORb | 95% CI | N | % | AORb | 95% CI |
Sexual orientation (reference: heterosexual) | ||||||||
Heterosexual | 6,778 | 44.0 | — | 14,757 | 28.2 | — | ||
Gay and lesbian | 203 | 47.1 | 1.34 | .92–1.95 | 413 | 36.5 | 1.69** | 1.26–2.28 |
Bisexual | 188 | 44.4 | 1.29 | .83–2.02 | 340 | 28.1 | 1.18 | .85–1.65 |
Other | 58 | 25.8 | .51 | .26–1.02 | 106 | 26.6 | 1.15 | .59–2.24 |
Age (years) (reference: 45–54) | ||||||||
18–24 | 575 | 24.8 | .38** | .27–.54 | 1,687 | 15.7 | .43** | .34–.55 |
25–34 | 1,026 | 34.7 | .57** | .44–.73 | 2,991 | 22.8 | .71** | .60–.85 |
35–44 | 1,096 | 44.6 | .80 | .63–1.01 | 2,655 | 30.1 | 1.03 | .87–1.21 |
45–54 | 1,428 | 54.5 | — | 2,833 | 34.6 | — | ||
55–64 | 1,582 | 51.2 | .65** | .53–.80 | 2,795 | 35.1 | .82* | .70–.97 |
≥65 | 1,520 | 44.6 | .34** | .27–.43 | 2,655 | 31.8 | .44** | .37–.54 |
Race-ethnicity (reference: Hispanic) | ||||||||
White | 4,968 | 47.9 | 1.10 | .86–1.40 | 11,307 | 31.1 | 1.39** | 1.16–1.65 |
Black | 863 | 35.7 | .57** | .42–.77 | 1,530 | 23.8 | .72* | .57–.89 |
Hispanic | 1,044 | 37.8 | — | 2,011 | 21.9 | — | ||
Other/multiple races | 329 | 25.2 | .48** | .33–.71 | 738 | 15.5 | .65* | .48–.88 |
Missing data | 23 | 33.8 | .84 | .21–3.45 | 30 | 16.8 | .54 | .12–2.51 |
Sex (reference: male) | ||||||||
Male | 2,705 | 37.7 | — | 5,777 | 23.3 | — | ||
Female | 4,522 | 48.3 | 1.51** | 1.31–1.76 | 9,839 | 31.9 | 1.50** | 1.35–1.66 |
U.S. citizenship (%) (reference: yes) | ||||||||
Yes | 6,864 | 45.3 | — | 14,854 | 29.2 | — | ||
No | 363 | 22.5 | .53** | .37–.74 | 751 | 15.2 | .71* | .53–.96 |
Missing data | 0 | .0 | nac | nac | 11 | 18.3 | 1.29 | .17–9.52 |
Education (reference: high school graduate) | ||||||||
Less than high school | 1,483 | 40.2 | .86 | .70–1.07 | 2,248 | 30.4 | .96 | .81–1.13 |
High school graduate | 2,005 | 42.1 | — | 3,716 | 28.5 | — | ||
Some college | 1,584 | 43.9 | 1.08 | .88–1.33 | 3,459 | 29.2 | 1.12 | .97–1.30 |
Bachelor's degree or higher | 1,333 | 46.5 | 1.25* | 1.00–1.56 | 4,350 | 25.2 | .95 | .81–1.11 |
Missing data | 822 | 51.4 | 1.34* | 1.06–1.68 | 1,843 | 32.7 | 1.19 | 1.00–1.43 |
Relationship status (reference: married or living with a partner) | ||||||||
Married or living with a partner | 2,630 | 44.4 | — | 6,868 | 27.6 | — | ||
Formerly married | 2,756 | 51.5 | 1.15 | .97–1.36 | 4,500 | 38.0 | 1.24** | 1.10–1.39 |
Never married | 1,830 | 35.4 | .89 | .73–1.09 | 4,227 | 23.3 | 1.09 | .94–1.25 |
Missing data | 11 | 40.6 | .67 | .09–5.13 | 21 | 13.3 | .29 | .079–1.09 |
Child <18 in the household (reference: no) | ||||||||
No | 5,358 | 46.2 | — | 10,945 | 29.8 | — | ||
Yes | 1,869 | 39.2 | .77* | .65–.92 | 4,671 | 26.0 | .90 | .79–1.02 |
Family income relative to federal poverty guidelines (FPG) (reference: ≥400% of FPG) | ||||||||
≤100% of FPG | 2,152 | 45.7 | 1.00 | .77–1.29 | 3,477 | 33.5 | 1.01 | .84–1.22 |
100%–199% of FPG | 1,847 | 44.0 | 1.00 | .79–1.27 | 3,347 | 30.2 | .95 | .81–1.12 |
200%–399% of FPG | 1,623 | 44.3 | 1.02 | .82–1.27 | 3,966 | 28.3 | 1.02 | .89–1.18 |
≥400% of FPG | 1,240 | 44.3 | — | 4,067 | 26.1 | — | ||
Missing data | 365 | 35.2 | .66* | .47–.92 | 759 | 20.3 | .58** | .44–.76 |
Current cigarette smoker (reference: no) | ||||||||
No | 4,951 | 43.4 | — | 11,747 | 26.8 | — | ||
Yes | 2,266 | 45.4 | 1.09 | .93–1.28 | 3,852 | 34.0 | 1.24** | 1.11–1.40 |
Missing data | 10 | 19.0 | .20* | .05–.84 | 17 | 2.1 | .03* | .002–.37 |
Health status (reference: excellent, very good, good) | ||||||||
Excellent, very good, good | 4,206 | 36.4 | — | 11,393 | 23.1 | — | ||
Poor, fair | 3,021 | 55.5 | 1.70** | 1.45–2.00 | 4,214 | 44.9 | 1.87** | 1.63–2.14 |
Missing data | 0 | 100.0 | nac | nac | 9 | 66.3 | 15.77** | 4.47–55.62 |
Needs help with ADLs/IADLs (reference: no) | ||||||||
No | 5,831 | 40.4 | — | 13,763 | 25.9 | — | ||
Yes | 1,396 | 61.5 | 1.49** | 1.23–1.81 | 1,853 | 51.9 | 1.63** | 1.39–1.91 |
Health insurance status (reference: private) | ||||||||
Private | 2,199 | 41.0 | — | 7,159 | 24.1 | — | ||
Public | 3,968 | 52.8 | 1.59** | 1.33–1.92 | 6,365 | 39.4 | 1.76** | 1.53–2.03 |
Uninsured | 1,038 | 23.2 | .60** | .46–.78 | 2,035 | 16.1 | .71* | .58–.88 |
Missing data | 22 | 25.4 | 1.24 | .40–3.81 | 57 | 17.6 | 1.06 | .44–2.54 |
Office visit in the prior 12 months (reference: yes) | ||||||||
Yes | 6,365 | 48.8 | — | 13,660 | 31.7 | — | ||
No | 823 | 9.9 | .18** | .13–.24 | 1,914 | 6.2 | .20** | .15–.25 |
Missing data | 39 | 33.6 | .52 | .23–1.16 | 42 | 58.8 | 3.07* | 1.18–7.98 |
Unmet medical care due to cost in prior 12 months (reference: no) | ||||||||
Yes | 1,482 | 38.9 | .82* | .68–.99 | 2,440 | 28.6 | .89 | .76–1.04 |
No | 5,740 | 45.2 | — | 13,168 | 28.4 | — | ||
Missing data | 5 | 64.0 | 1.14 | .14–9.27 | 8 | 33.8 | 1.73 | .42–7.22 |
TABLE 4. Association between demographic and health characteristics and taking medication for feelings of depression and anxiety among participants in the NHIS with frequent feelings of depression or anxietya
Table 4 also compares the prevalence of taking medication for anxiety among the respondents reporting frequent feelings of anxiety. After the analyses adjusted for sociodemographic characteristics, gay and lesbian adults who reported frequent feelings of anxiety were more likely than heterosexual adults who reported frequent feelings of anxiety to take medication for anxiety (AOR=1.69, 95% CI=1.26–2.26). Among all respondents with frequent feelings of anxiety, the likelihood of taking medication for anxiety was greater among whites versus Hispanics, females, adults who were formerly married versus currently married, current cigarette smokers, adults with poor/fair health versus excellent/very good/good health, adults needing help with ADLs or IADLS, and adults with public health insurance.
Discussion
This study used representative data from the NHIS and found that adults who self-identified as a sexual minority were more likely to report frequent feelings of depression and anxiety compared with their heterosexual peers. This study suggests that public health initiatives should focus on mental health promotion, disease prevention, and treatment of depression and anxiety among sexual-minority populations.
Preventing depression and anxiety among persons who identify as a sexual minority may require multifaceted and multisector approaches. Mental health promotion and disease prevention should be included in the national dialogue about combatting stigma around mental health. Mental health promotion efforts should incorporate the social determinants of health as a framework for addressing the root causes of psychological distress and mental illness among persons with sexual-minority status in the United States. For example, public policy should ensure a welcoming and safe environment for individuals who identify as a sexual minority—which may require legal protections from discrimination in all facets of society, including health care, employment, housing, and education.
At the time of this writing, persons who identify as a sexual minority can be the victim of a hate crime in 20 states without legal repercussions and can lose their jobs because of their sexual orientation in 28 states (34). Preventing violence and traumatic experiences against persons with a sexual-minority orientation may help reduce the prevalence of distress and anxiety in the sexual-minority population in the long term. Recent research suggests that some legal protections (e.g., same-sex marriage laws) may be associated with reductions in implicit and explicit bias toward the sexual-minority community (35) and improved mental health and well-being as well (36, 37).
Meanwhile, health care facilities and providers can also play an important role in detecting, preventing, and treating depression and anxiety among sexual-minority populations. Not only should providers conduct routine screening for mood disorders among patients who identify as a sexual minority, but health care facilities and providers should ensure that their practices are uniformly welcoming and affirming, regardless of patients’ sexual orientation. Subtle cues can be used in clinical settings to communicate that the setting is a welcoming and safe environment for patients with a sexual-minority orientation, such as collecting sexual-orientation and gender identity data in health records, displaying health information featuring same-sex couples, and using gender-neutral language that does not assume that the patient engages in heteronormative romantic relationships (38). Mental health providers should also be mindful of the clinical guidelines for treating patients with a sexual-minority orientation, which include affirming identification as a sexual minority as a normal variation in human sexuality that does not need to be changed and recognizing discrimination and stigma against sexual-minority status as a risk factor for mental illness (39–41).
We also found that after the analysis controlled for sociodemographic characteristics and health status, some adults who identified as a sexual minority were more likely than their heterosexual peers to take medication for depression and anxiety. Even among adults with frequent anxiety, gay and lesbian adults were more likely than heterosexual adults to take medication for anxiety. These are interesting findings that warrant further research, given that they suggest that persons who identify as a sexual minority may be more likely to seek and receive (or possibly misuse) mental health services, treatment, and medication. It is possible that stigma surrounding mental health may be less of a concern for those who identify as a sexual minority than for heterosexual adults. Indeed, one study with a sample of college students showed that gay, lesbian, and bisexual students reported less personal stigma about mental illness compared with heterosexual students (42). Although this analysis cannot explore the relationships between attitudes about mental health care and the receipt of medication, future research should explore whether and how mental health stigma varies by sexual orientation. Additional research should continue to monitor and evaluate the effectiveness of various mental health treatments among sexual-minority populations, especially as more data on sexual orientation and gender identity are collected in health surveys and electronic health records. There were several limitations to using data from the NHIS for this study. First, all responses to the NHIS are self-reported and may suffer from selection issues and recall bias. Respondents who choose to disclose their sexual-minority status may be different than those who do not accurately disclose their sexual-minority orientation. Some research suggests that adults who do not answer the sexual-orientation question are more likely to be a member of a racial-ethnic minority group, a non-English speaker, and a resident of an urban community (43). However, an increasing proportion of adults are willing to report their sexual orientation in health surveys (44). Other responses may be subject to social-desirability bias. For instance, some participants may have been reluctant to accurately describe their mental health and treatment to avoid being viewed negatively.
We were also limited by the small number of questions on depression and anxiety in the AFD supplement to the NHIS. Although the participants were asked how frequently they felt depressive or anxious feelings, they were not asked whether they had ever received a diagnosis of depression or anxiety from a health care professional. Meanwhile, the questions on depression and anxiety may not be as valid as formal diagnostic evaluations, such as the PHQ-9—the nine questions in the Patient Health Questionnaire that ascertain the severity of depression. More research should compare the validity, sensitivity, and specificity of the AFD questions for depression and anxiety. Relatedly, participants were asked only about whether they were taking any medications for their feelings. The wording of this question does not specifically ask about prescription medications, so respondents may include prescribed medications, over-the-counter medications, and possibly vitamins or herbal supplements. Meanwhile, some participants living with depression and anxiety may not take any medications but may be receiving psychotherapy, participating in support groups, or using complementary and alternative medicine for their mood. Given the elevated attention to mental health in the United States, the NCHS should incorporate additional questions related to mental health surveillance and mental health services utilization into the adult questionnaire for the main sample of the NHIS.
Conclusions
This study compared the prevalence of self-reported feelings of depression and anxiety, as well as the odds of taking medication for these feelings, among persons with a heterosexual or sexual-minority orientation. Consistent with previous research, we found that persons who self-identified as a sexual minority were more likely than heterosexual adults to report frequent feelings of depression and anxiety. We also found that persons with a sexual-minority orientation were more likely than heterosexuals to take medication for depression and anxiety. Given the elevated prevalence of anxiety and depression in sexual-minority populations, we recommend using a multifaceted approach to address mental health disparities among these groups. This approach should include key roles for policy makers, public health researchers, and health care providers and emphasize mental health promotion and disease prevention. Addressing discrimination in health care and public policy toward persons who self-identify as a sexual minority may help alleviate depression and anxiety among lesbians, gay men, bisexual individuals, and other non-heterosexual populations in the United States.
1 : The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC, National Academies Press, 2011Google Scholar
2 : Mental health in sexual minorities: recent indicators, trends, and their relationships to place in North America and Europe. Health Place 2009; 15:1029–1045Crossref, Medline, Google Scholar
3 : Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: results from NHANES III. Am J Public Health 2000; 90:573–578Crossref, Medline, Google Scholar
4 : The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: the role of key health indicators and risk and protective factors. Gerontologist 2013; 53:664–675Crossref, Medline, Google Scholar
5 : Sexual orientation and risk factors for suicidal ideation and suicide attempts among adolescents and young adults. Am J Public Health 2007; 97:2017–2019Crossref, Medline, Google Scholar
6 : Experiences of discrimination and their impact on the mental health among African American, Asian and Pacific Islander, and Latino men who have sex with men. Am J Public Health 2013; 103:868–874Crossref, Medline, Google Scholar
7 : Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: a systematic review and meta-analysis. J Sex Res 2018; 55:435–456Crossref, Medline, Google Scholar
8 : Mental health issues and discrimination among older LGBTI people. Int Psychogeriatr 2015; 27:1411–1416Crossref, Medline, Google Scholar
9 : The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health 2001; 91:927–932Crossref, Medline, Google Scholar
10 : Sexual orientation and suicide ideation, plans, attempts, and medically serious attempts: evidence from local Youth Risk Behavior Surveys, 2001–2009. Am J Public Health 2014; 104:262–271Crossref, Medline, Google Scholar
11 : Mental health and suicidality among racially/ethnically diverse sexual minority youths. Am J Public Health 2014; 104:1129–1136Crossref, Medline, Google Scholar
12 : Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States. Am J Public Health 2010; 100:468–475Crossref, Medline, Google Scholar
13 : Severe mental illness in LGBT populations: a scoping review. Psychiatr Serv 2016; 67:779–783Link, Google Scholar
14 : Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. Couns Psychol 2010; 38:442–454Crossref, Google Scholar
15 : Minority stress and mental health in gay men. J Health Soc Behav 1995; 36:38–56Crossref, Medline, Google Scholar
16 : Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129:674–697Crossref, Medline, Google Scholar
17 : How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol Bull 2009; 135:707–730Crossref, Medline, Google Scholar
18 : Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychol 2008; 27:455–462Crossref, Medline, Google Scholar
19 : The relationship between experiences of discrimination and mental health among lesbians and gay men: an examination of internalized homonegativity and rejection sensitivity as potential mechanisms. J Consult Clin Psychol 2012; 80:917–927Crossref, Medline, Google Scholar
20 Medley G, Lipari RN, Bose J, et al: Sexual orientation and estimates of adult substance use and mental health: results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review, Oct 2016. www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm#topofpageGoogle Scholar
21 : Predictors of mental health services use among lesbian and heterosexual women. Psychiatr Rehabil J 2006; 29:289–298Crossref, Medline, Google Scholar
22 : Utilization of mental health services. J Gay Lesbian Soc Serv 2002; 14:51–66Crossref, Google Scholar
23 : Influence of gender, sexual orientation, and need on treatment utilization for substance use and mental disorders: findings from the California Quality of Life Survey. BMC Psychiatry 2009; 9:52Crossref, Medline, Google Scholar
24 : Characteristics of lesbian, gay, bisexual, and transgender individuals entering substance abuse treatment. J Subst Abuse Treat 2006; 30:135–146Crossref, Medline, Google Scholar
25 : Mental health service utilization among lesbian, gay, bisexual, and questioning or queer college students. J Adolesc Health 2017; 61:294–301Crossref, Medline, Google Scholar
26 : Mental health service use among lesbian, gay, and bisexual older adults. Psychiatr Serv 2015; 66:743–749Link, Google Scholar
27 : Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. J Consult Clin Psychol 2003; 71:53–61Crossref, Medline, Google Scholar
28 : Sexual orientation differences in functional limitations, disability, and mental health services use: results from the 2013–2014 National Health Interview Survey. J Consult Clin Psychol 2017; 85:1111–1121Crossref, Medline, Google Scholar
29 : Sexual orientation, treatment utilization, and barriers for alcohol related problems: findings from a nationally representative sample. Drug Alcohol Depend 2016; 161:323–330Crossref, Medline, Google Scholar
30 : Sexual orientation and substance abuse treatment utilization in the United States: results from a national survey. J Subst Abuse Treat 2013; 44:4–12Crossref, Medline, Google Scholar
31 National Center for Health Statistics: Health, United States, 2016: With Chartbook on Long-Term Trends in Health. Washington, DC, Department of Health and Human Services, 2017Google Scholar
32 Blewett LA, Drew JAR, Griffin R, et al: IPUMS Health Surveys: National Health Interview Survey, Version 6.2. Minneapolis, University of Minnesota, 2016Google Scholar
33 User Note: Adult Functioning and Disability & Quality of Life Supplements. Minneapolis, University of Minnesota. https://nhis.ipums.org/nhis/userNotes_afdqol.shtml. Accessed April 22, 2019Google Scholar
34 : 2018 State Equality Index. Washington, DC, Human Rights Campaign Foundation, 2018Google Scholar
35 : Same-sex marriage legalization associated with reduced implicit and explicit antigay bias. Proc Natl Acad Sci USA 2019; 116:8846–8851Crossref, Medline, Google Scholar
36 : Effect of same-sex marriage laws on health care use and expenditures in sexual minority men: a quasi-natural experiment. Am J Public Health 2012; 102:285–291Crossref, Medline, Google Scholar
37 : Same-sex legal marriage and psychological well-being: findings from the California Health Interview Survey. Am J Public Health 2013; 103:339–346Crossref, Medline, Google Scholar
38 : Cultural competence and LGBT issues in psychiatry. Psychiatr Times, July 31, 2015Google Scholar
39 Scasta D, Bialer P: Position Statement on Issues Related to Homosexuality. Washington, DC, American Psychiatric Association, 2013. https://webcache.googleusercontent.com/search?q=cache:ZH2nn3tkT-UJ:https://www.psychiatry.org/File%2520Library/About-APA/Organization-Documents-Policies/Policies/Position-2013-Homosexuality.pdf+&cd=1&hl=en&ct=clnk&gl=usGoogle Scholar
40 : Guidelines for psychological practice with lesbian, gay, and bisexual clients. Am Psychol 2012; 67:10–42Crossref, Medline, Google Scholar
41 Cabaj RP: Working With LGBTQ Patients. Washington, DC, American Psychiatric Association. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/working-with-lgbtq-patients. Accessed July 26, 2019Google Scholar
42 : Stigma and help seeking for mental health among college students. Med Care Res Rev 2009; 66:522–541Crossref, Medline, Google Scholar
43 : Sexual orientation in the 2013 National Health Interview Survey: a quality assessment. Vital Health Stat 2; 2014; 169:1–32Google Scholar
44 : Trends in sexual orientation missing data over a decade of the California Health Interview Survey. Am J Public Health 2015; 105:e43–e50Crossref, Medline, Google Scholar