Systematic review of mental health and DSH in lesbian, gay and bisexual people

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Systematic review of mental health and DSH in
lesbian, gay and bisexual people

• Michael King
• Jo Semlyen
• Sharon See Tai
• Helen Killaspy
• David Osborn
• Dmitri Popelyuk
• Irwin Nazareth
• Mental Health Sciences, UCL Medical School

Tender funded by the National Institute for
Mental Health in England
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Policy background

• NIMHE National Suicide Prevention Strategy (2002)
  to decrease suicide rate in high risk groups
• Goal 1 (reduction of risk in high risk groups)
• Criteria for high risk group
• known statistical risk
• number of suicides known
• evidence for preventative measures
• monitoring possible
• LGB possibly a high risk group but insufficient
  data

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Policy background

• Sexual Orientation and Gender Identity Advisory
  Group to DH recommended systematic review

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Original question

• Are lesbian, gay and bisexual people a high risk
  group in terms of DSH and suicide?
• Later expanded to risk of mental disorder

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Epidemiological evidence on mental health/DSH

• Most studies North American
• Volunteers or convenience samples
• Random sampling difficult or impossible
• Findings - increased psychopathology, self harm
  and substance misuse
• Little attempt to systematise findings or
  estimate the level of risk

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Objective of our review

• To undertake a systematic review and
  meta-analysis of the risks of mental disorder,
  substance misuse, suicide, suicidal ideation and
  DSH in lesbian, gay and bisexual people

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Data sources

• Electronic databases - Medline, Embase, PsycInfo,
  Cinahl, the Cochrane Library Database, the Web of
  Knowledge, the Applied Social Sciences Index and
  Abstracts, the International Bibliography of the
  Social Sciences, Sociological Abstracts, the
  Campbell Collaboration and centres for grey
  literature
• Internet search - Google and Google Scholar
• Authors contacted where necessary
• References of papers examined
• Articles published January 1966 to April 2005

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Studies that.

• considered self identification as gay, lesbian or
  bisexual
• used the terms homosexual and bisexual and/or
• assessed same sex attraction.  

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Study selection

• Population based, controlled studies including
  the outcomes
• a) psychiatric disorder (incl. substance misuse
  disorders) using international criteria (ICD,
  DSM)
• b) psychiatric disorder, alcohol or drug
  dependence using validated instruments
• c) alcohol misuse (defined as above UK safe
  drinking limits)
• d) suicide
• e) suicidal ideation and
• f) deliberate self harm - intentional self
  poisoning or injury irrespective of the apparent
  purpose of the act (NHS Centre for Reviews 1998).

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Screening

• All titles and abstracts screened by two
  researchers
• Excluded if did not meet eligibility criteria or
  if unpublished dissertation theses, published
  abstracts, case reports, letters, commentaries,
  or review papers
• Selected papers examined by pairs of authors
• Disagreements discussed and consensus agreements
  at steering group meetings

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Data extraction

• Authors, year, study setting, study design,
  population and sampling, response rate.
• Prevalence estimates, odds ratios and
  attributable risks for outcomes in last 12 months
  and over lifetime.
• For continuous data - means and standard
  deviations.

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Studies rated on 4 indicators of quality

• sampling non random 1, random 2
• representativeness response rates lt601,
  gt602
• population definition selected sample (e.g.
  school students) 1 general population 2
• sample size lt100 LB or GB people 1, gt100 LB or
  GB people2.
• Cochrane Handbooks guidance on non-experimental
  studies
• (2 indicating higher quality than 1).

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Meta-analyses

• Collate data from different studies to calculate
  pooled OR.
• At least 2 studies with extractable data required
  for the outcome of interest
• Random effects models
• uses inverse variance methods to calculate the
  pooled effect estimate in which the weight given
  to each study is the inverse of the variance of
  the study estimate
• thus more weight is given to larger studies.

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Odds ratio

• Participants with and without the outcome of
  interest studied retrospectively to see if they
  have been exposed to the potentially causative
  factor (in this case, LGB).
• The OR gives an indication of the strength of
  association between exposure and outcome e.g.
  OR2 means the odds of depression for LGB twice
  that of non-LGB

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Attributable risk

• Difference in proportions of outcome for exposed
  (LGB) and non exposed (non-LGB) group.
• Quantifies the risk attributable to being LGB
• AR 0.1 means 10 of risk of depression is
  attributable to being LGB. Or, in 100 people
  with depression, the depression could be
  attributed to being LGB in 10 people.

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Search
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Papers/Studies

• 13705 papers identified
• 476 selected for further examination
• 28 (25 studies) met inclusion criteria.

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Included studies

• 28 papers relating to 25 studies
• 20 included in meta-analysis
• 4 cohort
• 21 cross-sectional
• 9 used random sampling 2 multi-stage sampling 2
  snowball sampling 1 systematic sampling (26
  years follow up data on a birth cohort) and 7
  did not specify their sampling
• 7 countries (US, Canada, UK, Europe, Australia,
  NZ)
• 17/25 (68) USA
• All published 1997 onwards
• Data on 214,344 heterosexual and 11,971 non
  heterosexual people aged 12 and over

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Sexuality was defined in a number of ways even
within the same study

• 4 studies used same sex attraction
• 13 - same sex behaviour
• 15 - participant self-identification
• 3 - score above zero on Kinsey Scale
• 9 studies used two, and 1 used three definitions
• 18 studies used a specific time frame to assess
  sexuality.
• Self-identified sexuality was based on the
  categories heterosexual, homosexual or bisexual
  or included the choices gay or lesbian.

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Quality rating of 25 studies included

• Only 1 study met all four of our quality
  criteria,
• 7 studies met 3/4 quality markers

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SUICIDE ATTEMPTS
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Suicidal ideation
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DSH (each row based on 2 studies)
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Depression
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Anxiety
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Alcohol dependence
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Drug dependence
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Summary of attributable risks - men and women

• Suicide attempts lifetime 0.06 - 0.25
• Suicide attempts previous 12 months 0.01- 0.21
• Suicidal ideation lifetime 0.12 - 0.40
• Suicidal ideation previous 12 months 0.07 - 0.13
• DSH lifetime 0.12 - 0.31
• Depression last 12 months 0.05 - 0.17
• Depression lifetime 0.19 - 0.33
• Anxiety previous 12 months 0.05 - 0.08
• Alcohol dependence previous 12 months 0.04 - 0.06
• Drug dependence previous 12 months 0.002 - 0.05

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Conclusions

• 2 fold excess in risk of suicide attempts in the
  preceding year in LGB men and women
• 4 fold excess in risk of suicide attempts in GB
  men over a lifetime.
• Depression, anxiety, alcohol and substance misuse
  were at least 1.5 times more common in LGB
  people.
• Findings similar in men and women but
• LB women were at particular risk of substance
  dependence
• lifetime risk of suicide attempts was especially
  high in GB men.

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Strengths

• Studies with consistent definitions of sexual
  orientation and contemporaneous comparison groups
  
• Subgroups of men women and life-time vs. recent
  outcomes - most valid and least assumptions about
  data
• Avoidance of selection bias by exclusion of
  studies in specific settings (e.g. bars, support
  groups or health services used by LGB people)
• All studies used well-described and potentially
  replicable mental health outcomes

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Limitations

• Only 1 study met all four of our quality
  criteria, while only 7 met 3 out of 4 quality
  markers.
• Number of studies in each meta-analysis was
  relatively small
• thus could not interpret funnel plots to
  investigate sources of bias or run a
  meta-regression analysis to account for the
  variable quality of the studies identified in
  this review.

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Possible explanations for our findings

• Growing up and living in intolerant societies
  particularly non-western countries
• Childhood differences and bullying
• Stresses of openness
• Social behaviour and use of substances -
  lifestyle
• Difficulties establishing stable partnerships
• Developmental disorder

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Tasks that heterosexuals do not face

• Awareness of orientation difference
• Acceptance of that difference
• Decision to come out moment to moment
• Decide who will/should know
• Creating supports and acceptance
• Living as a gay, lesbian, bisexual person
• Bisexuals also face struggle for acceptance with
  gays and straights

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Role of Substance Use

• Socialising and limited options
• Reaction to social stress homophobia and
  heterosexism
• HIV and AIDS concerns--consequences of
  methamphetamine and club drug use and abuse

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Where from here?

• More efforts to study completed suicide
• Recognition as high-risk group
• Now included as a group with special needs
  under Goal Two of the Nat Suicide Prevention
  Strategy for England (to promote the well being
  of the wider population).
• Assessment of services for LGB people and the
  attitudes of therapists

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www.nimhe.csip.org.ukclick on
publicationsclick on public health and well
being
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On a brighter note

• What kind of therapy and therapist might LGB
  people welcome?

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