mental health and substance abuse thesis

Common Comorbidities with Substance Use Disorders Research Report Part 1: The Connection Between Substance Use Disorders and Mental Illness

Many individuals who develop substance use disorders (SUD) are also diagnosed with mental disorders, and vice versa. 2,3 Although there are fewer studies on comorbidity among youth, research suggests that adolescents with substance use disorders also have high rates of co-occurring mental illness; over 60 percent of adolescents in community-based substance use disorder treatment programs also meet diagnostic criteria for another mental illness. 4

Data show high rates of comorbid substance use disorders and anxiety disorders—which include generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. 5–9 Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder, 6,9–11 attention-deficit hyperactivity disorder (ADHD), 12,13 psychotic illness, 14,15 borderline personality disorder, 16 and antisocial personality disorder. 10,15 Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population. 17 As Figure 1 shows, the overlap is especially pronounced with serious mental illness (SMI). Serious mental illness among people ages 18 and older is defined at the federal level as having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities. Serious mental illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment. 18 Around 1 in 4 individuals with SMI also have an SUD.

Data from a large nationally representative sample suggested that people with mental, personality, and substance use disorders were at increased risk for nonmedical use of prescription opioids. 19 Research indicates that 43 percent of people in SUD treatment for nonmedical use of prescription painkillers have a diagnosis or symptoms of mental health disorders, particularly depression and anxiety. 20

Youth—A Vulnerable Time

Although drug use and addiction can happen at any time during a person’s life, drug use typically starts in adolescence, a period when the first signs of mental illness commonly appear. Comorbid disorders can also be seen among youth. 21–23 During the transition to young adulthood (age 18 to 25 years), people with comorbid disorders need coordinated support to help them navigate potentially stressful changes in education, work, and relationships. 21

Drug Use and Mental Health Disorders in Childhood or Adolescence Increases Later Risk

The brain continues to develop through adolescence. Circuits that control executive functions such as decision making and impulse control are among the last to mature, which enhances vulnerability to drug use and the development of a substance use disorder. 3,24 Early drug use is a strong risk factor for later development of substance use disorders, 24 and it may also be a risk factor for the later occurrence of other mental illnesses. 25,26 However, this link is not necessarily causative and may reflect shared risk factors including genetic vulnerability, psychosocial experiences, and/or general environmental influences. For example, frequent marijuana use during adolescence can increase the risk of psychosis in adulthood, specifically in individuals who carry a particular gene variant. 26,27

It is also true that having a mental disorder in childhood or adolescence can increase the risk of later drug use and the development of a substance use disorder. Some research has found that mental illness may precede a substance use disorder, suggesting that better diagnosis of youth mental illness may help reduce comorbidity. One study found that adolescent-onset bipolar disorder confers a greater risk of subsequent substance use disorder compared to adult-onset bipolar disorder. 28 Similarly, other research suggests that youth develop internalizing disorders, including depression and anxiety, prior to developing substance use disorders. 29

Untreated Childhood ADHD Can Increase Later Risk of Drug Problems

Numerous studies have documented an increased risk for substance use disorders in youth with untreated ADHD, 13,30 although some studies suggest that only those with comorbid conduct disorders have greater odds of later developing a substance use disorder. 30,31 Given this linkage, it is important to determine whether effective treatment of ADHD could prevent subsequent drug use and addiction. Treatment of childhood ADHD with stimulant medications such as methylphenidate or amphetamine reduces the impulsive behavior, fidgeting, and  inability to concentrate that characterize ADHD. 32

That risk presents a challenge when treating children with ADHD, since effective treatment often involves prescribing stimulant medications with addictive potential. Although the research is not yet conclusive, many studies suggest that ADHD medications do not increase the risk of substance use disorder among children with this condition. 31,32 It is important to combine stimulant medication for ADHD with appropriate family and child education and behavioral interventions, including counseling on the chronic nature of ADHD and risk for substance use disorder. 13,32

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Electronic Theses, Projects, and Dissertations

Understanding the link between substance abuse and mental health.

Crystal Ann Horton , California State University - San Bernardino Follow

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Master of Social Work

School of Social Work

First Reader/Committee Chair

Janet Chang

Treating people with co-occurring or dual diagnosis disorders requires an integrated treatment approach due to the complex health and social needs of people who suffer from mental illness and drug addiction. An integrated approach is not only necessary but crucial to treat both the drug addiction and mental illness concurrently. The aim of this study is to explore the impact that non- integrated care can have on the number of relapses that dually diagnosed people can have. The study found that there is no correlation between concurrent treatment and the number of relapses that dually diagnosed people may have. Social workers will need to be able to recognize mental illness that co-occurs with substance use in order to effectively treat clients to determine what treatment approach should be used. Social workers are trained to use a biopsychosocial approach to capture all aspects of the client’s life. This I especially important for clients that may be dually diagnosed.

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Horton, Crystal Ann, "UNDERSTANDING THE LINK BETWEEN SUBSTANCE ABUSE AND MENTAL HEALTH" (2017). Electronic Theses, Projects, and Dissertations . 492. https://scholarworks.lib.csusb.edu/etd/492

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Understanding Abuse, Mental Health, and Substance Use: The Role of Victimization in a Jail Population

• Published: 18 October 2023
• Volume 48 , pages 1320–1342, ( 2023 )

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• M. A. Kowalski   ORCID: orcid.org/0000-0002-8289-2932 1 ,
• M. Campagna 2 ,
• E. M. Wright   ORCID: orcid.org/0000-0002-4653-3596 3 &
• R. Spohn   ORCID: orcid.org/0000-0002-9986-951X 2  

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The role of victimization in criminal behavior has been researched previously, particularly in justice-involved youth and prison samples. The contribution of such adversity in jail samples is less articulated. The current study examines the effect of physical abuse, sexual abuse, and polyvictimization (physical and sexual abuse) on behavioral health and substance use outcomes in a sample of individuals who went through the intake process at one jail. Through use of logistic regression models, we examined the impact of abuse on internalizing mental health issues, externalizing mental health issues, and substance use disorder. Findings demonstrated relationships between abuse and internalizing disorders, abuse and externalizing disorders, as well as between abuse and substance use disorder, with the effect of sexual abuse greater for women and the impact of polyvictimization larger for men. Policy implications are discussed.

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We use the terms “trauma” and “victimization” broadly but focus on physical abuse, sexual abuse, and polyvictimization (physical and sexual abuse) in this study.

We focus on behavioral health disorders in the current study, which can include mental illness.

Three or more symptoms represent “high” severity for these measures. The median for both measures was 2.

We also ran analyses with SUD coded differently (no disorder = 0 or presence of mild, moderate, or severe disorder = 1), and there were few substantive differences.

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M. A. Kowalski

School of Criminology and Criminal Justice, Nebraska Center for Justice Research, University of Nebraska Omaha, 6001 Dodge Street, Omaha, NE, 218 CPACS68182, USA

M. Campagna & R. Spohn

Justice Policy Center at the Urban Institute, Washington, D.C., USA

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Kowalski, M.A., Campagna, M., Wright, E.M. et al. Understanding Abuse, Mental Health, and Substance Use: The Role of Victimization in a Jail Population. Am J Crim Just 48 , 1320–1342 (2023). https://doi.org/10.1007/s12103-023-09744-6

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Published : 18 October 2023

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DOI : https://doi.org/10.1007/s12103-023-09744-6

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• Physical abuse
• Sexual abuse
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When Substance Abuse and Psychiatric Issues Collide

Co-occurring disorders have taken a toll on celebrities and regular folk alike..

Updated April 5, 2024 | Reviewed by Hara Estroff Marano

• What Is Psychiatry?
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• Many people have a substance use disorder (SUD) and serious psychiatric issue at the same time.
• Experts and the public have struggled with whether drugs caused psychiatric illness or vice versa.
• Carrie Fisher and Matthew Perry may have self-medicated over distress, or SUDs triggered psychiatric ills.
• Sexual, physical, or emotional traumatic events in childhood increase risks for co-occurring disorders.

Often starting in adolescence or young adulthood, many individuals have both a substance abuse disorder and at least one psychiatric disorder, although which diagnosis came first is frequently unclear. This “double trouble” problem is also called “co-occurring disorders (CODS),” as well as “concurrent disorders” and “dual diagnosis.”

The combination of disorders has been discussed in speculative articles about celebrities like Charlie Sheen, Demi Lovato, Justin Bieber, Jhene Aiko, Britney Spears, and Russell Brand. More in-depth scientific and biographic articles about Ernest Hemingway, Carrie Fisher, and Kurt Cobain have helped explain the complexity of CODs. Some of us were mesmerized and sad watching their struggles. Kurt Cobain’s lyrics, performance, and even some of his songs (like “Lithium” and “All Apologies” ) come to my mind as both a fan and a psychiatrist.

But it’s not just celebrities who are suffering from both substance abuse and mental health issues. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2022 , 21.5 million people in the United States had both a substance abuse disorder and a mental illness.

In the past, experts believed it was best to treat one disorder (usually the substance issue) and assumed any psychiatric issues would sort themselves out. However, if the psychiatric issue persisted, it was eventually treated.

In contrast, current thinking is both disorders should be treated in about the same time frame, because ignoring either could be problematic for the patient. If someone is severely depressed, anxious, or has another psychiatric disorder, it may be possible for them to detoxify from a substance, but it’s very hard to develop longer-term control over substance dependence and any accompanying mental illnesses when both issues are not addressed.

For adolescents and young adults with underlying psychiatric disorders, abusing substances provides an unfortunate early opportunity for incorporating bad learning. For example, if they struggle with anxiety , teens may discover that alcohol calms their nerves, making them less anxious about meeting new people or engaging in social interactions. Early self- medication of psychiatric symptoms is double trouble, as alcohol causes brain changes and effects that can trigger alcohol use disorder (AUD.) Some people describe the first drink as magical, that first taste feeling like the key to previously locked-out relief.

More Intense Treatment Is Needed with SUDs Combined with Psychiatric Diagnoses

Individuals diagnosed with co-occurring disorders often need more intense treatment than others due to the complexity of their cases. They also may face greater consequences from their substance abuse compared to patients diagnosed with a mental illness only. Examples of such possible consequences may include a greater exacerbation of their psychiatric symptoms, hallucinations and/or suicidal thinking, an increase in aggressive and violent behaviors, concurrent medical, nutritional, and infectious issues, more emergency room visits than other patients, and a greater number of falls and injuries.

Those with CODs are also more likely to experience head injuries and physical fights with others as well as sexually transmitted infections (STIs). Some have a greater frequency of involuntary inpatient psychiatric placements. These patients need a psychiatric assessment and treatment from experts in both addictions and psychiatry.

Possible Causes of CODs

One theory to explain CODS, the self-medication theory, was developed by the late Harvard psychiatrist and psychoanalyst Ed Khantzian, M.D. He assumed anhedonia (the inability to experience pleasure) or suffering in general was the driving force behind addiction. This theory hypothesizes that underlying psychological disorders compel individuals to self-medicate their feelings with alcohol and/or drugs. In addition, patients are sometimes distinguished by their drugs of choice. For instance, patients with an alcohol use disorder might have been battling social anxiety and self-medicating with alcohol for performance anxiety, shyness, or nervousness in social settings; stimulants such as cocaine or methamphetamine often are used by those with depression or untreated attentional disorders like attention deficit hyperactivity disorder (ADHD).

The self-medication hypothesis was first put forth in a 1985 cover article in the American Journal of Psychiatry. It focused on how and why individuals are drawn to and become dependent on drugs. The self-medication hypothesis was derived from clinical evaluation and treatment of thousands of patients spanning five decades and remains a credible theory.

As I have stated in the American Journal of Psychiatry , it is one of the most “intuitively appealing theories” about addiction. But drugs of abuse and addiction can also cause psychiatric illnesses by targeting the brain’s mood and pleasure systems and inadvertently undermining them.

Neuroscientist Kenneth Blum developed the theory of reward-deficiency syndrome (RDS) as the cause for co-occurring addictive disorders and psychiatric diagnoses. In many ways, RDS is a natural extension of Khantzian’s theory, but it’s an update, attributing the cause to an underlying dopamine deficiency or neurochemical dysfunction that supports drug-seeking/self-medication.

People with RDS, which may be inherited, are miserably unhappy and their lives may be intolerable due to their inability to gain satisfaction from work, relationships, or their accomplishments.

An emerging, newer approach of “preaddiction” as an early or moderate stage of substance abuse is championed by leaders of the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute of Mental Health (NIMH). Preaddiction is conceptually analogous to prediabetes, a risk factor for type-2 diabetes. Prediabetes has contributed to a quantum leap in early detection of people at risk for type-2 diabetes, shortened delays between symptom onset and treatment entry before the onset of diabetes, and overall been a remarkable success in halting progression to diabetes. Similarly, the earliest possible detection of substance abuse will save more lives as experts develop and focus on the evolving concept of preaddiction.

A Possible Environmental Cause: Adverse Childhood Events (ACEs)

In the late twentieth century, a large insurance provider in California worked with researchers to identify adverse childhood experiences (ACEs) that later reverberated in the lives of adults. The researchers found that individuals who reported the greatest numbers of ACEs—such as physical abuse, sexual abuse , loss of a biological parent, witnessing physical violence, and other severely traumatic childhood events—were significantly more likely than those with no ACEs to have psychiatric problems and substance abuse issues in adulthood. They were also at greater risk for suicidal behaviors.

Nirvana's Kurt Cobain was a person with bipolar disorder , substance use and a heroin habit, according to a cousin who described their family history in detail and noted that two uncles had killed themselves with guns. Cobain, who suicided in 1994, purportedly had at least four ACEs, including witnessing domestic violence , experiencing psychological abuse , being neglected, and suffering from his parents’ divorce . Such a score markedly increased Cobain’s risk for suicide as an adult.

Treatment of CODs Should Not Be Delayed

Although an extensive description of how CODs should best be treated is beyond the scope of this article, the key point is to not delay treatment of one disorder in favor of the other. Instead, as much of a simultaneous approach as possible is best. This often means a team of experts is needed, including a psychiatrist, psychologist, therapists, and others to assess the problem, determine whether inpatient, residential, or outpatient treatment is best, and develop a cohesive treatment plan for the patient.

In opioid use disorder treatment, the current standard of care is to focus on prevention of overdose and replacement of opioids with medication-assisted treatments (MATs.) However, detoxification from opioids or maintenance on a MAT would provide little symptomatic relief for a person with opioid use disorder, suicidal ideas, and bipolar illness.

It is also recommended to evaluate individuals for past or recent trauma and co-occurring psychiatric and medical illnesses and treat patients accordingly. Often this means psychotherapy is needed as well as psychiatric treatments. Psychotherapy may include cognitive behavioral therapy (CBT), motivation enhancement therapy (MET), dialectical behavior therapy (DBT), and other forms of therapy. Trained and experienced therapists are crucial. Depending on the substance on which patients depend, medication treatment for their detoxification, relapse prevention, and craving may or may not be available. Currently, medication treatments exist for tobacco use disorder, alcohol use disorder, and opioid use disorder.

Summing It Up

Not only celebrities but many people with a substance use disorder have at least one other psychiatric problem, and when this situation occurs, all disorders need to be identified and treated. I recommend professional help in checking for substance use disorders in psychiatric patients and also looking for psychiatric illness and a history of trauma in people with substance use disorders.

Future breakthroughs in genetic and other scientific research should make clearer why some individuals are more prone to such disorders, as well as lead experts toward the best medications, therapies, and other treatments to alleviate much more of this terrible suffering.

Cross, Charles R. Heavier than Heaven : a Biography of Kurt Cobain. New York :Hyperion, 2001.

Gold MS. Dual disorders: nosology, diagnosis, & treatment confusion--chicken or egg? Introduction. J Addict Dis. 2007;26 Suppl 1:1-3. doi: 10.1300/J069v26S01_01. PMID: 19283969.

Buckley PF, Brown ES. Prevalence and consequences of dual diagnosis. J Clin Psychiatry. 2006 Jul;67(7):e01. doi: 10.4088/jcp.0706e01. PMID: 17107226.

Mark S. Gold, M.D., is a pioneering researcher, professor, and chairman of psychiatry at Yale, the University of Florida, and Washington University in St Louis. His theories have changed the field, stimulated additional research, and led to new understanding and treatments for opioid use disorders, cocaine use disorders, overeating, smoking, and depression.

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Mental Health Disparities Among Homosexual Men and Minorities: A Systematic Review

Muhammad hadi malik.

1 Sargodha Medical College, Sargodha, Pakistan

Shahid Iqbal

2 Rawal Institute of Health Sciences, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan

Muhammad Noman

3 Islam Medical College, Sialkot, Pakistan

Zouina Sarfraz

4 Fatima Jinnah Medical University, Lahore, Pakistan

Azza Sarfraz

5 The Aga Khan University, Karachi, Pakistan

Shabbir Mustafa

Associated data.

Supplemental material, sj-docx-1-jmh-10.1177_15579883231176646 for Mental Health Disparities Among Homosexual Men and Minorities: A Systematic Review by Muhammad Hadi Malik, Shahid Iqbal, Muhammad Noman, Zouina Sarfraz, Azza Sarfraz and Shabbir Mustafa in American Journal of Men's Health

Mental health disparities in sexual minorities, particularly homosexual and bisexual men, are a significant public health concern. This study examines six key themes: general psychiatric issues, health services, minority stress, trauma and PTSD, substance and drug misuse, and suicidal ideation. The aim is to provide a comprehensive synthesis of the evidence, identify potential intervention and prevention strategies, and address knowledge gaps in understanding the unique experiences of homosexual and bisexual men. Reported as per the PRISMA Statement 2020 guidelines, PubMed, PsycINFO, Web of Science, and Scopus were searched until February 15, 2023, with no language restrictions. A combination of the following keywords and MeSH terms was used: homosexual, bisexual, gay, men who have sex with men, mental health, psychiatric disorders, health disparities, sexual minorities, anxiety, depression, minority, stress, trauma, substance, drug misuse, and/or suicidality. Out of 1,971 studies located through database searching, 28 were included in this study pooling a total of 199,082 participants from the United States, the United Kingdom, Australia, China, Canada, Germany, the Netherlands, Israel, Switzerland, and Russia. Thematic findings of all the studies were tabulated and thereby synthesized. Addressing mental health disparities in gay, bisexual men, and sexual minorities requires evidence-based, comprehensive approaches, culturally competent care, accessible services, targeted prevention strategies, community-based support, public awareness, routine screenings, and research collaboration. This inclusive, research-informed approach can effectively reduce mental health issues and enable optimal well-being in these populations.

Introduction

Mental health disparities among sexual minorities, specifically homosexual and bisexual men, represent a significant public health concern. Despite the growing body of research on this subject, sexual minority (SM) individuals continue to experience higher rates of mental health issues when compared with their heterosexual counterparts ( Reczek, 2020 ). This phenomenon is likely multifaceted, stemming from various psychosocial and environmental factors, including discrimination, stigma, and minority stress ( Correro & Nielson, 2020 ). To address knowledge gaps, the present systematic review aims to provide a comprehensive synthesis and evaluation of the available evidence on mental health disparities among homosexual, bisexual men, and sexual minorities. This systematic review will focus on six key themes: general psychiatric issues, health services, “minority stress,” trauma and PTSD, substance and drug misuse, and suicidal ideation.

The first theme in this systematic review will explore general psychiatric issues prevalent among homosexual and bisexual men and other sexual minorities. Research has indicated that these populations experience higher rates of mood disorders, anxiety, and other mental health conditions compared with their heterosexual counterparts. The second theme will focus on access to and utilization of health services by homosexual and bisexual men and less advantaged peers than their heterosexual counterparts. Given the unique mental health challenges faced by these individuals, understanding the barriers and facilitators to access appropriate mental health care is crucial. This theme will consider the role of culturally competent and affirmative mental health services in addressing these disparities. The third theme will delve into the concept of “minority stress” as a key factor contributing to mental health disparities among homosexual and bisexual men and sexual minorities. Minority stress refers to the unique stressors experienced by individuals belonging to marginalized groups, which can have a significant impact on their mental health. The fourth theme of this systematic review will address the prevalence and impact of trauma and post-traumatic stress disorder (PTSD) among homosexual and bisexual men and sexual minorities. This population may be at an increased risk of experiencing trauma due to factors such as hate crimes, harassment, and intimate partner violence. The fifth theme will examine the issue of substance and drug misuse among homosexual and bisexual men and sexual minorities. Research has suggested that this population is more likely to engage in substance and drug use because of increased minority stress/increased psychosocial risk factors, which can have significant implications for their mental health ( Abreu et al., 2023 ; Flenar et al., 2017 ). The sixth and final theme of this systematic review will focus on suicidal ideation among homosexual and bisexual men and sexual minorities. Studies have consistently reported higher rates of suicidal ideation and suicide attempts in this population.

The relationship between sexual orientation and mental health has been the subject of increasing research efforts over the past few decades. However, most of the literature up until now (February 15, 2023) has focused primarily on the experiences of lesbian, gay, and bisexual (LGB) individuals as a single, homogeneous group ( Russell & Fish, 2016 ). This approach fails to account for the unique experiences of homosexual and bisexual men, whose mental health outcomes may differ from other SM populations. The existing literature predominantly concentrates on negative mental health outcomes, neglecting the potential for resilience and protective factors within this population ( Ramirez & Paz Galupo, 2019 ). This systematic review investigates the underlying mechanisms contributing to mental health disparities among homosexual and bisexual men, with an emphasis on identifying potential avenues for intervention and prevention strategies.

This systematic review is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement 2020 guidelines to ensure a rigorous and transparent methodology. This study, focused on analyzing existing literature, does not involve primary data collection or interaction with human participants, and therefore, is exempt from obtaining ethical approval. The research poses no potential risks or harm to any subjects, adhering to the relevant institutional guidelines. The protocol for this systematic review is registered in the Open Science Framework (OSF): osf.io/3n6q9.

Study Selection

The study selection process involved a comprehensive search of electronic databases, including PubMed, PsycINFO, Web of Science, and Scopus. The search strategy employed a combination of keywords and MeSH terms related to mental health, disparities, and sexual minorities. The Boolean logic was applied (and/or), with the following keywords: Homosexual, Bisexual, Gay, Men who have sex with men, Mental health, Psychiatric disorders, Health disparities, Sexual minorities, Anxiety, Depression, Minority, Stress, Trauma, Substance, Drug misuse, and/or Suicidality. The search string is appended in Supplementary Table 1 . Reference lists of relevant articles and previous systematic reviews were screened to identify additional studies (umbrella methodology). Only publications in the previous 10 years (January 2012 to February 15, 2023) were included with no restrictions on the language (i.e., non-English studies were translated to English). Two independent reviewers screened titles and abstracts of the identified articles for potential eligibility. Full-text articles were obtained for further assessment, with any disagreements between the reviewers resolved through discussion or consultation with a third reviewer. The bibliographic management tool utilized in this study was EndNote X9 (Clarivate Analytics).

Inclusion and Exclusion Criteria

Inclusion criteria for the systematic review comprised.

• Original empirical research, including observational, cross-sectional, and longitudinal studies.
• Studies focusing on mental health disparities among homosexual, bisexual men, and sexual minorities.
• Studies providing quantitative or qualitative data on the key themes of the review (General Psychiatric issues, Health Services, “Minority Stress,” Trauma and PTSD, Substance and Drug Misuse, and Suicidal Ideation).

Exclusion Criteria Encompassed

• Non-empirical articles, such as editorials, commentaries, and narrative reviews.
• Studies that do not provide sufficient data on mental health disparities among the target population.
• Studies that solely focus on heterosexual populations or do not differentiate between sexual orientation groups in their analysis.

Data Synthesis and Presentation

The data from the included studies were extracted using a standardized data extraction form to maintain consistency and reduce potential bias. The extracted data were thereby organized under the following headings: author and year, title, study type, inclusion/selection criteria, scale/questionnaire used, location, participants, and key findings. All reviewers conducted the data extraction process, with any discrepancies resolved through discussion or consultation with the last reviewer. This approach enhanced the reliability and validity of the extracted data.

The extracted data were synthesized through a narrative synthesis approach, which involved organizing and summarizing the findings in a coherent and structured manner. This method allowed for a thorough examination of the included studies, taking into consideration the various factors that may have contributed to the observed mental health disparities among homosexual and bisexual men and sexual minorities.

The narrative synthesis was organized according to the key themes identified during the data extraction process. For each theme, a summary of the relevant findings was presented, followed by a summary of the results of the different studies. This synthesis highlighted potential patterns or trends that emerged.

The presentation of the synthesized data involved a combination of textual descriptions and tabulation. The textual descriptions provided a detailed summary of the key findings, focusing on the prevalence, risk factors, and underlying mechanisms of mental health disparities among homosexual and bisexual men and disenfranchised groups/minorities. Whereas, the table was used to organize and display the extracted data in a structured and accessible format. This allowed for a clear and concise presentation of the study characteristics, participant demographics, mental health outcomes, and key findings related to the themes.

Risk of Bias Synthesis

The methodological quality and risk of bias of the included studies were assessed using appropriate tools based on the study design. The Cochrane Risk of Bias tool for randomized controlled trials (ROB 2) and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool were utilized for randomized and non-randomized trials. The Newcastle–Ottawa Scale (NOS) checklist was used for observational studies. Risk of bias assessments was conducted independently by two reviewers, with any discrepancies resolved through discussion or consultation with a third reviewer.

In the identification phase, 1,971 studies were located of which 183 duplicates were removed. In the screening phase, 1,788 titles and abstracts were screened; of those, 231 studies were sought for retrieval and assessed for full-text eligibility. Twenty-eight studies were included in this systematic review. The total participant count of all populations was 199,082. The PRISMA flowchart is illustrated in Figure 1 . The findings are further elucidated below.

PRISMA Flowchart Illustrating the Study Selection Process

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

General Psychiatric Conditions and Outcomes

Seven studies were collectively presented for general psychiatric characteristics and outcomes ( Chen et al., 2012 ; Gevonden et al., 2014 ; Gonzales et al., 2016 ; Hart et al., 2020 ; Hylton et al., 2017 ; Lyons et al., 2012 ; Price-Feeney et al., 2019 ). The total sample comprised 88,397 participants from Australia, China, the Netherlands, Russia, and the United States. One study was an interventional trial whereas the other six were cross-sectional observational studies. The studies are characterized in Table 1 .

Characteristics of All the Included Studies (N = 28)

Hart et al. (2020) reported on sexually transmitted diseases (STDs) and high HIV prevalence among gay and bisexual men globally. Their study provided evidence of a 10-session cognitive behavioral therapy (CBT) intervention to reduce substance use, social anxiety, and sexual risk behaviors in HIV-negative respondents. Post 10 sessions of CBT, the authors reported a 50% reduction in STD/HIV sexual risk behavior during the 6 months; reductions in problematic alcohol use and social anxiety were reported. Overall, CBT emerged as an efficacious approach to reducing HIV/STD risk behavior, social anxiety, and problematic alcohol use in gay and bisexual men ( Hart et al., 2020 ).

Price-Feeney et al. (2019) examined whether LGB youth living in a rural community had worse health status compared with heterosexual counterparts living in a nonrural community. The authors pooled a total of 5,100 youths aged 13 to 18 in the United States between 2010 and 2011. The findings underscored that LGB youth underwent more psychological and social challenges including depression, substance use, bullying, and low self-esteem over 1 year as compared with nonrural and rural heterosexual youth. The rural community living status was not a contributor to other challenges for the LGB youth. The study recommended that health care providers ensure an LGB-inclusive environment to promote self-disclosure and provide clinical services to address these psychosocial challenges ( Price-Feeney et al., 2019 ).

Hylton et al. (2017) led a cross-sectional survey study in Moscow, Russia between 2010 and 2013 and enrolled 1,367 MSM. The authors studied the relationship between recent stigma, sexual identity, and probable depression by applying logistic regression models. Depression was defined by a score of 23 or more on the Center for Epidemiological Studies Depression scale (CES-D). In total, 36.7% of participants had probable depression with bisexual men’s sexual identity acting as a protective factor against probable depression. Recent stigma led to increased chances of probable depression. An interaction was found between anti-gay laws and stigma. Among those that experienced stigma, there was a 1.67-fold increase in probably depression post the passing of anti-gay laws. The authors highlight the co-occurrence of depression among MSM in Russia, which was exacerbated by laws denying homosexual identity and recent stigma ( Hylton et al., 2017 ).

Gonzales et al. (2016) analyzed data from the 2013 and 2014 National Health Interview Survey. This was the first study to question self-identified sexual orientation to ascertain health outcomes from the leading U.S. health survey. An analysis was conducted to compare health risks and health factors between LGB (gay, N = 624 and bisexual, N = 515) and heterosexual adults ( N = 67,150). It was determined that LGB adults faced substantial disparities compared with their heterosexual counterparts; causes included stressors such as heavy drinking, severe psychological distress, and smoking. The authors further highlighted the need for sensitivity toward sexual minorities during health screening ( Gonzales et al., 2016 ).

Gevonden et al. (2014) investigated whether sexual minorities were at higher risk of developing psychotic symptoms due to overlapping stressors as ethnic minorities such as defeat, social exclusion, and discrimination. The authors conducted a national cross-sectional survey using the Composite International Diagnostic Interview of individuals between the age of 18 and 64 years (NEMESIS 1 and NEMESIS 2). A total of 11,235 LGB individuals were pooled. The participants were more likely to have experienced psychotic symptoms as compared with their heterosexual counterparts. Mediators of this association comprised bullying, childhood trauma, and discrimination. The study concludes that exposure to minority stress is a key mechanism that links psychosis and other mental health problems and minority status ( Gevonden et al., 2014 ).

Chen et al. (2012) assessed the social, behavioral, and psychological characteristics of MSM in China to understand the risks associated with HIV transmission. A total of 714 responses were analyzed where a high-risk and a control group were classified. MSM notably had high-risk behaviors including heavy alcohol consumption, intentional attempts of suicide, a history of sexual abuse in childhood, and a mistaken belief that HIV was protected through condom use alone. The authors reported that the two groups did not have significant differences in education levels, sexual orientation, drug use, discrimination, and social stigma experiences. The study concludes that interventions targeted at HIV and AIDS transmission among MSM must account for different psychological and social characteristics of the group with and without high-risk behaviors ( Chen et al., 2012 ).

Lyons and colleagues (2012) enrolled 1,135 gay males aged 40 years or older in an online survey. A nationwide study was conducted in Australia to explore the psychological impact of HIV in both HIV-positive and HIV-negative groups. The findings revealed that individuals with HIV were more likely to receive treatment for a psychiatric condition, but were not more likely to obtain treatment for a physical health condition other than HIV. Men with HIV reported higher levels of psychological distress. The underlying factors of poorer mental health included living alone, not working or lower income, experiencing discrimination, receiving treatment for a major health condition, and considering one’s sexual orientation as a key part of self-identity. The reported disparities in HIV-negative and positive gay men were larger for mental not physical health. The authors suggest that more attention is required to address the underlying psychosocial factors among those living with HIV ( Lyons et al., 2012 ).

Health Services and Mental Health

Three studies addressed health services for homosexual men and sexual minorities ( Grov et al., 2013 ; Rimes et al., 2018 ; Stanley & Duong, 2015 ). The total participant count was 16,589 with studies from the United States and the United Kingdom. All three studies were observational and cross-sectional in nature. The characteristics of these studies are listed in Table 1 .

Rimes et al. (2018) compared clinical, sociodemographic, and treatment characteristics in adult patients who received psychological interventions from Improving Access to Psychological Therapies (IAPT) in London, UK. Data were reported for 3,744 men ( N = 75, bisexual; N = 645, gay; and N = 3,024, heterosexual) who were analyzed for pre- and post-treatment changes. The findings suggested that bisexual men had higher chances of having depression caseness as compared with gay men; however, anxiety caseness was higher in the group as compared with heterosexual or gay men. Insignificant differences were reported for treatment outcomes otherwise. The authors highlighted the need to understand the reasons behind differential outcomes in the male groups; these included discrimination, stigma, or traumas about sexual orientation while obtaining therapy services or in daily life ( Rimes et al., 2018 ).

Stanley and Duong’s (2015) key objective was to test the correlation between mental health service utilization and sexual orientation among older gay and bisexual adults; they assessed the possible impact of excessive alcohol use, psychological distress, and self-perceived poor general health. The authors utilized data from the 2011 New York City Community Health Survey with a sample of 5,138 adults aged 50 or above. Logistic regression modeling was applied to determine the associations between mental health service use and sexual orientation, where it was revealed that LGB older adults were more likely than heterosexual counterparts to have utilized psychiatric medication and counseling. These trends were computed over 1 year. Alcohol use, distress, and self-perceived health were insignificant mediators of the correlation. Overall, LGB older adults faced difficulties in accessing mental health services, and further research was warranted to make more assertive conclusions ( Stanley & Duong, 2015 ).

Grov and colleagues (2013) identified the importance of five health issues, namely body image, drugs and alcohol, HIV and STDs, mental health, and smoking by pooling 660 bisexual and gay men in New York, USA. The authors applied a time-space sampling method in bathhouses and bars/clubs to collect data. Participants were assessed for recent sexual risk behavior, substance use, smart device use, and demographics. As opposed to previous research in the area, the authors identified that STDs and HIV were both received as the most important health issues. Mental health and drugs were rated high, suggesting the importance of HIV prevention in addressing these issues. Most of the respondents owned smart devices, suggestive of the usefulness of online platforms for health prevention and education in the target group ( Grov et al., 2013 ).

“Minority Stress”

Four studies specifically reported psychiatric problems with “minority stress” ( Pachankis et al., 2015 ; Przedworski et al., 2015 ; Sattler et al., 2017 ; Wight et al., 2012 ). In total, 35,520 participants were assessed with origins from Germany and the United States. Three studies were observational in nature; one was a comparative, population-based study, with another being a retrospective cohort, and the third was a cross-sectional student health survey. One study was a randomized controlled trial. The studies are tabulated in Table 1 .

Sattler and colleagues (2017) aimed to investigate the mental health differences between gay and bisexual men compared with heterosexual males in Germany while assessing for stress in the sample. A total of 931 gay/bisexual male participants were assessed using the SCL-90-S questionnaire. Utilizing linear regression, the authors reported that bisexual and gay men had higher levels of mental health problems with stress being a significant predictor. Further research was suggested to manage and reduce the impact of “minority stress” on mental health outcomes among bisexual and gay men ( Sattler et al., 2017 ).

Pachankis et al. (2015) administered transdiagnostic cognitive behavioral therapy (CBT) to 63 adult gay and bisexual men to reduce minority stress, and improve health risks and mental health. A comparison of immediate treatment subjects was made to those on a 3-month waitlist group. The participants submitted self-reports and interviews of past-90-days behaviors. Transdiagnostic CBT significantly reduced alcohol use, depression, sexual compulsivity, and past-90-day condomless sex with casual partners. A moderate improvement in anxiety and heavy drinking was reported. The study intervention was considered potentially helpful in providing evidence-based treatment to LGB-affirmative adults ( Pachankis et al., 2015 ).

Przedworski et al. (2015) compared the mental health outcomes of SM and heterosexual college students. They collected data from the 2007 to 2011 College Student Health Survey, which enrolled 34,324 students across 40 institutes in Minnesota, USA. The findings revealed that SM groups including gay and bisexual students were more likely to report any psychiatric diagnosis along with mental distress as compared with heterosexual counterparts. All groups excluding “unsure men” had higher odds of experiencing two or more stressful life events. The study findings support the notion that the group experiences worse mental health outcomes and they may benefit from targeted structural, social, and individual interventions to address disparities ( Przedworski et al., 2015 ).

Wight and colleagues (2012) tested the correlation between mental health and stress in midlife and old gay-identified males. The authors did not account for HIV status and aimed to explore the impact of emotional support and mastery on this correlation, as well as the impact of same-sex marriage. Data was obtained within the United States of the Multicenter AIDS Cohort Study. A total of 202 participants aged 44 to 75 years were enrolled between 2009 and 2010. The findings revealed that SM stress including excessive HIV bereavements, gay-related stigma, and aging-related stress including fiscal concerns impacted mental health. A partial mediator correlation was found for the sense of mastery. On the contrary, being legally married was protective against stressors, whereas HIV status, education, and ethnicity/race had no noteworthy impact ( Wight et al., 2012 ).

Trauma and PTSD

Two studies reported outcomes on trauma and PTSD ( Blosnich et al., 2022 ; Lucas et al., 2018 ). A total of 19,306 participants were pooled from the United States. The studies were observational in nature. The studies are enlisted in Table 1 .

Blosnich et al. (2022) compared and investigated the differences in potentially traumatic events (PTEs) and probably posttraumatic stress disorder (PTSD) in a sample of 18,866 Vietnam veterans who self-identified as gay or bisexual (139 males at birth), compared with heterosexual respondents. Data were obtained from the 2016 to 2017 Vietnam Era Health Retrospective Observational study survey. A multivariable regression analysis was conducted where gay and bisexual veterans were reportedly more likely to have current probably PTSD and had experienced PTEs compared with heterosexual veterans. The differences in PTSD outcomes of LGB and heterosexual veteran groups were partially due to differential PTEs exposure. The authors conclude that sexual orientation is an imperative factor when accounting for mental health outcomes of LGB veterans ( Blosnich et al., 2022 ).

Lucas and colleagues (2018) compared the rates of military sexual assault (MSA), PTSD, and depression in non-LGB and LGB veterans. A total of 2583 participants were enrolled from the United States of which 110 were LGB and 330 were non-LGB veterans. The veterans were matched by gender and age. The findings indicated that LGB veterans were more likely to have experienced MSA and have higher rates of depression and probably PTSD. Overall, the authors find that MSA mediates associations with depression and PTSD in LGB veterans. The authors recommend that health care workers assess for MSA when caring for LGB veterans, particularly groups that meet psychiatric thresholds for depression and PTSD ( Lucas et al., 2018 ).

Substance and Drug Misuse

Six studies focused on substance and drug misuse in gay, bisexual men, either alone or compared with heterosexual counterparts ( Fallin-Bennett et al., 2017 ; Heffner et al., 2020 ; Ip et al., 2017 ; Jordan et al., 2014 ; Roth et al., 2018 ; Starks et al., 2019 ). Two of the studies were randomized trials; one was controlled and the second was a pilot, interventional trial. Four were cross-sectional surveys. A total of 10,944 participants were included from the United States and Canada. The studies are characterized in Table 1 .

Heffner and colleagues (2020) compared baseline characteristics and treatment outcomes in SM and non-SM smokers in bisexual versus gay smokers. The authors conducted a randomized controlled trial of two web-based cessation treatments. At enrollment, SM smokers screened positive for all the mental health conditions assessed and were more exposed to passive smoking at home. The differences in baseline traits did not translate into differential treatment outcomes. Cessation outcomes did not significantly differ in SM and non-SM smokers or within SM subgroups. Regardless, the SM smoking group’s willingness/ability to quit smoking could be further understood by taking into account their psychosocial profile for targeted interventions. While there were similar quitting rates in SM and non-SM smokers, the former group must be considered for a younger age, racial/ethnic minority status, lower socioeconomic status, and higher prevalence of mental health symptoms ( Heffner et al., 2020 ).

Starks et al. (2019) assessed the efficacy of a substance use module (SUM) and communication training (CT) training videos to reduce sexual HIV transmission and drug use in male couples. In total, 70 male couples, with a total of 140 MSM were randomized to four groups: (a) couples HIV testing and counseling (CHTC); (b) CT videos and CHTC; (c) SUM and CHTC; and (d) CT videos, SUM, and CHTC. The study substantiated that completing SUM without CT videos significantly reduced drug use with related problems. However, those that viewed CT videos retained a reduction during the 3- and 6-month follow-up period. The authors reported CHTC to be an effective method for delivering substance use interventions to MSM couples. No differences in sexual behaviors were observed among the groups ( Starks et al., 2019 ).

Roth et al. (2018) conducted bivariate and multivariate analysis by comparing bisexual and gay men for substance use patterns in the Momentum Study; participants were classified based on sexual attraction, self-identity, and sexual behavior while controlling for sociodemographic, sexual behaviors, and psychosocial factors. Bivariate analysis revealed that bisexual men had higher multiple substance use in all samples ( p < .05). Heroin and nonprescription stimulants were significant in all multivariate regression models. The authors reported that bisexual men have higher substance use levels, lower education and income, and higher anxiety and depression scores compared with gay men. These findings suggest that tailored health programs are required for gay and bisexual men ( Roth et al., 2018 ).

Fallin-Bennett et al. (2017) examined the use of other tobacco products (OTP) among young adult LGB bar patrons; they assessed the relationship between intention to quit, past quit attempts, and binge drinking with OTP use. A cross-sectional survey of adults aged 18 to 26 years in nightclubs/bars in seven US cities between 2012 and 2014 was conducted. The findings revealed that the GB men were more likely to smoke electronic cigarettes, and hookah and use chew and snus. The authors highlighted the need for bar-based interventions to address the use of all forms of tobacco in SM, high-risk groups ( Fallin-Bennett et al., 2017 ).

Ip et al. (2017) assessed the misuse of anabolic-androgenic steroids (AAS) in homosexual men. AAS has notably been used to enhance body image based on studies from Australia and the United Kingdom, however, the trend has been reported minimally in the United States. Ip and colleagues compared heterosexual ( N = 73) and homosexual ( N = 220) male gym members in various districts in San Francisco. A 114-item survey was administered, where it was determined that 10% of homosexual men reported lifetime use of AAS. The respondents regularly engaged in high-risk injection practices and sexual behaviors, placing them at a greater risk of spreading and contracting HIV/other infectious diseases. In sum, the authors find that AAS and other enhancing drugs serve as a potential vector in spreading infectious diseases; therefore, it is necessary to be mindful of psychological health and sexual behavior characteristics in SM groups ( Ip et al., 2017 ).

Jordan et al. (2014) examined the differences in tobacco use between SM (LGBQ) and heterosexual youths in the United States. The Out, Proud, and Healthy survey for LGBQ youth and the Missouri Youth Tobacco Survey for general population youth were utilized for data. The results highlighted that while LGBQ youth-initiated smoking at a later age, they were more likely to be poly-tobacco users, current smokers, use cigarillos/cigars, and be exposed to secondhand smoke in vehicles. Increased odds of being a current smoker were associated with older age, LGBQ, female gender, using OTP, and being exposed to secondhand smoke in vehicles. The authors suggest the need for sexual orientation data to be collected in tobacco consumption surveys to address health disparities in LGBQ youth. Overall, LGBQ groups are at a high risk of secondhand smoke and tobacco use as compared with their heterosexual counterparts ( Jordan et al., 2014 ).

Suicidal Ideation

Six studies addressed suicidal ideation in gay, bisexual men, either alone or compared with heterosexual counterparts ( Diamond et al., 2012 ; Hill & Pettit, 2012 ; Lian et al., 2015 ; Lyons et al., 2019 ; Swannell et al., 2016 ; Wang et al., 2012 ). Five of the studies were cross-sectional studies, with two population-based surveys, two representative sample studies, and one retrospective study; one phase I/II controlled, interventional, clinical trial was included. The total participant count was 28,326 with locations including Australia, China, Israel, Switzerland, and the United States. The characteristics of these studies are enlisted in Table 1 .

Lyons et al. (2019) aimed to fill gaps in information on suicide epidemiology among gay individuals. Based on the National Violent Death Reporting System data obtained from 18 states in the United States between 2003 and 2014, the sociodemographic characteristics and suicidal circumstances were compared between gay male decedents and nongay male decedents. Logistic regression analysis was conducted to investigate associations between sexual orientation, suicide, and precipitating circumstances. The authors identified differences based on age, mechanism of injury, suicidal intent and planning, and precipitating circumstances. The study highlights the need for culturally sensitive suicide prevention efforts to account for the needs of sexual minorities ( Lyons et al., 2019 ).

Swannell et al. (2016) studied the relationship between sexual orientation, suicidality measures, and non-suicidal self-injury in Australian adults. A national, representative sample of 10,531 adults was included where males and females were analyzed separately by applying logistic regression models. The results revealed that SM individuals had a greater risk of self-injury and suicidality as compared with their heterosexual counterparts. Similarly, gay males were more likely to report suicide attempts and suicidal ideation as compared with heterosexual men. The study highlights the need for clinicians to openly discuss suicide and self-harming thoughts/behaviors with clients, particularly those who identify as sexual minorities. Therapeutic strategies are essential in enhancing personal/social resources and reducing internalized stigma ( Swannell et al., 2016 ).

Lian et al. (2015) studied the relationship between suicide and sexual orientation in Asian youth. In their cross-sectional study, 17,016 individuals aged 15–24 were included from Hanoi, Shanghai, and Taipei in China. The study identified that the overall prevalence of suicidal ideation and attempts in the past 12 months was higher in LGB youth as compared with heterosexual counterparts (12.8% vs. 8.1% and 4.0% vs. 2.4%, respectively). Suicidal attempts and ideation were reportedly the highest in Taipei, followed by Shanghai and Hanoi. The multivariate logistic regression analysis revealed that youth in Taipei were at higher risk of suicidal ideation. Overall, the findings suggest that suicidality was a common occurrence in Asian youth and urbanized cities ( Lian et al., 2015 ).

Diamond and colleagues (2012) aimed to modify attachment-based family therapy (ABFT) to fit suicidal LGB adolescents and gather initial efficacy data in an open trial. The study comprised two phases; the first involved a treatment development team that adapted ABFT to meet the unique need of suicidal LGB youth. The second consisted of enrolling 10 suicidal LGB youth that underwent 3 months of ABFT. The findings suggested that the population was responsive to family-based therapy as documented with significant decreases in depression, suicidal ideation, material attachment-related anxiety, and avoidance and with high treatment retention. The authors conducted the first-ever family-based treatment tested and adapted specifically for suicidal LGB adolescents. Larger samples are required testing to ensure that the results are more generalizable ( Diamond et al., 2012 ).

Hill and Pettit (2012) aimed to test a model explaining the relationship between suicidal ideation and sexual orientation in college students. The model proposed that thwarted belongingness and perceived burdensomeness could account for this association. A total of 198 LGB college students were enrolled who reported higher levels of suicidal ideation and perceived burdensomeness compared with their heterosexual counterparts. While perceived burdensomeness partially accounted for the relationship between suicidal ideation and sexual orientation, thwarted belongingness did not. An indirect effect was more pronounced in individuals who anticipated and perceived rejection due to sexual orientation. The authors highlight the importance of addressing perceived burdensomeness in prevention and interventional treatment efforts targeted at suicide reduction in SM groups ( Hill & Pettit, 2012 ).

Wang et al. (2012) examined suicidality risks in young men of different sexual orientations in Switzerland. In total, 571 participants whom either self-identified gay/bisexual men or other MSM were included. The findings of three probability surveys revealed that men under the age of 25 reported the highest 12-month suicidal ideation/suicide attempt prevalence. In gay/bisexual men between the age of 16 and 20, the lifetime prevalence of suicide attempts was 5.1% to 22%. The group was significantly more likely to report 12-month suicidal plans, ideation, and attempts. The ratios and prevalence of suicidal behavior varied among men based on age and sexual orientation. Overall, the study highlights the need for targeted suicide prevention strategies for men of diverse sexual orientations ( Wang et al., 2012 ).

Risk of Bias (Quality) Assessment

The risk of bias synthesis and quality assessment is presented in the Supplementary Materials summarizing the methodological quality of each study and highlighting potential limitations in the evidence base. Supplementary Figure 1 presents bias assessments of the included trials (non-randomized and randomized) using ROBINS-I and ROB 2 tools (Cochrane). The quality assessment of nonrandomized observational studies is presented in Supplementary Table 2 (NOS).

The results of this systematic review shed light on the mental health disparities among homosexual, bisexual men, and less advantaged peers than their heterosexual counterparts across various mental health dimensions. The studies reviewed in this analysis originate from different countries with the highest representation from the United States ( N = 16), followed by Canada/Australia/China ( N = 2 each). A wide range of methodologies (i.e., randomized controlled trials, open-label pilot-testing, observational cohorts, population-based studies) were applied involving diverse participant samples (i.e., urban/rural, different social/economic backgrounds). The key findings from these studies emphasize the complex and multifaceted nature of mental health disparities in this population, warranting further investigation and targeted interventions.

This systematic review assessed seven studies reporting general psychiatric traits and outcomes in sexual minorities, emphasizing the need for tailored interventions and inclusive health care environments. The studies highlighted that sexual minorities face unique mental health challenges and risk behaviors, with minority stress being a crucial mechanism linking mental health problems to minority status. Factors such as stigma, discrimination, and trauma related to sexual orientation contributed to these disparities. Three cross-sectional, observational studies were examined, focusing on health services for homosexual men and sexual minorities, totaling 16,589 participants from the United States and the United Kingdom. The findings emphasized the complexities in accessing and utilizing mental health services among sexual minorities, suggesting that innovative approaches like online platforms may be beneficial in providing health prevention and education. This review examined four studies on psychiatric problems related to “minority stress,” totaling 35,520 participants from Germany and the United States. The findings highlighted the challenges disenfranchised groups/minorities face regarding mental health and stress, suggesting the need for tailored interventions and support to address disparities. Our review analyzed two studies that reported outcomes on trauma and PTSD among sexual minorities, with a total of 19,306 participants from the United States. The findings emphasized the increased vulnerability of SM veterans to potentially traumatic events (PTEs), posttraumatic stress disorder (PTSD), and depression compared with their heterosexual counterparts. The results underscored the importance of considering sexual orientation when addressing mental health outcomes in LGB veterans and suggested that health care providers should assess for military sexual assault (MSA) when caring for this population. Further research is needed to better understand the factors contributing to these disparities and to develop targeted strategies for supporting SM veterans experiencing trauma and PTSD.

This systematic review examines six studies on substance and drug misuse in gay and bisexual men (10,944 participants from the United States and Canada) and six studies on suicidal ideation in gay and bisexual men (28,326 participants from Australia, China, Israel, Switzerland, and the United States). The studies reveal the need for tailored interventions and programs addressing substance misuse and suicide in these populations, as well as further research to understand contributing factors and develop targeted strategies. Key findings include the importance of understanding the psychosocial profile of SM smokers, efficacy of substance use modules and couples HIV testing and counseling for male couples, tailored health programs based on substance use patterns, bar-based interventions for tobacco use, anabolic-androgenic steroid misuse prevalence and associated high-risk behaviors in homosexual men, and higher risks of secondhand smoke and tobacco use in LGBQ youth. Regarding suicidal ideation, the studies emphasize the need for culturally sensitive suicide prevention efforts, open discussion of suicide and self-harming thoughts/behaviors with clients who identify as sexual minorities, the prevalence of suicidal ideation and attempts in LGB youth (particularly in urbanized cities), the potential efficacy of attachment-based family therapy for suicidal LGB adolescents, the role of perceived burdensomeness in suicidal ideation and sexual orientation, and targeted suicide prevention strategies for men of diverse sexual orientations.

As of February 15, 2023, the scientific literature contains a limited number of systematic reviews and meta-analytical studies that specifically focus on mental health disorders in lesbian, gay, and bisexual individuals. For instance, King et al. (2008) conducted a systematic review between 1966 and 2005 to locate 25 studies. The authors reported a nearly two-fold rise in suicide attempts in the LGB population (Risk ratio: 2.47); similarly, the risk of anxiety and depression was nearly 1.5 times higher in the LGB population (RR: 1.54–2.58) ( King et al., 2008 ). Escobar-Viera and colleagues (2018) published a systematic review focusing on the use of social media and depression in LGB populations by collating data between 2003 and 2017. The authors included 11 articles where cyberbullying was the most studied experience associated with suicidality and depression ( Escobar-Viera et al., 2018 ). Strongylou and colleagues (2022) conducted a mixed-methods study examining remote mental health-seeking behaviors among GBM in Ireland and the United Kingdom during the COVID-19 lockdown period. Based on 1368 participants’ data, the authors identified that recent anxiety experiences and a previous mental health diagnosis were enabled in accessing resources during the lockdown ( Strongylou et al., 2022 ).

There are certain limitations of our study. First, some populations had confounders such as an add-on diagnosis of PTSD, which may have skewed mental health outcomes. Second, the inclusion of LGB populations may pose limitations in generalizability because analytical outcomes were grouped for SM women as well. Finally, an inherent participant bias is that not all SM participants may have reported stress, simply because they did not identify as “minorities.” Therefore, on certain counts, self-reporting bias exists.

The recommendations and future directions are as follows:

• Culturally Competent Care: Health care providers should receive training in culturally competent care, enabling them to understand and address the unique challenges faced by sexual minorities. This will help build trust and rapport with patients, ensuring that they feel comfortable discussing their mental health concerns and substance misuse.
• Accessible Mental Health Services: Ensure that mental health services are accessible, inclusive, and non-judgmental for disenfranchised groups/minorities. This includes offering specialized support groups, therapy, and counseling services tailored to the needs and experiences of gay, bisexual, and other SM individuals.
• Targeted Prevention and Intervention Programs: Develop and implement targeted prevention and intervention programs that address the specific risk factors and mental health issues faced by gay, bisexual men, and sexual minorities. This includes substance misuse, trauma, PTSD, and suicidal ideation. These programs should be evidence-based and culturally sensitive.
• Community-Based Support: Encourage the development and promotion of community-based support networks for disenfranchised groups/minorities. This includes peer support groups, LGBTQ+ community centers, and safe spaces where individuals can share their experiences, access resources, and build resilience against minority stress.
• Public Awareness Campaigns: Launch public awareness campaigns that promote understanding, acceptance, and support for minorities. These campaigns should challenge stigma, discrimination, and misinformation surrounding LGBTQ+ mental health, and emphasize the importance of mental well-being for all individuals, regardless of their sexual orientation.
• Routine Screening for Mental Health Issues: Health care providers should routinely screen for mental health issues, trauma, substance misuse, and suicidal ideation in SM patients. Early detection and intervention are crucial for improving mental health outcomes in these populations.
• Ensuring confidentiality: Mental health care providers must ensure that confidentiality is maintained. This can be achieved by implementing privacy policies and procedures and ensuring that all staff is trained to handle sensitive information appropriately.
• Offer anonymous hotlines: Anonymous hotlines can provide individuals with a confidential and anonymous way to seek support and information about mental health concerns. These hotlines can be staffed by mental health professionals or trained volunteers.
• Research and Collaboration: Further research on mental health issues, minority stress, and risk factors specific to gay, bisexual men, and sexual minorities must be encouraged including effective prevention and intervention strategies tailored to these populations. Collaborations must be fostered between the medical scientific community, LGBTQ+ organizations, and policymakers to develop comprehensive solutions to address mental health disparities.

In conclusion, addressing the mental health disparities faced by gay, bisexual men, and sexual minorities necessitates a concerted effort from the health care community, medical professionals, and key stakeholders. A comprehensive approach, grounded in evidence-based practices, is vital to tackle the unique challenges experienced by these individuals. By adopting culturally competent care, ensuring the availability and accessibility of mental health services, devising targeted prevention and intervention strategies, cultivating community-based support systems, raising public awareness, conducting routine screenings for mental health issues, and promoting research and collaborative initiatives, it becomes possible to effectively reduce the burden of mental health issues such as minority stress, trauma, PTSD, substance and drug misuse, and suicidal ideation in these populations. Through a concerted, inclusive, and research-informed approach, society can pave the way for disenfranchised groups/minorities to access the necessary resources, support, and care required to attain and maintain optimal mental well-being.

Supplemental Material

Acknowledgments.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental material: Supplemental material for this article is available online.

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The Unlikely Force Behind a Push to Legalize ‘Shrooms’ in New York

A lobbying effort led in part by religious groups has state lawmakers considering two different measures that would legalize psilocybin, a drug known as “magic mushrooms.”

By Claire Fahy and Grace Ashford

Reporting from the State Capitol in Albany, N.Y.

Religious texts state that when Moses climbed to the top of Mount Sinai, he was spoken to by God and inscribed that message onto stone tablets that became known as the Ten Commandments. Thunder rumbled, trumpets blared and lightning shot across the sky.

It was, by biblical and other standards, an extraordinary moment. Moses had been fasting and was clearly in an altered state of consciousness when God appeared to him, scholars say.

But what if, as at least one Jewish scholar has suggested, Moses was also high?

It may sound like blasphemy, but some religious scholars say they see an overlap between the pursuit of the divine and the use of psychedelic drugs — an unlikely partnership that underpins one of the most unusual legislative efforts in New York this session.

The goal is to expand access in the state to psilocybin, a psychedelic compound found in over 200 types of mushrooms that has been used as a part of religious experiences — as well those of a spiritual and existential sort — for thousands of years.

“There has been a long, documented history of humans interacting positively on religious, spiritual and cultural grounds with psilocybin,” said Aaron Genuth, president of Darkhei Rephua , a Jewish nonprofit that pushes for the legalization of psychedelics.

That history could trace as far back as biblical times. Benny Shanon, a psychology professor at the Hebrew University of Jerusalem , argued in 2008 that the Israelites may have come across hallucinogenic plants as they wandered in the desert ahead of Moses’ revelation.

Many Jewish scholars and leaders caution against searching for evidence of drug use in religious texts, and find Professor Shanon’s theory offensive. But Mr. Genuth and others assert that psychedelics can deepen religious practice.

“I think the momentum is continuing to grow and the issue is becoming more mainstream and less stigmatized,” Mr. Genuth said.

Religion aside, researchers have discovered the compound’s remarkable effects on neuroplasticity and its potential as a treatment for various mental and physical health issues. In 2020, Oregon became the first state to legalize psilocybin for medical use, and a handful of cities, including Seattle; Oakland, Calif.; and Ann Arbor, Mich., have more broadly decriminalized hallucinogens.

New York is considering several proposals to make psilocybin available for public use, two of which are pending in committee. The first, sponsored by Assemblyman Pat Burke of Buffalo, takes a relatively conservative approach, allowing trained “facilitators” to dispense psilocybin in a controlled setting to help treat conditions like anxiety, depression and substance abuse.

The second, carried by Assemblywoman Linda Rosenthal of New York City’s Upper West Side, would legalize some plant- and fungus-based hallucinogens for personal use, including psilocybin and mescaline. The bill would allow for the substances to be used, cultivated and given as gifts; sales would remain prohibited.

Ms. Rosenthal said the measure was intended in part to help people cope with anxiety toward the end of their lives.” I thought people should be able to have access for that kind of use without being prosecuted and without having to buy it illegally,” she said.

Neither bill seems like it has enough support to come to the Assembly floor for a vote this session. Even so, proponents believe that change is possible.

On a lobbying day earlier this year, advocates including several rabbis, a culinary mushroom purveyor, and representatives of a handful of nonprofits blanketed the main artery between lawmakers’ offices and the Capitol with tables offering mushroom-shaped stickers, chocolate and free soap from Dr. Bronner’s — one of the highest-profile corporate supporters of psychedelic medicine — in an effort to persuade lawmakers of the fantastic possibilities of the fungus.

Those lobbying for the bill’s passage come from a range of faiths that have found psilocybin and other drugs can enhance users’ religious experiences.

But the largest religious contingent features a number of Orthodox Jewish people fighting to legalize psilocybin, colloquially known as “magic mushrooms.”

The Jewish community is not by and large pro-drugs, Mr. Genuth said, but he contended that some people have come around after having positive experiences with psilocybin that made them feel closer to God.

“I have connected to people who are Methodist, Buddhist, Rastafarian and other faith streams,” he said.

One of those connections is Zachary Stamp, a practicing Buddhist who is not involved in lobbying efforts but does support the legalization of psilocybin.

Mr. Stamp suffered from post-traumatic stress disorder, bipolar disorder, opioid addiction and alcohol dependency after serving in the Marine Corps in Afghanistan. One night at a party, he was offered the psychedelic LSD, which he described as a profound experience that led to his using psilocybin and giving up alcohol and pain medication.

Mr. Stamp, 31, added that in the Buddhist faith, some look at Siddhartha Gautama, commonly known as the Buddha, who sat meditating under a tree for seven weeks until he achieved enlightenment, as having entered an altered state similar to that of Moses when God appeared before him. The psychedelic experience, Mr. Stamp said, can mirror that of long-term fasting, helping modern-day followers of many religions deepen their practices.

“There’s just something about having this profound spiritual awakening,” Mr. Stamp said. “By legalizing it, it helps to normalize something that probably shouldn’t have been made illegal in the first place.”

The movement to legalize psychedelics like psilocybin grew in 2022, when voters in Colorado approved a referendum to decriminalize possession and use of certain psychedelic plants. Some states have resisted: In California, Gov. Gavin Newsom vetoed an attempt to legalize psilocybin , citing the need for stricter frameworks “to prevent against exploitation during guided treatments.”

The National Institutes of Health has cited psilocybin’s long history of use for treating mental illnesses, but said that substantive research remains to be done into the drug’s medicinal uses. High doses can lead to hallucination, and side effects include “ increased heart rate or nausea .”

Despite those findings, a paper published in the Journal of the American Medical Association found that, based on the model of cannabis legalization, the majority of states will legalize psychedelics by 2037. According to data from LexisNexis , a research software site, more than 70 bills related to psilocybin have been introduced across 26 states since December.

The proposals in New York come as the state is facing the repercussions of its uneven efforts to build a legal cannabis marketplace. In 2021, the Legislature legalized recreational marijuana use and allowed those who had been harmed by the war on drugs to have the first opportunity to get dealer licenses. But legal and logistical challenges have delayed the rollout of legal products in the years since, allowing the illicit market to proliferate.

Despite broad cultural and chemical differences between the two substances, psilocybin could nonetheless face similar barriers thanks to severe restrictions at the federal level. That prohibition has the potential to seriously complicate even those efforts that would keep the substance tightly controlled.

Corinne Carey, who leads lobbying efforts for New Yorkers for Mental Health Alternatives, said the group was so far agnostic about approaches — supporting both Ms. Rosenthal’s blanket legalization and Mr. Burke’s medicalized approach, which she acknowledged could be more politically acceptable in the short term.

“Our goal is to expand access as much as possible, in any possible way,” Ms. Carey said.

A political strategist who turned to psilocybin for burnout and discovered a new sense of purpose, Ms. Carey is one of many who have come to embrace psychedelics with the fervor common among religious converts.

Members of law enforcement and the military have also played a critical role in advocating the use of psychedelics to ease anxiety, depression and post-traumatic stress disorder, which they experience at higher rates than civilians.

That includes Ethan Abend, a former New York City police detective who said he turned to psychedelics after pharmaceutical options failed to help him cope with the traumatic brain injury he received on the job.

“That changed my life,” Mr. Abend said. “He has since become involved in a group that helps others in his situation travel outside the United States to obtain psychedelics. Not all of the feedback has been positive.

“I bumped into some resistance,” he said, “from old-school people that bought into the war on drugs” and became convinced that illegal products must be harmful.

“Why,” he added somewhat playfully, “would the government mislead us?”

Claire Fahy reports on New York City and the surrounding area for The Times. She can be reached at [email protected]. More about Claire Fahy

Grace Ashford covers New York government and politics for The Times. More about Grace Ashford

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