For more than 25 years, the issue I’ve seen most frequently in my work with gay and lesbian clients is depression. Other therapists have reported the same pattern. In Loving Someone Gay, the first book to address our mental health concerns, psychologist Don Clark called depression a major mental health issue for gays and lesbians. He believed that the homophobic environment, suppressed anger, a self-imposed limitation on awareness of feelings, and a lack of emotional nurturing for our gay identities, all put us at greater risk for depression. (He wrote this book before AIDS arrived, with all the challenges it brought to our lives).

Research also points to a high prevalence of depression in our communities. One study found that it strikes gays four to five times more severely than their non-gay peers. A survey in 2000 found that for gay men, depression was their most serious health concern after HIV, and that for lesbians, depression and mental health was their number one concern. And a 1989 study by the U.S. Department of Health and Human Services showed that gays and lesbians are two to three times more likely to attempt suicide than heterosexuals.

Everyone experiences depressed moods and periods of sadness and discouragement, and most people get through them without professional help. The problem requires treatment when it interferes with our lives enough to disrupt daily activities, goals and plans. One of the tricky things about depression is that it can creep up on us so slowly that it feels “normal,” a case of “been down so long it looks like up to me.” I’ve talked with many clients who have felt defeated, helpless, and hopeless for years, but are actually surprised when I suggest that they may be suffering from depression. Often what brings clients to therapy are issues which they don’t recognize as signs of depression, such as anxiety or insomnia.

So here are some common signs of depression:
Persistent feelings of sadness or emptiness
Hopelessness and pessimism
Dread and anxiety
Feelings of guilt, worthlessness, or loss of confidence
Loss of interest in activities you used to enjoy, including sex
Restlessness, irritability
Decreased energy
Difficulty concentrating, remembering, or making decisions
Appetite and/or weight changes
Difficulty sleeping, early-morning awakening, or oversleeping
Thoughts of death or suicide

Depression can make us less motivated to take care of ourselves, and make it easier to engage in high-risk behaviors, which means that awareness of depression is linked to HIV prevention. Many depressed people also have problems with alcohol or other drugs. Some drugs, especially uppers like crystal meth, relieve depression briefly, but make it much worse in the long run. I’m convinced that the crystal meth epidemic in our community is closely linked to the prevalence of depression.

If you believe you may be suffering from depression, an important first step is to get a thorough physical exam. That’s because, in at least 10% of major depressive episodes, the underlying cause is a physical disorder such as thyroid disease, anemia, recent viral infection, side-effect of other medications or a neurological problem.
When these are ruled out, the standard of care for severe depression is a combination of antidepressant medications and psychotherapy. The new medications that have arrived since the beginning of the “Prozac revolution” are powerful and highly effective, and the number of options is constantly increasing. But you may initially have to face frustrations. You may have to try several medications before you find one that works for you, and then it can take up to eight weeks before you feel significant improvement in your mood. You may also experience uncomfortable side-effects. Often, the side-effects will diminish or disappear altogether as the nervous system adjusts to the treatment. It’s important to be patient, not to give up on the medication prematurely, and to work closely with a doctor, ideally, a psychiatrist with specialized knowledge of these medications.

Broadly speaking, the psychotherapeutic approaches which are most effective are those that are active, structured and directive, and focused on identified target symptoms and on current issues rather than on the past.  The research suggests that three specific approaches have demonstrated value-added benefits.  These are: Cognitive-Behavioral Therapy, Interpersonal Psychotherapy, and Behavioral Therapies. However, many experienced clinicians use an eclectic approach that combines techniques from more than one “brand.” In general, seasoned clinicians have the value-added benefit of clinical wisdom and experience, which represents the practitioner side of the science/practitioner equation.

If you decide to see a therapist, it’s a good idea to meet with several before making a decision. That’s because therapy happens in a relationship, and, as in any relationship, the “chemistry” is vital.  If you don’t feel safe and comfortable at the outset, it’s probably better to move on. Therapy is more likely to be successful if you experience your therapist as an ally who is warm, empathic, non-judgmental, and optimistic about your prognosis.

Tom Moon is a psychotherapist in San Francisco. He can be reached at 415 626-1346.