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Addressing a quadruple diagnosis

July 15, 2011
by Joseph M. Amico, MDiv, CAS, LISAC
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Complicated issues for gay men require careful assessment and treatment planning
Joseph m. amico, mdiv, cas, lisac
Joseph M. Amico, MDIV, CAS, LISAC

Back in the early 1990s when folks first started talking about dual diagnosis, I used to ask, “What do you mean dual diagnosis?” Typically responders would try to give me a definition of the term. My next comment would be, “I understand what dual diagnosis means. I just don't have any patients who have only two diagnoses!”

For the past 25 years most of my clinical work has been with the LGBTQ community. Much of that work has been either at a residential substance abuse treatment program or an inpatient psychiatric hospital as well as my own private practice. Most of the gay men I have treated suffer from what Eric Cuestas-Thompson coined as “quadruple diagnosis” in a 1997 article in Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention.1 I've been using the term ever since, but it fits even more today with the concurrent use of crystal meth among gay men.

Effect of HIV diagnosis

Clearly not every gay man who seeks treatment is HIV-positive and/or has AIDS. However, the preponderance among those seeking treatment in the facilities where I have worked is astounding. There are a number of mental health conditions that accompany a long-term disease, including grief and loss issues. When someone is first diagnosed with a long-term disease such as cancer, diabetes or AIDS, there is understandably a natural grieving process. The grieving caused by the AIDS diagnosis is not only the fact that “now I have this thing running throughout my body that will eventually kill me,” but other reactions include, “No one will ever have sex with me again,” “I'll never find a lover/partner,” “I'm damaged goods; no one will want me,” or “I'm a marked man.”

The toll on self-esteem and self-confidence is huge, and that in and of itself often leads to substance abuse or other compulsive behaviors to cope with the feelings.

There are three places in the progression of HIV/AIDS that affect the other co-occurring factors: initial diagnosis of the disease or presence of HIV in the body; sero-conversion from HIV+ to an AIDS diagnosis; and living long-term with a chronic, fatal disease. Clearly, just getting the diagnosis or finding out one has sero-converted from HIV to AIDS are huge issues.

But what we have been seeing in the past two decades are the effects of long-term survivorship. In the 1980s and early ′90s everyone expected to die from this disease. Now with the advances of various medical protocols, people can live a long time and even reverse the decline of T-cells or improve their viral loads. But taking the medications every day is a reminder that “I have this dread disease and will never be cured.”

This causes some men to go on “drug holidays.” They decide to stop taking their HIV meds because they are sick and tired of waking up every day and having to take their meds, reminding them that they have this disease. “I just want to be normal,” they say.

For those who also may have a mental health condition, these drug holidays include stopping their medications for depression, bipolar disorder, anxiety or other mental health issues. This becomes a potentially dangerous decision, physically and mentally.

The challenge in the acute psychiatric facilities has been to know both the medical (HIV/AIDS) condition and the mental health diagnosis in order to know how to get the person stabilized once again. We in behavioral health know what it means when someone stops taking bipolar or depression medication, and how difficult it might be to get them stabilized and back to a therapeutic level.

Once we add the disruption of the HIV/AIDS medication regime as well, it becomes even more complicated. Some of those medications interact with each other in certain ways, and “drug holidays” on the HIV/AIDS side can create mutations in the way the HIV is interacting in the body-so the same medications may no longer have the same effect.

Behavioral health concerns

Now let's consider the mental health issues on their own. One study found that suicide attempts were six times greater in gay men than in the general population. Another study reports that more than 17 percent of American gay and bisexual men suffer from depression, compared with 9.5 percent of all adults.

A biennial survey of high school students in Massachusetts reports that LGBT teenagers are four times more likely than their straight peers to have attempted suicide in the prior year. When compared to heterosexual men, gay men appear to be at a greater risk for the diagnosis of major depression, according to Lilly USA.2 Further, those who are gay are nearly 2.5 times more likely to suffer from anxiety, substance abuse and post-traumatic stress disorder (PTSD).

Early research on substance abuse in the LGBT community has been challenged and widely discussed, but it's safe to say when taking all of the studies into account that gay men (and lesbians) are heavier substance abusers than the general or heterosexual population. Most will agree that the stress of growing up in a society where one is not accepted for who one is fully, and the fact that violence continues against sexual minorities in our society, contributes to suppression, shame and eventually substance abuse and other compulsive behaviors as coping mechanisms.

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