ARTICLES
Mental Health Service Use Among Lesbian, Gay, and Bisexual Older Adults Ian H. Stanley, B.A., and Jeffrey Duong, Ph.D.
Objective: Empirical efforts to measure use of mental health services among lesbian, gay, and bisexual (LGB) older adults have been notably lacking. Thus this study assessed associations between sexual orientation and mental health service use among older adults and determined the mediating role of nonspecific psychological distress, excessive alcohol use, and self-perceived poor general medical health. Methods: Data from the 2011 New York City Community Health Survey were analyzed. The analytic sample comprised 5,138 adults ages 50 and over. Logistic regression modeling was used to examine associations between sexual orientation (LGB versus heterosexual) and past-year mental health service use (counseling or medication), adjusting for sociodemographic and clinical characteristics. Mediation analyses using bootstrapping were conducted.
The number of older adults identifying as lesbian, gay, or bisexual (LGB) is projected to rapidly increase over the next few decades as the U.S. population becomes older and more diverse (1–4). The aging of the U.S. population is expected to place a greater demand on the mental health care system (5), reflecting, in part, a large increase in the number of older Americans with psychiatric disorders (6). Despite these epidemiological changes, empirical efforts to measure use of mental health services among LGB older adults have been notably lacking (1,7,8). As an initial step to assess need and to develop tailored interventions and public health policies, it is important to characterize mental health service use among LGB older adults and to determine factors that may account for service utilization in this population. For older adults with depression or other psychiatric disorders, there are efficacious treatments—including medication, psychotherapy, or both—that can mitigate suffering (9–12). However, engaging older adults in treatment by a mental health specialist—for example, a psychiatrist, clinical psychologist, or social worker—is a considerable challenge (13–16). In fact, older adults are more likely than their younger counterparts to receive psychiatric care from a nonpsychiatric provider, such as a primary care physician PS in Advance
Results: Among LGB older adults, 23.9% reported receiving counseling, and 23.4% reported taking psychiatric medication in the past year. LGB respondents were significantly more likely than heterosexuals to have received counseling (adjusted odds ratio [AOR]=2.16, 95% confidence interval [CI]=1.49–3.13) and psychiatric medication (AOR=1.97, CI=1.36–2.86). Psychological distress, excessive alcohol use, and self-perceived poor general medical health did not mediate the association between sexual orientation and mental health service use. Conclusions: LGB older adults were more likely than heterosexuals to utilize mental health services, and this association was not explained by indicators of general medical, mental, or behavioral health. Psychiatric Services in Advance (doi: 10.1176/appi.ps.201400488)
(17), in part because of a shortage of mental health clinicians specializing in aging (5). Past research has demonstrated that LGB adults utilize mental health services at higher rates and for a longer duration compared with heterosexuals (18–21). The reasons for this finding, however, are not clear. Furthermore, it is not well understood if this association is true for older LGB adults in particular. POTENTIAL DETERMINANTS OF MENTAL HEALTH SERVICE USE Little research to date has explored factors that might explain mental health service use in the growing population of LGB older adults. The minority stress model (22) represents a conceptual framework for identifying potential determinants of mental health service use among LGB older adults. The model posits that social forces—including discrimination, stigma, and prejudice—create an adverse environment for individuals in sexual minority groups, conferring increased risk for stress responses such as alcohol abuse, psychological distress, or poor perceived health. However, it is possible that individuals in sexual minority groups may engage in coping behaviors in response to the stress of ps.psychiatryonline.org 1
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having a stigmatized identity. These strategies might include utilization of counseling, psychiatric medication, and other mental health services (22). Minority stress may manifest as nonspecific psychological distress, which has a heterogeneous presentation and is broadly characterized by depressive symptoms, anxious symptoms, or both (23). One study estimated that among men ages 25 to 74, members of sexual minority groups were approximately three times more likely than heterosexuals to report elevated psychological distress (18). Similarly, among adults ages 50 and older, LGB respondents had significantly higher rates of psychological distress compared with heterosexuals (24). In later life, untreated psychological distress has pernicious health outcomes, including hastened mortality (25,26). It is possible that this stress response may explain mental health service use among LGB older adults. However, few empirical studies have investigated this possibility. Excessive alcohol use represents another potential determinant of mental health service utilization among LGB older adults. According to studies of younger and middleaged adults, LGB individuals are significantly more likely to report excessive alcohol use, experience greater alcoholrelated morbidity, such as impairment in daily activities, and are more likely to report receiving treatment for alcohol use compared with heterosexuals (27,28). In a population-based survey of older adults, LGB individuals were significantly more likely than heterosexuals to report excessive alcohol use (29), although no studies to our knowledge have examined if these elevated rates might account for mental health service utilization among this population. For older adults in particular, mental health is inextricably linked to general medical health (26,30), and thus a perception that one’s general medical health is poor may be an additional factor that accounts for service use among LGB older adults. Specifically, psychiatric care needs may manifest as somatic complaints (31), and therefore rating one’s health as poor may serve as a proxy for mental illness. Indeed, past research has demonstrated elevated levels of poor general health among LGB older adults (32). STUDY OBJECTIVES The purpose of this study was to describe and compare mental health service use among LGB and heterosexual adults ages 50 and older. Informed by the minority stress model (22), we also sought to identify potential mediators that might explain mental health service use among LGB older adults. Drawing from prior research that demonstrated greater mental health services utilization among LGB adults ages 18 and older (18), we hypothesized that LGB older adults will be more likely than heterosexual older adults to have utilized counseling and psychiatric medications in the past year. Earlier studies have reported increased mental health concerns, such as alcohol abuse and psychological distress, and poor self-perceived general medical health among LGB persons (33); individuals who 2
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report similar concerns and observations are more likely to utilize mental health treatment (16). Accordingly, we hypothesized that psychological distress, excessive alcohol use, and poor perceived general medical health will simultaneously mediate the association between sexual orientation and past-year counseling and psychiatric medication use. The findings of the study will be a key step toward developing tailored interventions and public health policies for the growing population of LGB older adults. METHODS Sample and Procedures Data from the 2011 New York City (NYC) Community Health Survey (CHS) were used (34). The CHS includes noninstitutionalized adults (18 years and older) who live in NYC and have either a landline or a cell phone. Among those who were contacted and determined to be eligible, 89.1% agreed to participate and provided verbal assent. The analytic sample for the study comprised all adults ages 50 and older (N=5,138). The institutional review board of the NYC Department of Health and Mental Hygiene approved the NYC CHS data collection. Measures Demographic characteristics. Demographic characteristics included self-reported age, sex, race (white or nonwhite), sexual orientation (LGB or heterosexual), insurance status (public, private, public and private, or none), and poverty status (,200% or $200% of the federal poverty level [FPL]). Mental health service utilization. Respondents were asked, “If ever, when did you last receive counseling for any problem you were having with your emotions, nerves, or mental health?” The answer choices included “in the last month,” “in the last 6 months,” “in the last year,” “over a year ago,” or “never.” A dichotomous variable was created to indicate the use of counseling in the past year, with 1 indicating that counseling was present (past month, past six months, or past year) and 0 indicating counseling was not present (over a year ago or never). Similarly, for psychiatric medication utilization, participants were asked, “If ever, when was the last time you took prescription medication for any problem you were having with your emotions, nerves, or mental health?” The answer choices were identical to those for the counseling use measure, and a dichotomous variable for past-year psychiatric medication use was created as previously described. Nonspecific psychological distress. Past-year nonspecific psychological distress was assessed via the Kessler 6 (K6) (23). The K6 is a six-item measure of nonspecific psychological distress. Participants reported how often they felt six symptoms of psychological distress (for example, hopelessness) during a monthlong period in which they felt the most depressed, anxious, or emotionally stressed. Responses are rated on a 5-point scale, with 0 indicating none of the time PS in Advance
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and 4 indicating all of the time; possible scores range from 0 to 24. Consistent with recommendations (23,35), individuals whose K6 composite score was greater than 12 were categorized as having experienced nonspecific psychological distress in the past year. The K6 has strong psychometric properties, including high internal consistency (a=.89) (36) and predictive validity for DSM-IV psychiatric diagnoses (35). Excessive alcohol use. Excessive alcohol use was assessed according to guidelines from the National Institute on Alcohol Abuse and Alcoholism (37). Men who reported having five or more drinks and women who reported having four or more drinks at least once in the past 30 days were coded as positive for excessive alcohol use. This threshold has been used in previous investigations of excessive alcohol use among LGB older adults (29). Self-perceived general medical health. Self-perceived poor general medical health was measured using a single item from the Health-Related Quality of Life scale (38). Participants were asked, “Would you say that in general your health is excellent, very good, good, fair, or poor?” Responses were dichotomized such that “fair” or “poor” were coded as poor self-perceived general medical health. The item is a widely used health indicator that is predictive of functional decline and mortality (39). Data Analysis To address our first hypothesis—older adults who identify as LGB are significantly more likely than heterosexual older adults to utilize past-year counseling and psychiatric medication—we used bivariate cross-tabulations to estimate the prevalence of treatment utilization among the older adults in our sample and chi square tests of independence to identify significant differences in prevalence estimates between LGB and heterosexual individuals. We then constructed logistic regression models to compute odds ratios (ORs), adjusted odds ratios (AORs), and 95% confidence intervals (CIs) examining whether sexual orientation was a predictor of mental health service use in both unadjusted (model 1) and adjusted (model 2) models. Model 2 adjusted for sociodemographic covariates (sex, race, insurance status, and poverty level). These analyses were conducted separately for each outcome variable (counseling and psychiatric medication). To address our second hypothesis—psychological distress, excessive alcohol use, and poor general medical health simultaneously mediate the association between sexual orientation and past-year counseling and psychiatric medication, respectively—we examined whether sexual orientation was a significant predictor of mental health service use while simultaneously adjusting for our covariates and our proposed mediator variables: psychological distress, excessive alcohol use, and general medical health (model 3). We then followed an adaptation of mediation analysis criteria outlined by Baron and Kenny (40). As such, the following criteria were assessed to evaluate our proposed mediators: significant associations PS in Advance
between the predictor variable and the outcome variables, significant associations between the predictor variable and the proposed mediator variables, significant associations between the proposed mediators and the outcome variables, and attenuated associations between the predictor variable and the outcome variable when the proposed mediators were added to the logistic regression model. Recent methodological advances have called for the testing of mediation significance even if these criteria are not fully met, especially if the selection of proposed mediators is guided by theory and there is a theoretical rationale for an indirect effect (41–43). To determine significance of the total indirect effect, direct effect, and total effect, a bootstrapping analysis with 10,000 repetitions was conducted; a 95% biascorrected CI was considered statistically significant if the point estimate of the indirect effect did not cross zero. For all variables, there were very few missing or incomplete data (,2% for each variable). All analyses were conducted in Stata/SE, version 13.0, with significance level set at p,.05. RESULTS Sample Characteristics Participant characteristics are described in Table 1. The sample had an average age of 65.3 years (range 50–98), was mostly female (61.2%), and was racially diverse (48.5% nonwhite). Almost all (91.5%) respondents reported having some type of health insurance, and over a third (35.1%) reported an income that was below 200% of the FPL. Approximately 1 in 25 (4.1%) respondents reported being LGB. Overall, 23.9% (CI=18.1%–29.8%) of LGB and 13.1% (CI=12.1%–14.1%) of heterosexual respondents reported receiving counseling in the past year (x2=20.06, df=1, p,.001). Further, 23.4% (CI=17.7%–29.2%) of LGB and 14.7% (CI=13.7%–15.8%) of heterosexual respondents reported taking psychiatric medication in the past year (x2=11.87, df=1, p=.001). Logistic Regression and Mediation Models Results from the unadjusted and adjusted logistic regression models analyzing whether sexual orientation was a predictor of the proposed mediator variables are presented in Table 2. Sexual orientation was not a significant predictor of psychological distress in both the unadjusted or adjusted models. However, LGB respondents were significantly more likely than heterosexual respondents to report excessive alcohol use (OR=2.66; AOR=1.78) and were significantly less likely to report poor general medical health (OR=.55; AOR=.76). Results from logistic regression models for past-year counseling use are presented in Table 3. In an unadjusted model, LGB respondents were over two times more likely than heterosexuals to report past-year counseling (OR=2.09); similar results were found in a model adjusting for sociodemographic characteristics (AOR=2.24). In the model that included our proposed mediators (psychological distress, excessive alcohol use, and poor general medical health), the association persisted, with LGB respondents having elevated odds of reporting ps.psychiatryonline.org
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past-year counseling use compared with heterosexual respondents (AOR=2.16). The bootstrap analyses showed that the proposed mediators accounted for 14.96% of the total effect of sexual orientation on counseling; although the indirect effect of sexual orientation on counseling use via the proposed mediators was not significant, the direct effect of sexual orientation on counseling use remained significant (coefficient=.087, CI=.044–.126). Results from logistic regression models for past-year psychiatric medication use are presented in Table 4. LGB respondents were significantly more likely than heterosexuals to report past-year psychiatric medication use in both an unadjusted model (OR=1.77) and a model that adjusted for sociodemographic characteristics (AOR=2.04). In the model that included our proposed mediators (psychological distress, excessive alcohol use, and poor general medical health), the association between sexual orientation and past-year psychiatric medication use persisted (AOR=1.97). In our bootstrap analyses, the hypothesized mediators accounted for 15.81% of the total effect of sexual orientation on counseling; the indirect effect was nonsignificant, but the direct effect of sexual orientation on psychiatric medication use remained significant (coefficient=.076, CI=.032–.115).
TABLE 1. Characteristics of 5,138 survey respondents ages 50 and oldera N
%
Psychiatric medication (past year) Yes No Missing data
Characteristic
767 4,292 79
14.9 83.5 1.5
Counseling (past year) Yes No Missing data
695 4,368 75
13.5 85.0 1.5
Sexual orientation Lesbian, gay, or bisexual Heterosexual Missing data
209 4,547 382
4.1 88.5 7.4
Psychological distress Yes No
436 4,702
8.5 91.5
Excessive alcohol use Yes No Missing data
381 4,689 68
7.4 91.3 1.3
General medical health Poor Good Missing data
1,510 3,565 63
29.4 69.4 1.2
Age (M6SD) Sex Female Male
3,146 1,992
61.2 38.8
Race White Nonwhite
2,647 2,491
51.5 48.5
Insurance status Public, private, or both None Missing data
4,701 376 61
91.5 7.3 1.2
Poverty status ,200% federal poverty level (FPL) $200% FPL Missing data
1,804 2,742 592
35.1 53.4 11.5
a
DISCUSSION
65.3610.6
Very little is known about use of mental health services among vulnerable subpopulations of older adults, including those who are LGB (7,44). To address this gap, we characterized mental health service use in a large, diverse sample of communitydwelling LGB older adults and determined if associations between sexual orientation and service use were accounted for by psychological distress, excessive alcohol use, and poor selfperceived general medical health. Consistent with our first hypothesis, LGB older adults were over two times more likely to have received counseling and were nearly two times more likely to have taken psychiatric medications in the past year, compared with heterosexual older adults. These findings remained significant even after the analyses controlled for demographic characteristics—for example, sex—and robust barriers to mental health services, such as health insurance. Our findings are consistent with a previous study, which found that LGB adults in midlife were over three
Source: New York City Community Health Survey, 2011 (34)
TABLE 2. Predictors of potential determinants of mental health service utilization among 5,138 survey respondents ages 50 and older
Psychological distress Predictor Lesbian, gay, or bisexual (reference: heterosexual) Female (reference: male) White (reference: nonwhite) Public or private insurance (reference: none) ,200% federal poverty level (FPL) (reference: $200% FPL) 4
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Poor general medical health
Excessive alcohol use
OR
95% CI
AOR
95% CI
OR
95% CI
AOR
95% CI
OR
95% CI
AOR
95% CI
1.18
.73–1.89
1.60
.97–2.63
2.66
1.84–3.86
1.78
1.20–2.63
.55
.39–.79
.76
.52–1.12
1.40 1.18 .98
1.10–1.79 .93–1.49 .65–1.46
.49 1.22 .54
.39–.62 .96–1.55 .37–.79
1.13 .62 1.22
.97–1.32 .54–.73 .93–1.60
3.28
2.57–4.18
.61
.47–.80
4.28
3.67–4.98
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medication use were not explained by the proposed mediators included in our model. Model 1 Model 2 Model 3 Rather, we found that perceived general medical health, psychological distress, and excessive Predictor OR 95% CI AOR 95% CI AOR 95% CI alcohol use explained only 15% and 16% of the Lesbian, gay, or bisexual 2.09 1.50–2.91 2.24 1.58–3.19 2.16 1.49–3.13 total effect of sexual orientation on counseling (reference: heterosexual) and psychiatric medication use, respectively. Female (reference: male) 1.35 1.12–1.64 1.33 1.09–1.63 White (reference: nonwhite) 1.97 1.62–2.40 2.04 1.65–2.52 Furthermore, the indirect effect of sexual oriPublic or private insurance 2.23 1.41–3.54 2.27 1.41–3.66 entation on both counseling and psychiatric (reference: none) medication use through these hypothesized 2.08 1.71–2.52 1.49 1.19–1.85 ,200% federal poverty mediators was not significant. Nevertheless, level (FPL) (reference: sexual orientation had a significant direct effect $200% FPL) Psychological distress – – 6.54 5.07–8.43 on both of our outcomes. (reference: not present) Our findings suggest that LGB older adults Excessive alcohol use – – 1.19 .86–1.64 may be accessing treatment at elevated rates (reference: not present) for reasons beyond the burden of general Poor general medical health – – 1.33 1.07–1.66 medical, mental, and behavioral health con(reference: not present) cerns. Past research utilizing a sample of a Bootstrapping analyses of the mediation of psychological distress, excessive alcohol use, and younger and midlife adults demonstrated that poor general medical health on effects of sexual orientation on past-year use of counseling found bias-corrected coefficients of .015 (95% CI [CI]=–.003 to .033) for the total indirect despite not having a current psychiatric disoreffect, .087 (CI=.044 to .126) for the direct effect, and .102 (CI=.055 to .147) for the total effect. der, nearly one in five LGB adults utilized psychiatric services, for reasons that included times more likely than other middle-aged adults to report coping with a stigmatized identity and more normative beliefs seeing a mental health provider in the past year (18). However, in the LGB community about seeking mental health treatment to our knowledge, this study is the first empirical investigation (45). As noted, the minority stress model (22) may explain describing mental health service use among LGB adults in later increased service use by conceptualizing counseling and psylife. chiatric medication as coping responses to having a stigmatized In order to identify factors that explain differences in service identity, regardless of level of current or recent psychiatric use between heterosexual and LGB older adults, we assessed functioning or general medical health. It is also possible that the role of multiple simultaneous mediators—perceived general people receiving recent (past year) treatment who may not medical health, psychological distress, and excessive alcohol have a past-year DSM diagnosis—of which our proposed use. Contrary to our second hypothesis, the associations mediators are reliable and valid proxies (35)—are a resilient between sexual orientation and counseling and psychiatric group who have benefited from treatment in the past and who remain in treatment to maintain treatment gains and prevent relapse (46). TABLE 4. Predictors of use of psychiatric medication in the past year among Notwithstanding the strengths of our study, 5,138 survey respondents ages 50 and oldera including being among the first to characterize Model 1 Model 2 Model 3 mental health service use among LGB older Predictor OR 95% CI AOR 95% CI AOR 95% CI adults, the study had several limitations. Our Lesbian, gay, or bisexual 1.77 1.28–2.47 2.04 1.44–2.89 1.97 1.36–2.86 sample comprised noninstitutionalized older (reference: heterosexual) adults living in an urban area; our results may Female (reference: male) 1.37 1.14–1.65 1.34 1.10–1.63 not generalize to nonurban or institutionalized White (reference: nonwhite) 2.08 1.72–2.52 2.24 1.83–2.76 settings, such as nursing homes. We also do not Public or private insurance 2.52 1.59–4.00 2.79 1.71–4.55 know about the type of counseling (such as (reference: none) group or individual) or the type of medication ,200% federal poverty 2.13 1.77–2.57 1.44 1.17–1.78 level (FPL) (reference: that participants used (such as selective sero$200% FPL) tonin reuptake inhibitors or benzodiazepines). Psychological distress 6.77 5.25–8.71 We were also unable to determine whether the (reference: not present) medications that respondents used were preExcessive alcohol use 1.25 .91–1.71 scribed to them specifically or if they were (reference: not present) Poor general medical health 1.74 1.41–2.14 obtained through other means. The survey also (reference: not present) did not ascertain the duration or current status a Bootstrapping analyses of the mediation of psychological distress, excessive alcohol use, and of treatment or whether the participants used poor general medical health on effects of sexual orientation on past-year use of psychiatric their medication as instructed. Also, because of medication found bias-corrected coefficients of .014 (95% CI [CI]=–.005 to .033) for the total concerns about statistical power, we did not indirect effect, .076 (CI=.032 to .115) for the direct effect, and .090 (CI=.044 to .125) for the total effect. study bisexual individuals separately; studying TABLE 3. Predictors of use of counseling in the past year among 5,138 survey respondents ages 50 and oldera
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this population separately should be considered in future research (47). Further, the cross-sectional design precluded us from making causal inferences. Future research that tests potential mediators by using longitudinal designs can advance our understanding of the link between sexual orientation and services use. Psychological distress manifests in variegated forms, and a more nuanced psychiatric assessment may provide better insight into specific current and lifetime diagnoses (such as social anxiety disorder), symptoms (such as avoidance), or psychological mechanisms (such as social disconnectedness) driving this association. Future research may also utilize more nuanced assessments of alcohol use and general medical health. It is important to also consider factors besides psychiatric diagnoses in identifying which LGB older adults may need mental health services (21). CONCLUSIONS Older adults who are LGB accessed mental health services at elevated rates compared with heterosexual older adults, and this relationship was not explained by psychological distress, excessive alcohol use, and poor general medical health. These findings suggest that LGB older adults may be utilizing mental health services at elevated rates for reasons beyond concerns regarding physical, mental, or behavioral health. Given the emerging body of data that suggests that persons who are LGB access mental health treatment at higher rates compared with heterosexuals, it is necessary to ensure our current system of care can meet the needs of this population for care (4). The aging population is placing unprecedented demands on the mental health care system, and, as previously mentioned, there is a noticeable shortage of geriatric psychiatrists, clinical geropsychologists, and geriatric social workers to respond to the increasing number of older adults needing mental health care (5,48–50). Findings from this study provide incremental evidence for the need to develop, test, and implement tailored interventions and public health policies for older adults who are members of sexual minority groups. AUTHOR AND ARTICLE INFORMATION Mr. Stanley is with the Department of Psychology, Florida State University, Tallahassee (e-mail: [email protected]). Dr. Duong is with the University of California, Davis, School of Medicine, Sacramento. The authors report no financial relationships with commercial interests. Received October 24, 2014; accepted December 5, 2014; published online April 15, 2015.
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24. Fredriksen-Goldsen KI, Kim H-J, Emlet CA, et al: The Aging and Health Report: Disparities and Resilience Among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle, Wash, Institute for Multigenerational Health, 2011 25. Bruce ML, Leaf PJ, Rozal GPM, et al: Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study. American Journal of Psychiatry 151:716–721, 1994 26. Penninx BW, Geerlings SW, Deeg DJ, et al: Minor and major depression and the risk of death in older persons. Archives of General Psychiatry 56:889–895, 1999 27. Cochran SD, Keenan C, Schober C, et al: Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the US population. Journal of Consulting and Clinical Psychology 68:1062–1071, 2000 28. Burgard SA, Cochran SD, Mays VM: Alcohol and tobacco use patterns among heterosexually and homosexually experienced California women. Drug and Alcohol Dependence 77:61–70, 2005 29. Fredriksen-Goldsen KI, Kim H-J, Barkan SE, et al: Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. American Journal of Public Health 103: 1802–1809, 2013 30. Lin EHB, Katon W, Von Korff M, et al: Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial. JAMA 290:2428–2429, 2003 31. Drayer RA, Mulsant BH, Lenze EJ, et al: Somatic symptoms of depression in elderly patients with medical comorbidities. International Journal of Geriatric Psychiatry 20:973–982, 2005 32. Fredriksen-Goldsen KI, Emlet CA, Kim H-J, et al: The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: the role of key health indicators and risk and protective factors. Gerontologist 53:664–675, 2013 33. Herek GM, Garnets LD: Sexual orientation and mental health. Annual Review of Clinical Psychology 3:353–375, 2007 34. Community Health Survey 2011. New York, New York City Department of Health and Mental Hygiene, 2011. Available at www. nyc.gov/html/doh/html/data/survey.shtml 35. Kessler RC, Green JG, Gruber MJ, et al: Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. International Journal of Methods in Psychiatric Research 19(suppl 1):4–22, 2010 36. Kessler RC, Andrews G, Colpe LJ, et al: Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine 32:959–976, 2002
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37. NIAAA council approves definition of binge drinking. NIAAA Newsletter 3:3, 2004. Available at pubs.niaaa.nih.gov/publications/ Newsletter/winter2004/Newsletter_Number3.pdf 38. Hennessy CH, Moriarty DG, Zack MM, et al: Measuring healthrelated quality of life for public health surveillance. Public Health Reports 109:665–672, 1994 39. Lee Y: The predictive value of self-assessed general, physical, and mental health on functional decline and mortality in older adults. Journal of Epidemiology and Community Health 54:123–129, 2000 40. Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 51:1173–1182, 1986 41. Morera OF, Castro FG: Important considerations in conducting statistical mediation analyses. American Journal of Public Health 103:394–396, 2013 42. Rucker DD, Preacher KJ, Tormala ZL, et al: Mediation analysis in social psychology: current practices and new recommendations. Social and Personality Psychology Compass 5:359–371, 2011 43. Hayes AF: Beyond Baron and Kenny: statistical mediation analysis in the new millennium. Communication Monographs 76:408–420, 2009 44. Mayer KH, Bradford JB, Makadon HJ, et al: Sexual and gender minority health: what we know and what needs to be done. American Journal of Public Health 98:989–995, 2008 45. Grella CE, Greenwell L, Mays VM, et al: Influence of gender, sexual orientation, and need on treatment utilization for substance use and mental disorders: findings from the California Quality of Life Survey. BMC Psychiatry 9:52, 2009 46. Druss BG, Wang PS, Sampson NA, et al: Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey Replication. Archives of General Psychiatry 64:1196–1203, 2007 47. Ross LE, Dobinson C, Eady A: Perceived determinants of mental health for bisexual people: a qualitative examination. American Journal of Public Health 100:496–502, 2010 48. Zimmerman JA, Fiske A, Scogin F: Mentoring in clinical geropsychology: across the stages of professional development. Educational Gerontology 37:355–369, 2011 49. Scharlach A, Damron-Rodriguez J, Robinson B, et al: Educating social workers for an aging society: a vision for the 21st century. Journal of Social Work Education 36:521–538, 2000 50. Mojtabai R: Diagnosing depression in older adults in primary care. New England Journal of Medicine 370:1180–1182, 2014
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Mental Health Service Use Among Lesbian, Gay, and Bisexual Older Adults Ian H. Stanley, B.A., and Jeffrey Duong, Ph.D.
Objective: Empirical efforts to measure use of mental health services among lesbian, gay, and bisexual (LGB) older adults have been notably lacking. Thus this study assessed associations between sexual orientation and mental health service use among older adults and determined the mediating role of nonspecific psychological distress, excessive alcohol use, and self-perceived poor general medical health. Methods: Data from the 2011 New York City Community Health Survey were analyzed. The analytic sample comprised 5,138 adults ages 50 and over. Logistic regression modeling was used to examine associations between sexual orientation (LGB versus heterosexual) and past-year mental health service use (counseling or medication), adjusting for sociodemographic and clinical characteristics. Mediation analyses using bootstrapping were conducted.
The number of older adults identifying as lesbian, gay, or bisexual (LGB) is projected to rapidly increase over the next few decades as the U.S. population becomes older and more diverse (1–4). The aging of the U.S. population is expected to place a greater demand on the mental health care system (5), reflecting, in part, a large increase in the number of older Americans with psychiatric disorders (6). Despite these epidemiological changes, empirical efforts to measure use of mental health services among LGB older adults have been notably lacking (1,7,8). As an initial step to assess need and to develop tailored interventions and public health policies, it is important to characterize mental health service use among LGB older adults and to determine factors that may account for service utilization in this population. For older adults with depression or other psychiatric disorders, there are efficacious treatments—including medication, psychotherapy, or both—that can mitigate suffering (9–12). However, engaging older adults in treatment by a mental health specialist—for example, a psychiatrist, clinical psychologist, or social worker—is a considerable challenge (13–16). In fact, older adults are more likely than their younger counterparts to receive psychiatric care from a nonpsychiatric provider, such as a primary care physician PS in Advance
Results: Among LGB older adults, 23.9% reported receiving counseling, and 23.4% reported taking psychiatric medication in the past year. LGB respondents were significantly more likely than heterosexuals to have received counseling (adjusted odds ratio [AOR]=2.16, 95% confidence interval [CI]=1.49–3.13) and psychiatric medication (AOR=1.97, CI=1.36–2.86). Psychological distress, excessive alcohol use, and self-perceived poor general medical health did not mediate the association between sexual orientation and mental health service use. Conclusions: LGB older adults were more likely than heterosexuals to utilize mental health services, and this association was not explained by indicators of general medical, mental, or behavioral health. Psychiatric Services in Advance (doi: 10.1176/appi.ps.201400488)
(17), in part because of a shortage of mental health clinicians specializing in aging (5). Past research has demonstrated that LGB adults utilize mental health services at higher rates and for a longer duration compared with heterosexuals (18–21). The reasons for this finding, however, are not clear. Furthermore, it is not well understood if this association is true for older LGB adults in particular. POTENTIAL DETERMINANTS OF MENTAL HEALTH SERVICE USE Little research to date has explored factors that might explain mental health service use in the growing population of LGB older adults. The minority stress model (22) represents a conceptual framework for identifying potential determinants of mental health service use among LGB older adults. The model posits that social forces—including discrimination, stigma, and prejudice—create an adverse environment for individuals in sexual minority groups, conferring increased risk for stress responses such as alcohol abuse, psychological distress, or poor perceived health. However, it is possible that individuals in sexual minority groups may engage in coping behaviors in response to the stress of ps.psychiatryonline.org 1
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having a stigmatized identity. These strategies might include utilization of counseling, psychiatric medication, and other mental health services (22). Minority stress may manifest as nonspecific psychological distress, which has a heterogeneous presentation and is broadly characterized by depressive symptoms, anxious symptoms, or both (23). One study estimated that among men ages 25 to 74, members of sexual minority groups were approximately three times more likely than heterosexuals to report elevated psychological distress (18). Similarly, among adults ages 50 and older, LGB respondents had significantly higher rates of psychological distress compared with heterosexuals (24). In later life, untreated psychological distress has pernicious health outcomes, including hastened mortality (25,26). It is possible that this stress response may explain mental health service use among LGB older adults. However, few empirical studies have investigated this possibility. Excessive alcohol use represents another potential determinant of mental health service utilization among LGB older adults. According to studies of younger and middleaged adults, LGB individuals are significantly more likely to report excessive alcohol use, experience greater alcoholrelated morbidity, such as impairment in daily activities, and are more likely to report receiving treatment for alcohol use compared with heterosexuals (27,28). In a population-based survey of older adults, LGB individuals were significantly more likely than heterosexuals to report excessive alcohol use (29), although no studies to our knowledge have examined if these elevated rates might account for mental health service utilization among this population. For older adults in particular, mental health is inextricably linked to general medical health (26,30), and thus a perception that one’s general medical health is poor may be an additional factor that accounts for service use among LGB older adults. Specifically, psychiatric care needs may manifest as somatic complaints (31), and therefore rating one’s health as poor may serve as a proxy for mental illness. Indeed, past research has demonstrated elevated levels of poor general health among LGB older adults (32). STUDY OBJECTIVES The purpose of this study was to describe and compare mental health service use among LGB and heterosexual adults ages 50 and older. Informed by the minority stress model (22), we also sought to identify potential mediators that might explain mental health service use among LGB older adults. Drawing from prior research that demonstrated greater mental health services utilization among LGB adults ages 18 and older (18), we hypothesized that LGB older adults will be more likely than heterosexual older adults to have utilized counseling and psychiatric medications in the past year. Earlier studies have reported increased mental health concerns, such as alcohol abuse and psychological distress, and poor self-perceived general medical health among LGB persons (33); individuals who 2
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report similar concerns and observations are more likely to utilize mental health treatment (16). Accordingly, we hypothesized that psychological distress, excessive alcohol use, and poor perceived general medical health will simultaneously mediate the association between sexual orientation and past-year counseling and psychiatric medication use. The findings of the study will be a key step toward developing tailored interventions and public health policies for the growing population of LGB older adults. METHODS Sample and Procedures Data from the 2011 New York City (NYC) Community Health Survey (CHS) were used (34). The CHS includes noninstitutionalized adults (18 years and older) who live in NYC and have either a landline or a cell phone. Among those who were contacted and determined to be eligible, 89.1% agreed to participate and provided verbal assent. The analytic sample for the study comprised all adults ages 50 and older (N=5,138). The institutional review board of the NYC Department of Health and Mental Hygiene approved the NYC CHS data collection. Measures Demographic characteristics. Demographic characteristics included self-reported age, sex, race (white or nonwhite), sexual orientation (LGB or heterosexual), insurance status (public, private, public and private, or none), and poverty status (,200% or $200% of the federal poverty level [FPL]). Mental health service utilization. Respondents were asked, “If ever, when did you last receive counseling for any problem you were having with your emotions, nerves, or mental health?” The answer choices included “in the last month,” “in the last 6 months,” “in the last year,” “over a year ago,” or “never.” A dichotomous variable was created to indicate the use of counseling in the past year, with 1 indicating that counseling was present (past month, past six months, or past year) and 0 indicating counseling was not present (over a year ago or never). Similarly, for psychiatric medication utilization, participants were asked, “If ever, when was the last time you took prescription medication for any problem you were having with your emotions, nerves, or mental health?” The answer choices were identical to those for the counseling use measure, and a dichotomous variable for past-year psychiatric medication use was created as previously described. Nonspecific psychological distress. Past-year nonspecific psychological distress was assessed via the Kessler 6 (K6) (23). The K6 is a six-item measure of nonspecific psychological distress. Participants reported how often they felt six symptoms of psychological distress (for example, hopelessness) during a monthlong period in which they felt the most depressed, anxious, or emotionally stressed. Responses are rated on a 5-point scale, with 0 indicating none of the time PS in Advance
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and 4 indicating all of the time; possible scores range from 0 to 24. Consistent with recommendations (23,35), individuals whose K6 composite score was greater than 12 were categorized as having experienced nonspecific psychological distress in the past year. The K6 has strong psychometric properties, including high internal consistency (a=.89) (36) and predictive validity for DSM-IV psychiatric diagnoses (35). Excessive alcohol use. Excessive alcohol use was assessed according to guidelines from the National Institute on Alcohol Abuse and Alcoholism (37). Men who reported having five or more drinks and women who reported having four or more drinks at least once in the past 30 days were coded as positive for excessive alcohol use. This threshold has been used in previous investigations of excessive alcohol use among LGB older adults (29). Self-perceived general medical health. Self-perceived poor general medical health was measured using a single item from the Health-Related Quality of Life scale (38). Participants were asked, “Would you say that in general your health is excellent, very good, good, fair, or poor?” Responses were dichotomized such that “fair” or “poor” were coded as poor self-perceived general medical health. The item is a widely used health indicator that is predictive of functional decline and mortality (39). Data Analysis To address our first hypothesis—older adults who identify as LGB are significantly more likely than heterosexual older adults to utilize past-year counseling and psychiatric medication—we used bivariate cross-tabulations to estimate the prevalence of treatment utilization among the older adults in our sample and chi square tests of independence to identify significant differences in prevalence estimates between LGB and heterosexual individuals. We then constructed logistic regression models to compute odds ratios (ORs), adjusted odds ratios (AORs), and 95% confidence intervals (CIs) examining whether sexual orientation was a predictor of mental health service use in both unadjusted (model 1) and adjusted (model 2) models. Model 2 adjusted for sociodemographic covariates (sex, race, insurance status, and poverty level). These analyses were conducted separately for each outcome variable (counseling and psychiatric medication). To address our second hypothesis—psychological distress, excessive alcohol use, and poor general medical health simultaneously mediate the association between sexual orientation and past-year counseling and psychiatric medication, respectively—we examined whether sexual orientation was a significant predictor of mental health service use while simultaneously adjusting for our covariates and our proposed mediator variables: psychological distress, excessive alcohol use, and general medical health (model 3). We then followed an adaptation of mediation analysis criteria outlined by Baron and Kenny (40). As such, the following criteria were assessed to evaluate our proposed mediators: significant associations PS in Advance
between the predictor variable and the outcome variables, significant associations between the predictor variable and the proposed mediator variables, significant associations between the proposed mediators and the outcome variables, and attenuated associations between the predictor variable and the outcome variable when the proposed mediators were added to the logistic regression model. Recent methodological advances have called for the testing of mediation significance even if these criteria are not fully met, especially if the selection of proposed mediators is guided by theory and there is a theoretical rationale for an indirect effect (41–43). To determine significance of the total indirect effect, direct effect, and total effect, a bootstrapping analysis with 10,000 repetitions was conducted; a 95% biascorrected CI was considered statistically significant if the point estimate of the indirect effect did not cross zero. For all variables, there were very few missing or incomplete data (,2% for each variable). All analyses were conducted in Stata/SE, version 13.0, with significance level set at p,.05. RESULTS Sample Characteristics Participant characteristics are described in Table 1. The sample had an average age of 65.3 years (range 50–98), was mostly female (61.2%), and was racially diverse (48.5% nonwhite). Almost all (91.5%) respondents reported having some type of health insurance, and over a third (35.1%) reported an income that was below 200% of the FPL. Approximately 1 in 25 (4.1%) respondents reported being LGB. Overall, 23.9% (CI=18.1%–29.8%) of LGB and 13.1% (CI=12.1%–14.1%) of heterosexual respondents reported receiving counseling in the past year (x2=20.06, df=1, p,.001). Further, 23.4% (CI=17.7%–29.2%) of LGB and 14.7% (CI=13.7%–15.8%) of heterosexual respondents reported taking psychiatric medication in the past year (x2=11.87, df=1, p=.001). Logistic Regression and Mediation Models Results from the unadjusted and adjusted logistic regression models analyzing whether sexual orientation was a predictor of the proposed mediator variables are presented in Table 2. Sexual orientation was not a significant predictor of psychological distress in both the unadjusted or adjusted models. However, LGB respondents were significantly more likely than heterosexual respondents to report excessive alcohol use (OR=2.66; AOR=1.78) and were significantly less likely to report poor general medical health (OR=.55; AOR=.76). Results from logistic regression models for past-year counseling use are presented in Table 3. In an unadjusted model, LGB respondents were over two times more likely than heterosexuals to report past-year counseling (OR=2.09); similar results were found in a model adjusting for sociodemographic characteristics (AOR=2.24). In the model that included our proposed mediators (psychological distress, excessive alcohol use, and poor general medical health), the association persisted, with LGB respondents having elevated odds of reporting ps.psychiatryonline.org
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past-year counseling use compared with heterosexual respondents (AOR=2.16). The bootstrap analyses showed that the proposed mediators accounted for 14.96% of the total effect of sexual orientation on counseling; although the indirect effect of sexual orientation on counseling use via the proposed mediators was not significant, the direct effect of sexual orientation on counseling use remained significant (coefficient=.087, CI=.044–.126). Results from logistic regression models for past-year psychiatric medication use are presented in Table 4. LGB respondents were significantly more likely than heterosexuals to report past-year psychiatric medication use in both an unadjusted model (OR=1.77) and a model that adjusted for sociodemographic characteristics (AOR=2.04). In the model that included our proposed mediators (psychological distress, excessive alcohol use, and poor general medical health), the association between sexual orientation and past-year psychiatric medication use persisted (AOR=1.97). In our bootstrap analyses, the hypothesized mediators accounted for 15.81% of the total effect of sexual orientation on counseling; the indirect effect was nonsignificant, but the direct effect of sexual orientation on psychiatric medication use remained significant (coefficient=.076, CI=.032–.115).
TABLE 1. Characteristics of 5,138 survey respondents ages 50 and oldera N
%
Psychiatric medication (past year) Yes No Missing data
Characteristic
767 4,292 79
14.9 83.5 1.5
Counseling (past year) Yes No Missing data
695 4,368 75
13.5 85.0 1.5
Sexual orientation Lesbian, gay, or bisexual Heterosexual Missing data
209 4,547 382
4.1 88.5 7.4
Psychological distress Yes No
436 4,702
8.5 91.5
Excessive alcohol use Yes No Missing data
381 4,689 68
7.4 91.3 1.3
General medical health Poor Good Missing data
1,510 3,565 63
29.4 69.4 1.2
Age (M6SD) Sex Female Male
3,146 1,992
61.2 38.8
Race White Nonwhite
2,647 2,491
51.5 48.5
Insurance status Public, private, or both None Missing data
4,701 376 61
91.5 7.3 1.2
Poverty status ,200% federal poverty level (FPL) $200% FPL Missing data
1,804 2,742 592
35.1 53.4 11.5
a
DISCUSSION
65.3610.6
Very little is known about use of mental health services among vulnerable subpopulations of older adults, including those who are LGB (7,44). To address this gap, we characterized mental health service use in a large, diverse sample of communitydwelling LGB older adults and determined if associations between sexual orientation and service use were accounted for by psychological distress, excessive alcohol use, and poor selfperceived general medical health. Consistent with our first hypothesis, LGB older adults were over two times more likely to have received counseling and were nearly two times more likely to have taken psychiatric medications in the past year, compared with heterosexual older adults. These findings remained significant even after the analyses controlled for demographic characteristics—for example, sex—and robust barriers to mental health services, such as health insurance. Our findings are consistent with a previous study, which found that LGB adults in midlife were over three
Source: New York City Community Health Survey, 2011 (34)
TABLE 2. Predictors of potential determinants of mental health service utilization among 5,138 survey respondents ages 50 and older
Psychological distress Predictor Lesbian, gay, or bisexual (reference: heterosexual) Female (reference: male) White (reference: nonwhite) Public or private insurance (reference: none) ,200% federal poverty level (FPL) (reference: $200% FPL) 4
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Poor general medical health
Excessive alcohol use
OR
95% CI
AOR
95% CI
OR
95% CI
AOR
95% CI
OR
95% CI
AOR
95% CI
1.18
.73–1.89
1.60
.97–2.63
2.66
1.84–3.86
1.78
1.20–2.63
.55
.39–.79
.76
.52–1.12
1.40 1.18 .98
1.10–1.79 .93–1.49 .65–1.46
.49 1.22 .54
.39–.62 .96–1.55 .37–.79
1.13 .62 1.22
.97–1.32 .54–.73 .93–1.60
3.28
2.57–4.18
.61
.47–.80
4.28
3.67–4.98
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medication use were not explained by the proposed mediators included in our model. Model 1 Model 2 Model 3 Rather, we found that perceived general medical health, psychological distress, and excessive Predictor OR 95% CI AOR 95% CI AOR 95% CI alcohol use explained only 15% and 16% of the Lesbian, gay, or bisexual 2.09 1.50–2.91 2.24 1.58–3.19 2.16 1.49–3.13 total effect of sexual orientation on counseling (reference: heterosexual) and psychiatric medication use, respectively. Female (reference: male) 1.35 1.12–1.64 1.33 1.09–1.63 White (reference: nonwhite) 1.97 1.62–2.40 2.04 1.65–2.52 Furthermore, the indirect effect of sexual oriPublic or private insurance 2.23 1.41–3.54 2.27 1.41–3.66 entation on both counseling and psychiatric (reference: none) medication use through these hypothesized 2.08 1.71–2.52 1.49 1.19–1.85 ,200% federal poverty mediators was not significant. Nevertheless, level (FPL) (reference: sexual orientation had a significant direct effect $200% FPL) Psychological distress – – 6.54 5.07–8.43 on both of our outcomes. (reference: not present) Our findings suggest that LGB older adults Excessive alcohol use – – 1.19 .86–1.64 may be accessing treatment at elevated rates (reference: not present) for reasons beyond the burden of general Poor general medical health – – 1.33 1.07–1.66 medical, mental, and behavioral health con(reference: not present) cerns. Past research utilizing a sample of a Bootstrapping analyses of the mediation of psychological distress, excessive alcohol use, and younger and midlife adults demonstrated that poor general medical health on effects of sexual orientation on past-year use of counseling found bias-corrected coefficients of .015 (95% CI [CI]=–.003 to .033) for the total indirect despite not having a current psychiatric disoreffect, .087 (CI=.044 to .126) for the direct effect, and .102 (CI=.055 to .147) for the total effect. der, nearly one in five LGB adults utilized psychiatric services, for reasons that included times more likely than other middle-aged adults to report coping with a stigmatized identity and more normative beliefs seeing a mental health provider in the past year (18). However, in the LGB community about seeking mental health treatment to our knowledge, this study is the first empirical investigation (45). As noted, the minority stress model (22) may explain describing mental health service use among LGB adults in later increased service use by conceptualizing counseling and psylife. chiatric medication as coping responses to having a stigmatized In order to identify factors that explain differences in service identity, regardless of level of current or recent psychiatric use between heterosexual and LGB older adults, we assessed functioning or general medical health. It is also possible that the role of multiple simultaneous mediators—perceived general people receiving recent (past year) treatment who may not medical health, psychological distress, and excessive alcohol have a past-year DSM diagnosis—of which our proposed use. Contrary to our second hypothesis, the associations mediators are reliable and valid proxies (35)—are a resilient between sexual orientation and counseling and psychiatric group who have benefited from treatment in the past and who remain in treatment to maintain treatment gains and prevent relapse (46). TABLE 4. Predictors of use of psychiatric medication in the past year among Notwithstanding the strengths of our study, 5,138 survey respondents ages 50 and oldera including being among the first to characterize Model 1 Model 2 Model 3 mental health service use among LGB older Predictor OR 95% CI AOR 95% CI AOR 95% CI adults, the study had several limitations. Our Lesbian, gay, or bisexual 1.77 1.28–2.47 2.04 1.44–2.89 1.97 1.36–2.86 sample comprised noninstitutionalized older (reference: heterosexual) adults living in an urban area; our results may Female (reference: male) 1.37 1.14–1.65 1.34 1.10–1.63 not generalize to nonurban or institutionalized White (reference: nonwhite) 2.08 1.72–2.52 2.24 1.83–2.76 settings, such as nursing homes. We also do not Public or private insurance 2.52 1.59–4.00 2.79 1.71–4.55 know about the type of counseling (such as (reference: none) group or individual) or the type of medication ,200% federal poverty 2.13 1.77–2.57 1.44 1.17–1.78 level (FPL) (reference: that participants used (such as selective sero$200% FPL) tonin reuptake inhibitors or benzodiazepines). Psychological distress 6.77 5.25–8.71 We were also unable to determine whether the (reference: not present) medications that respondents used were preExcessive alcohol use 1.25 .91–1.71 scribed to them specifically or if they were (reference: not present) Poor general medical health 1.74 1.41–2.14 obtained through other means. The survey also (reference: not present) did not ascertain the duration or current status a Bootstrapping analyses of the mediation of psychological distress, excessive alcohol use, and of treatment or whether the participants used poor general medical health on effects of sexual orientation on past-year use of psychiatric their medication as instructed. Also, because of medication found bias-corrected coefficients of .014 (95% CI [CI]=–.005 to .033) for the total concerns about statistical power, we did not indirect effect, .076 (CI=.032 to .115) for the direct effect, and .090 (CI=.044 to .125) for the total effect. study bisexual individuals separately; studying TABLE 3. Predictors of use of counseling in the past year among 5,138 survey respondents ages 50 and oldera
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this population separately should be considered in future research (47). Further, the cross-sectional design precluded us from making causal inferences. Future research that tests potential mediators by using longitudinal designs can advance our understanding of the link between sexual orientation and services use. Psychological distress manifests in variegated forms, and a more nuanced psychiatric assessment may provide better insight into specific current and lifetime diagnoses (such as social anxiety disorder), symptoms (such as avoidance), or psychological mechanisms (such as social disconnectedness) driving this association. Future research may also utilize more nuanced assessments of alcohol use and general medical health. It is important to also consider factors besides psychiatric diagnoses in identifying which LGB older adults may need mental health services (21). CONCLUSIONS Older adults who are LGB accessed mental health services at elevated rates compared with heterosexual older adults, and this relationship was not explained by psychological distress, excessive alcohol use, and poor general medical health. These findings suggest that LGB older adults may be utilizing mental health services at elevated rates for reasons beyond concerns regarding physical, mental, or behavioral health. Given the emerging body of data that suggests that persons who are LGB access mental health treatment at higher rates compared with heterosexuals, it is necessary to ensure our current system of care can meet the needs of this population for care (4). The aging population is placing unprecedented demands on the mental health care system, and, as previously mentioned, there is a noticeable shortage of geriatric psychiatrists, clinical geropsychologists, and geriatric social workers to respond to the increasing number of older adults needing mental health care (5,48–50). Findings from this study provide incremental evidence for the need to develop, test, and implement tailored interventions and public health policies for older adults who are members of sexual minority groups. AUTHOR AND ARTICLE INFORMATION Mr. Stanley is with the Department of Psychology, Florida State University, Tallahassee (e-mail: [email protected]). Dr. Duong is with the University of California, Davis, School of Medicine, Sacramento. The authors report no financial relationships with commercial interests. Received October 24, 2014; accepted December 5, 2014; published online April 15, 2015.
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