Research paperOutcomes associated with anxiety and depression among men who have sex with men in Estonia
Introduction
Growing evidence supports the notion that gay, lesbian, and transgender populations are at increased risk for a wide range of mental health problems, including links with bipolar disorder, depression, suicidality, and drug and alcohol misuse (Cochran et al., 2013, Cochran and Mays, 2000, Farmer et al., 2013, Guerim et al., 2015). The preponderance of research was conducted in the United States and other Western cultures, while research is extremely limited on MSM from Eastern European nations, specifically independent nations in Central and Eastern European region. These nations have unique cultural and social characteristics dominating society for many years, including the importance of integration and devaluing of individualism during Soviet Union times (Kolves et al., 2006). Understanding the burden of disease among groups at increased risk is very important for any national response to public health and for men who have sex with men (MSM) in this region, there are unique challenges, such as lack of social support, integration, tolerance, and acceptance (Donoghoe et al., 2005).
Isolation and lack of identifiable peers as well as negative behaviors and images from the larger social groups can increase negative self-feelings regarding same sex attraction (Cochran and Mays, 2000, King et al., 2008, Mosack et al., 2013, Raymond et al., 2011, Ross et al., 2013). The result is internalized homophobia or ‘homonegativity’. This internalized homonegativity (IH) is a result of the treatment or perceived treatment of gay persons by society. IH has been shown to lead to increased depression and in some instances, high risk behavior in non-Western countries. The link to depression, discomfort, and anxiety as well as high risk behavior could have a cumulative effect if persons with depression are more likely to engage in high risk behaviors and experience high levels internalized depression and IH. Similar findings have included a disproportionate representation of MSM among persons with depressive and bipolar disorder, specifically persons who identify as bisexual (Akiskal, 2005, Guerim et al., 2015)
Recreational drug use, lower educational attainment, income, and more negative health outcomes have also been linked. The burden of mental health issues and substance use have been estimated in many European countries, using systematic reviews from national studies
Findings indicate that more than one quarter (27%) of adults aged 18–65 exhibited a symptomology consistent with a mental health disorder in the previous one year. Findings using data from the Global Burden of Disease Study identify Eastern Europe as the global region with the highest proportion of depression, substance misuse, and suicidality at close to three times that of the global burden (Ferrari et al., 2014, Whiteford et al., 2013). In this project, we sought to understand factors associated with anxiety and depression pertinent to MSM in Estonia, a Northern European nation with strong Eastern European culture.
Section snippets
Methods
We conducted an Internet based study among MSM in 2013. Eligibility criteria included: self-identified as male; living in Estonia; age 18 years and older; sexually attracted to men and/or have had sex with a man. The study was approved by the Tallinn Medical Research Ethics Committee. Before answering the questions, all participants were required to consent to participate.
An assessment with 144 primarily closed-ended questions was created using Lime Survey (Schmitz, 2014). The questionnaire׳s
Recruitment and promotion
The study was promoted through Estonia-based gay online social media, gay community organizations, national network of anonymous HIV testing sites and youth counseling centers. Advertisements directed users to a study splash page which described study aims. Additionally, potential respondents were informed their data would be anonymized, including neither IP-address tracking nor utilization of cookies on their local machine. Following submission, all respondents were automatically directed to a
Analyses
Statistical analyses were performed with STATA 11.0 (StataCorp LP. College Station, TX). Descriptive statistics were used to characterize participants. Associations between participant characteristics and depression/anxiety scores were evaluated by using the Wilcoxon rank-sum test or Fisher exact test, followed by univariate and multivariable logistic regressions. Multivariable logistic regression was used for multi-variable modeling. Bayesian Information Criteria (BIC) was used, along with 95%
Results
Overall, 430 people began the questionnaire with a 70.2 % (n=301) completion; 29.8 % (n=129) aborted the survey prior to completion. Of persons completing the survey, 12.3% (n=36) did not meet the inclusion criteria (18 were not Estonian residents, 10 were not MSM, and 8 did not meet the minimum age). This yielded a total sample size of 265 for analyses. Table 1 presents socio-demographic and health related data of the participants based on depressive symptoms cut-off level.
Almost one third
Discussion
According to our knowledge, this is the first study collecting information on the prevalence of anxiety and depressive symptoms and related factors among MSM in an eastern European country. One third of our sample screened positive for depressive symptoms and one fourth reported traits for anxiety. A study on depression among the general population in Estonia using the same instrument found that approximately 11% of the population self-reported symptoms consistent with depression in 2002 (
Role of funding source
This work has been supported by the National Institute for Health Development, Estonia, from Estonian Research Council Health promotion research program TerVE (Grant number 3.2.1002.11-0002) and National Health Plan 2009–2020.
Conflicts of interest
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that
Acknowledgments
The authors gratefully acknowledge: Juta Teller for help designing the web-based questionnaire, Julia Hristojeva and Julia Vinckler for adapting the Russian version of the questionnaire, Rain Uusen and Aare Raudsepp for input in questionnaire development, and Tanel Kreek in developing promotional materials.
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