Psychotherapeutic depression interventions adapted for sexual and gender minority youth: A systematic review of an emerging literature

Cognitive behavioural therapy for internalizing symptoms in LGBTQ+ people: a preliminary meta-analysis

Internalizing disorders are common in lesbian, gay, bisexual, transgender, queer, questioning, and otherwise non-heterosexual or non-cisgender (LGBTQ+) people. Few studies have evaluated the efficacy of cognitive behavior therapy (CBT), a well-established treatment for internalizing disorders, in LGBTQ+ people. The current study quantitatively synthesized outcomes from existing trials of CBT for internalizing disorders in LGBTQ+ people. Seven databases were searched, identifying 14 relevant studies with a total of 414 participants. A medium within-group effect size was found for depressive symptoms from pre-treatment to post-treatment (k = 14; g = 0.60; 95% CI: 0.44-0.76; I2 = 71.59) and pre-treatment to 2-6-month follow-up (k = 7; g = 0.63; 95% CI: 0.40-0.86; I2 = 71.59). For anxiety and related disorder symptoms, a medium within-group effect size was found from both pre-treatment to post-treatment (k = 10; g = 0.73; 95% CI: 0.47-0.99; I2 = 71.59) and to 3-9-month follow-up (k = 5; g = 0.70; 95% CI: 0.54-0.87; I2 = 36.04). Exploratory analyses indicated small between-group effects at post-treatment between intervention and control groups. Effect sizes were comparable to those in the general population, indicating preliminary support for treating internalizing disorders in LGBTQ+ people with CBT.

A Systematic Review of Evidence-Based Cognitive and/or Behavioural Interventions Targeting Mental Health in LGBTQ+ Populations

Background

Despite a minority stress-related higher risk to develop mental health difficulties, and problematic access to and treatment from healthcare providers, research into LGBTQ+ mental health support is limited. The aims of this systematic review were to explore evidence-based cognitive and/or behavioural interventions and adaptations targeting mental health in LGBTQ+ populations, before providing recommendations for future clinical and research directions.

Method

Six databases were searched in February-March 2022 and risk of bias evaluated using the Cochrane RoB 2/ROBINS-I tools. A narrative synthesis following the PICOS framework and the review questions was used to examine the results.

Results

Sixteen studies met inclusion criteria, including various interventions and adaptations, mental health difficulties, and other emotion- and minority stress-related processes/constructs. Risk of bias was judged as high, and critical/serious, respectively, in all studies. Outcomes included improvements in symptoms of depression (most statistically/clinically significant effects/large effect sizes), and anxiety, emotion regulation, and internalised homophobia in the pre-post studies.

Conclusion

Cognitive/behavioural interventions and adaptations for LGBTQ+ populations feature a range of therapeutic modalities and levels of adaptation, with largely positive effects, in the context of limited and heterogenous literature and risk of bias concerns, as well as limitations related to publication bias and inclusion criteria of the current work. Suggestions for future clinical and research directions include a focus on generic therapeutic competencies and metacompetencies, and affirmative, potentially more holistic approaches, as well as more consistency in methodology, more focus on underserved LGBTQ+ populations and intersectionality, and more detailed investigations into mechanisms of change.

Digital mental health interventions: A narrative review of what is important from the perspective of LGBTQIA+ people

OBJECTIVES

Digital mental health interventions are a promising therapeutic modality to provide psychological support to LGBTQIA+ (lesbian, gay, bisexual, trans, Queer, intersex, asexual, plus other gender, sexual, and romantic minority identities) people. The aim of this narrative review is to explore how the LGBTQIA+ community has been engaged in the design of digital mental health interventions, how content has been tailored to the LGBTQIA+ community, and features identified as important by LGBTQIA+ participants.

METHODS

A total of 33 studies were included in this review from a larger yield of 1933 identified from systematic searches of five databases (PsycINFO, PubMed, Scopus, CINAHAL, and Medline). Data were analyzed narratively and using content analysis.

RESULTS

Only half of the studies reported engaging the LGBTQIA+ community in intervention designs. Interventions have been tailored in a variety of ways to support LGBTQIA+ individuals-such as through affirming imagery, recruitment through LGBTQIA+ networks, and designing content to focus specifically on LGBTQIA+ issues. A range of features were identified as important for participants, namely how content was tailored to LGBTQIA+ experiences, providing connection to community, and links to other relevant LGBTQIA+ resources. While not a primary aim, results also showed that a wide range of digital modalities can significantly improve a range of mental health problems.

CONCLUSION

Digital interventions are an acceptable and effective form of therapeutic intervention, but future research needs to focus on meaningful engagement of community members to inform design and implementation.

Interpersonal Victimization, Substance Use, and Mental Health Among Sexual and Gender Minority Youth: The Role of Self-concept Factors

Reducing substance use and negative mental health outcomes of interpersonal victimization among sexual and gender minority youth (SGMY) represents a critical public health priority. Victimized individuals often develop cognitive schemas, or organized knowledge structures consisting of traits, values, and memories about the self, such as self-concept factors, in response to interpersonal victimization. Prior studies demonstrate the role of self-concept factors (e.g., mastery, control, and self-esteem) in explaining the relationship between victimization and substance use and mental health. However, mastery, control, and self-esteem have not been explored as mediators of interpersonal victimization and health among SGMY. This study is among the first to apply cognitive schema models of trauma-related health symptoms using a large sample of SGMY to examine (a) whether interpersonal victimization is associated with substance use (i.e., alcohol use, cannabis use, and cigarette use) and mental health problems (i.e., depressive symptoms, self-perceived stress, self-rated health issues) and (b) whether diminished sense of mastery and control and lower self-esteem can partially explain elevated rates of substance use and mental health problems in this population. We used the U.S.-based 2017 LGBTQ National Teen Survey (n = 17,112; Mage = 15.57, SD = 1.27); 6,401 (37.4%) identified as gay or lesbian, 7,396 (43.2%) as cisgender women, and 10,245 (59.9%) as White. Substance use and mental health variables were positively associated with interpersonal victimization variables and negatively associated with self-concept factors. Self-concept factors partially mediated the relationship between interpersonal victimization and mental health. This model explained 74.2% of the variance in mental health and 28.4% of the variance in substance use. Cognitive coping may represent an important modifiable factor that can be targeted by trauma-focused interventions in efforts to improve victimized SGMY's mental health. Findings call for the development of identity-affirmative, evidence-based, and trauma-focused interventions for SGMY to improve this populations' overall health.

Parental Support, Depressive Symptoms, and LGBTQ Adolescents: Main and Moderation Effects in a Diverse Sample

OBJECTIVE

Research has documented the importance of parental support as a protective factor against depressive symptoms among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. In this study, we assessed the relations between LGBTQ-specific parental support and depressive symptoms.

METHOD

Participants were 6,837 LGBTQ youth (ages 13-17) with diverse racial and ethnic, gender, and sexual identities. Main effect and moderation analyses examined interactions between LGBTQ-specific parental support with demographic variables on depressive symptoms, considering demographics as moderators.

RESULTS

We found that participants of color reported less LGBTQ-specific parental support than their White counterparts, that transgender and genderqueer participants reported less LGBTQ-specific parental support than their cisgender counterparts, and that non-monosexual participants reported less LGBTQ-specific parental support than their monosexual counterparts. Disparities in depressive symptoms were found for individuals who identified as Native American and Latinx, non-monosexual, and transgender and genderqueer, such that these groups reported higher levels of depressive symptoms. Further, we found a significant interaction between LGBTQ-specific parental support and ethnicity, with LGBTQ-specific parental support being less strongly associated with participants who identified as Latinx compared to those who did not identify as Latinx. We also found a significant interaction between LGBTQ-specific parental support and gender identity, with LGBTQ-specific parental support being more strongly related to depressive symptoms among participants who did not identify as boys compared to cisgender boys .

DISCUSSION

We discuss how to assess the impact of interlocking systems of oppression when working with LGBTQ youth and their parental figures.

Sexual Minority Stress, Mental Health Symptoms, and Suicidality among LGBTQ Youth Accessing Crisis Services

Sexual and gender minority youth are at elevated risk for suicide. Studies have separately established the relation between minority stress and mental health symptoms, as well as minority stress and suicidality. However, no known research has simultaneously examined different mental health mechanisms whereby minority stress may be associated with different suicidal experiences (e.g., suicidal ideation, suicide attempts). The present study used data from a national sample of 572 sexual and gender minority youth aged 12 to 24 (mean age = 17.59; SD = 3.13) recruited from an LGBTQ youth-focused suicide crisis prevention provider. Nearly one-third of the sample (30.2%) identified as transgender, genderqueer, or questioning. Nearly one quarter of the sample (24.3%) identified as gay, 17.1% as pansexual, 16.8% as bisexual, and 15.2% as lesbian. Structural equation modeling was used for mediation analyses to explain suicidal ideation and suicide attempts. Serial mediation models were determined to be the best fit for both suicide-related outcomes. Minority stress was associated with depressive and PTSD symptoms, which were linked with suicidal ideation and attempt through hopelessness. The findings supported the hypotheses that minority stress would be associated with suicidality not just directly, but also indirectly through multiple mental health symptom pathways.