Treating Co-Occurring Disorders And Acute Suicidality in the LGBTQ+ Community

The LGBTQ+ community struggles with Addiction and Suicidal Thoughts at rates 5-6 times higher than the general population. How can we as providers help? Here is a close up snapshot of a recent encounter.

“I’m losing more battles than I’m winning,” he said quietly. His dull eyes gazed out of the large sunny office window. He turned his baseball cap around from backwards to forwards and placed the brim low over his eyes. He remained silent. Then the tears began to fall. His emaciated upper body heaved with the force of his repressed silent cries as they gradually became more intense. Still, no sound. He raised his hands to cover his eyes. His antecubital fossa, the triangular shaped “funny bone” area where forearm meets upper arm, betrayed the spider bite like scar pattern typical of IV drug use.

I received an online patient message from Jack approximately two hours earlier. It simply stated, “I am inquiring about suicide prevention resources. I am not in immediate danger.” I called him as soon as I read the message. “I’ll be at your office at 11:30 am,” he said. Before I could respond, I was greeted with the familiar dull hum of the dial tone. “11:30 it is…” I replied to myself.

I had only seen Jack one other time in person. He came in one year earlier seeking help for a severe methamphetamine addiction. At that time, he lived with a platonic roommate named Robert, had very few friends or social support, and had a strained relationship with his mother. He loved his mother dearly, but she did not accept him for being gay. This pained him greatly. At the time, I referred him to our addiction recovery groups, and ordered standard labs. After that first appointment, he did not return for his follow-up appointments and did not answer my phone calls.

Now one year later, Jack appeared thirty pounds thinner and significantly sadder than before. The dark circles under his eyes reflected prolonged nights without sleep. And though it had only been a year since our first meeting, he looked ten years older. Only in his mid-twenties, gray and white strands of hair world now invaded his previously sandy blonde locks. Wrinkles curved around his previously smooth eye lines. Depression and Addiction often put the gas pedal on the body’s aging process.

And so we sat here today. I inhaled deeply and began: “Well, I’m glad you came. I’m worried about you.”

Jack shook his head slowly back and forth, sucking the air in tightly between his teeth. In a low, desolate tone, he finally replied, “You sound just like the lady on the suicide hotline from last night.” I studied his face, trying to decipher whether this was a good thing or a bad thing. His face and voice were stone: so monotone, so devoid of feeling and life. It was nearly impossible to decipher positive or negative emotion. This lack of feeling is a phenomenon commonly seen in depression. Think Eeyore from Winnie the Poo. When in doubt, I typically just stay quiet. Most people feel uncomfortable with prolonged silence. They eventually step in to fill the void. It worked. Jack continued, “I cannot do anything right.” He paused after the word “anything,” considering the magnitude of his misfortunes. “I can’t stop using meth. I can’t succeed with dating. I have $200,000 in debt. I’m now a convicted felon. I stopped going to my parole appointments. I even tried to quit my job but my boss said I was a good worker so he put me on leave of absence instead….I can’t even succeed in quitting my job!” he exclaimed.

Depression is a funny thing. It’s like walking around with black tinted sunglasses while everyone else sees the sun. It distorts your perception of reality.

“Wow. Sounds like you have been through an incredible amount of suffering in a short period of time. How has this impacted your thoughts of wanting to harm yourself?” I responded. As a psychiatrist, my job was to decide if Jack needed to be hospitalized for his immediate safety. First things first.

“That’s the worst part of this all,” he finally replied. “I’m even a failure when it comes to that.” As he finished this sentence, he began to cry even more heavily. I had two tissue boxes sitting on an end table beside the patient chairs, easily within reach and view. I typically don’t hand patients the tissue box unless they ask. Actively handing someone a Kleenex can unwittingly send the message that you are uncomfortable with their emotions. It’s like saying, “Don’t cry. Here is a tissue so you can stop and help me feel less uncomfortable.” That being said, I was a little torn on whether I should break my tissue box rule with Jack. He was drowning. He needed a life raft. I finally broke my own rule and handed him the tissue box. He paused and took a few Kleenexes with a look of relief. “You were talking about your growing safety concerns?” I nudged. He suddenly became much calmer- but in an eerie way, not a reassuring way…the same way the ocean turns from blue to gray before a storm. His face was again expressionless. He stared straight out of the large window; black tinted sunglasses on a bright sunny day. I wondered what else was behind those sad blue gray eyes. He began, “I’ve been so sad for so long. I just want that feeling to end. Now I don’t care if it ends.” He cleared his throat and continued, quietly, weakly, “That scares me, you know?” He avoided eye contact again, looking out the window. “I’ve folded my clothes neatly in my drawers, vacuumed my gross bedroom carpet, and even hid my needles so Robert doesn’t have to clean up any of my mess or find my drug junk. I know that’s dumb, but since he’s wheelchair bound, I don’t want to inconvenience him any more than is necessary.”

Suicide is the second leading cause of death in the United States among individuals between the ages of 15-24. I was starting to feel slightly queasy. I knew Jack needed to be hospitalized. I was hoping he would agree.

“Thank you for sharing this with me today,” I responded. “Sometimes it is not easy to talk about this kind of stuff, but it is important, and I’m glad you did. Help me understand, what has kept you from acting on these self harm thoughts so far?”

“My momma,” he promptly replied. When he said this, he suddenly appeared 12, instead of 25. Earnest eyes looked up at me intensely for the first time since he walked in. A flicker of light flashed across his ocean blue eyes before the storm of depression quickly closed back in. “I promised her last Christmas that I wouldn’t kill myself for at least a year. It’s only been six months.” He paused and visibly grimaced, as if removing a painful splinter from his finger. Suddenly, he pounded his right fist into the adjoining wall, screaming, “Damn her!” I startled, then quickly recovered, trying to ignore the miniature baseball sized dent nestled into my office wall just below the calendar. That’s what paint is for.

Again, I waited for him to continue. His initial flames of sorrow were now a fully kindled fire fury of pain. People are complicated. Jack was no exception. I didn’t pretend to understand his rage. But I could listen. He was silent for several more minutes. After spitting into the trashcan, he finished, “My momma told me that she hated faggots, but she’d hate to see me dead even more.”

I closed my eyes and looked away, quickly pinching my left pinky finger between my right thumb and index finger as forcefully as possible in an attempt to will back my own tears with a distraction of dull physical pain. Holy cow. Sometimes I just wanna give people a hug. Jack needed a lifetime of hugs.

I took another deep breath, heart pounding, and asked the most important question of the day: “Jack, will you agree to go into the hospital for a few days to start the process of getting well?” It was me this time who looked up at him earnestly. He did not say anything. He fiddled with his shoestring. I continued, “You wrote me. You came in. That tells me some part of you wants to get better. Lets work with that.”

He looked down at his needle marks. He looked back up at me, then back at the needle marks, weighing who he trusted more. He ran his index finger slowly over his forearm, fingering the track marks, his familiar friend and foe. The track marks were riddled with large visible dark red sores-the trademark sign of Xylazine, also known as “tranq.” Much of the meth supply in the US is now laced with Xylazine, which is a powerful sedative causing decreased heart rate and sedation. Similar to the heroin/cocaine combo of the 2010s known as a speedball, drug dealers now put Xylazine in meth to reduce the stimulating effect. The Xylazine powerfully constricts peripheral blood flow, leading to prominent large body wide ulcers that get progressively larger and necrotic. Jack’s eyes came to rest on me. He took his baseball cap off, straightened up his shoulders, and slowly but firmly stated, “I’ll go in. I’ll go in for my momma.”

The next morning, I received an email from the social worker at our local psychiatric inpatient unit. “Jack insisted that I let you know he made it here safely,” she wrote. “He also wanted me to tell you that he is feeling 0.001% better today,” she ended. I smiled. O.001% was worlds better than 0.000%. The journey of a thousand miles… Well, you know the rest.