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Sexual orientation and self-reported mood disorder diagnosis among Canadian adults Pakula, Basia; Shoveller, Jean A Mar 8, 2013

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RESEARCH ARTICLE Open AccessSexual orientation and self-reported mooddisorder diagnosis among Canadian adultsBasia Pakula* and Jean A ShovellerAbstractBackground: The prevalence and correlates of mood disorders among people who self-identify as lesbian, gay orbisexual (LGB) are not well understood. Therefore, the current analysis was undertaken to estimate the prevalenceand correlates of self-reported mood disorders among a nationally representative sample of Canadian adults(ages 18 to 59 years). Stratified analyses by age and sex were also performed.Methods: Using data from the 2007–2008 Canadian Community Health Survey, logistic regression techniques wereused to determine whether sexual orientation was associated with self-reported mood disorders.Results: Among respondents who identified as LGB, 17.1% self-reported having a current mood disorder while6.9% of heterosexuals reported having a current mood disorder. After adjusting for potential confounders, LGB-respondents remained more likely to report mood disorder as compared to heterosexual respondents (AOR: 2.93;95% CI: 2.55-3.37). Gay and bisexual males were at elevated odds of reporting mood disorders (3.48; 95% CI:2.81–4.31), compared to heterosexual males. Young LGB respondents (ages 18–29) had higher odds (3.75; 95% CI:2.96–4.74), compared to same-age heterosexuals.Conclusions: These results demonstrate elevated prevalence of mood disorders among LGB survey respondentscompared to heterosexual respondents. Interventions and programming are needed to promote the mental healthand well being of people who identify as LGB, especially those who belong to particular subgroups (e.g., men whoare gay or bisexual; young people who are LGB).Keywords: Mood disorders, Mental health, Sexual orientation, Sexual minorityBackgroundIt is estimated that nearly one in five Canadian adultswill experience a mental illness during their lifetime[1,2]. Mood disorders, such as depression and bipolardisorder, are among the most common mental illnessesin Canada [2], and pose potentially serious adverse ef-fects for people’s social and work or school lives as wellas for their general health and functioning [3]. Previousstudies in the United States (US) have found that les-bian, gay, and bisexual (LGB) people in general, andLGB youth in particular, consistently report poorer men-tal health compared to the general population, includinggreater depression, stress, anxiety, substance use, andsuicide [4-8]. These findings have been corroboratedin recent studies in the United Kingdom where non-heterosexual orientation was found to be associated withelevated levels of mental disorders, self-harm and suici-dality [9,10]. Few Canadian studies to date have exam-ined associations between sexual orientation and mentalhealth conditions (e.g., suicidality, depression, mood andanxiety disorders) in regional [11] and national [12,13]samples, noting poorer outcomes for LGB respondents.A person’s sexual orientation has also been shown tobe independently associated with mental health status,suggesting that the LGB people may face unique factorsassociated with being members of a sexual minority.For example, in one community-based study of adultlesbians and heterosexual women [7], non-heterosexualorientation was an independent predictor of depressivestress (a composite measure of depression indicators). Inanother community sample of lesbian and heterosexualwomen, sexual orientation also was a significant pre-dictor of mental health utilization controlling for known* Correspondence: bpakula@alumni.ubc.caSchool of Population and Public Health, University of British Columbia,Vancouver, British Columbia, Canada© 2013 Pakula and Shoveller; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.Pakula and Shoveller BMC Public Health 2013, 13:209http://www.biomedcentral.com/1471-2458/13/209confounders [14]. In two separate Canadian studies ofgay and bisexual men [12] and lesbian and bisexualwomen [13], sexual orientation was independently asso-ciated with mood and anxiety disorders after controllingfor smoking, BMI, and demographic characteristics.The factors that appear to affect the mental health ofLGB people are in large part similar to those affectingthe mental health of heterosexual people; however, LGBpeople tend to be more likely to report experiencingstressful life events and anxiety [5,7,8], exposure to dis-criminatory behaviour [15,16], social isolation, low so-cial supports and community belonging [5,17], and lowmental health service utilization [14,18]. Unique factorsnoted in the literature include perceived discrimination[19], externalized and internalized homophobia [20,21],negative disclosure reactions [22,23], heterosexism andheteronormativity [24].The majority of research on this topic has been con-ducted in the US [9], where, in many states, sexual mi-norities face relatively significant structural forms ofdiscrimination (e.g., barriers to health care and health in-surance; lack of power to make medical and legal deci-sions on behalf of an ill or deceased partner; lack ofopportunity for same sex marriage by the federal govern-ment and most state governments) [25,26]. In Canada, asmall number of studies examined the role of sexualorientation in mental health service utilization, and foundthat LGB people report higher unmet mental healthservice needs compared to non-LGB people [27,28]. How-ever, empirical research on the prevalence of mental disor-ders among LGB Canadians remains scant, in particularas it pertains to understanding the possible causes of theelevated prevalence. With the exception of a series ofstudies on the health of LGB youth in British Columbia,Canada [11,29], this gap in evidence also pertains to themental health of young people who identify as LGB. Thisstudy builds on existing studies in Canada to examine theprevalence and correlates of self-reported mood disorders,including effect modification by age and sex, in a nation-ally representative sample of LGB Canadian adults (ages18 to 59 years). This is a step towards understanding pos-sible mechanisms underlying the noted associations in theelevated prevalence of mood and other mental health dis-orders among LGB people [9] and in proposing appropri-ate interventions to addressing the observed inequities.MethodsData sourceData for the study were obtained from the 2007–2008Canadian Community Health Survey. The CCHS is anongoing, national, cross-sectional survey that collects in-formation on health status, health care utilization andhealth determinants for the Canadian population. TheCCHS is representative of approximately 98% of theCanadian population aged 12 and over living in privatedwellings in the 121 health regions from all provincesand territories. Excluded from the sampling frame areindividuals living on First Nations Reserves and CrownLands, institutional residents (e.g., federal penitentiaries),full-time members of the Canadian Forces, and residentsof extremely remote regions. Data are collected usingcomputer-assisted in-person and telephone interviewing.Further details on the methodology of the 2007–2008CCHS and its measures are reported by Statistics Canada[30]. Ethical approval for the use of the data was coveredby the publicly available data clause of the University ofBritish Columbia policy no. 89 on research and otherstudies involving human subjects.Study sampleThe 2007–2008 CCHS included 131,959 respondents toall the survey questions over the two-year period. Thesample in the present study was restricted to valid re-sponses for the study outcome (self-reported mooddisorder diagnosis) and primary explanatory variable (self-reported sexual orientation), for a total unweighted sam-ple of 76,630. Excluded invalid responses were those whoresponded “don’t know,” did not state, or refused to an-swer the questions on the two primary variables of inter-est. In the CCHS, the primary explanatory variable wasasked only of respondents ages 18 to 59; therefore thestudy sample is restricted to ages 18–59. Based on thesample size of 76,630 respondents, the study has 0.95power (alpha=0.05/beta=0.2) to detect a difference in theprevalence of mood disorders by sexual orientation equalto 0.02.Study variablesThe main outcome of the study was self-reported mooddisorder diagnosis (yes/no) based on the survey ques-tion: “Do you have a mood disorder such as depression,bipolar disorder, mania or dysthymia?” Respondents werereminded to self-report conditions diagnosed by a healthprofessional; however, they were not asked to elaborate onthe type of mood disorder diagnosis or the time whenthe diagnosis occurred. The primary explanatory variable,self-reported sexual orientation (heterosexual/ LGB), wasbased on the question: “Do you consider yourself to be:(heterosexual, homosexual, that is lesbian or gay, or bi-sexual)?” The sexual orientation variable was dichotomi-zed into two categories: heterosexual and lesbian/gay/bisexual (LGB).Potential confounders of the relationship between mooddisorders and sexual orientation were also examined inlight of previous evidence in the peer-reviewed literature[4,5,7,17,24] suggesting their association with both theoutcome and the primary explanatory variable. These in-cluded: sex, age, educational attainment, perceived lifePakula and Shoveller BMC Public Health 2013, 13:209 Page 2 of 7http://www.biomedcentral.com/1471-2458/13/209stress, sense of community belonging, and having a regu-lar general practitioner (GP), which served as a proxy forhealth service utilization.Age was derived from a continuous variable and grou-ped into three age categories (18–29, 30–39, 40–59).Perceived life stress was based on the question: “Think-ing about the amount of stress in your life, would yousay that most days are: (not at all stressful, not verystressful, a bit stressful, quite a bit stressful, or extremelystressful)?” Responses “not at all stressful,” “notvery stressful” and “a bit stressful” were recoded as “notvery stressful” and responses “quite a bit stressful” and“extremely stressful” were recoded as “very stressful.”Sense of community belonging was based on thequestion: “How would you describe your sense ofbelonging to your local community? Would you say it is:(very strong, somewhat strong, somewhat weak, or veryweak)?” Responses “very strong” and “somewhat strong”were recoded as “strong” and responses “somewhatweak” and “very weak” were recoded as “weak.” Thevariables sex (male/ female); having a regular medical doc-tor (yes/ no); and educational attainment, which denotedthe highest level of household educational attainment (lessthan secondary/ secondary/ other post-secondary/ post-secondary), preserved original survey question categories.Data analysesData analyses were conducted using SAS 9.3 (SAS Insti-tute Inc., Cary, NC). To appropriately account for theCCHS sampling procedures [30], probability weights wereapplied in all analyses to produce unbiased estimates andvariances that adjusted for the sampling strategy. Chi-square was used to examine bivariate relationshipsbetween self-reported mood disorder and the various cor-relates described above. The relationship between sexualorientation and mood disorder diagnosis was first exam-ined using an unadjusted OR with a 95% confidence inter-val (CI). Next, OR and 95% confidence intervals adjustedfor age and sex were calculated. After testing for collinear-ity (using Spearman’s rho) and interaction, a multivariablelogistic regression model with all study variables was usedto measure the presence and strength of the relationshipbetween sexual orientation and mood disorders, whilecontrolling for the effect of confounders. Adjusted ORsand corresponding 95% confidence intervals were calcu-lated (α=0.05). Stratified analyses were conducted to ex-plore effect modification by age and sex.Two sets of missing data were explored to determinewhether missing data were randomly distributed acrossstudy variables. First, all analyses were repeated on asample restricted to valid responses for all variables(n=75,490). Second, age, sex, and outcome distributionswere obtained for a sample with missing responses tothe sexual orientation question (i.e., those who answered‘don’t know,’ ‘refused,’ or ‘did not state’ a response re-coded as ‘missing’) (n=3,211).ResultsDescription of study populationTable 1 shows the distribution of all study variablesby mood disorder diagnosis. Of the total sample, 7.1%(n=6546) reported a mood disorder diagnosis. Respon-dents self-identifying as LGB were significantly more likelyto report mood disorder diagnosis, with 17.1% of LGBreporting a mood disorder compared to 6.9% of hetero-sexuals (p<0.0001, 1df). Canadians with mood disorderswere more likely to be female (9.6% vs. 4.7%) (p<.0001,1df), report very high levels of life stress (12.6% vs. 5.2%)(p<.0001, 1df), have a weak sense of community belonging(9.1% vs. 5.9%) (p<.0001, 1df), have a regular GP (7.8% vs.4.2%) (p<.0001, 1df), be in the older age groups (p<.0001,2df), and have lower levels of education (p<.0001, 3df).A total of 2.1% respondents (2.0% female and 2.2%male) self-identified as LGB. Chi-square analyses wereTable 1 Distribution of study sample by mood disorderdiagnosisCharacteristicsMood disorderYes Non=6546 (7.1%) n=70084 (92.9%)*Sexual orientationHeterosexual 6232 (6.9%) 68768 (93.1%)LGB 314 (17.1%) 1316 (83.0%)*SexMale 2112 (4.7%) 33329 (95.3%)Female 4434 (9.6%) 36755 (90.5%)*Self-perceived life stressNot very high 3571 (5.2%) 54469 (94.8%)Very high 2960 (12.6%) 15451 (87.4%)*Community belongingStrong 3293 (5.9%) 45596 (94.1%)Weak 3201 (9.1%) 23813 (90.9%)*Regular GPYes 5786 (7.8%) 56457 (92.2%)No 757 (4.2%) 13575 (95.8%)*Age18–29 1190 (5.8%) 16609 (94.2%)30–39 1415 (6.5%) 16978 (93.5%)40–59 3941 (8.1%) 36497 (91.9%)*EducationLess than secondary 1034 (10.4%) 8139 (89.6%)Secondary 1094 (7.1%) 12512 (92.9%)Other post-secondary 687 (8.3%) 6079 (91.7%)Post-secondary 3706 (6.4%) 43135 (93.6%)Note. Chi-square test: * p<.0001.Pakula and Shoveller BMC Public Health 2013, 13:209 Page 3 of 7http://www.biomedcentral.com/1471-2458/13/209performed to examine differences in the distribution ofall study variables across the primary explanatory vari-able (see Table 2). Compared to heterosexuals, LGB re-spondents were more likely to report: higher levels ofself-perceived life stress (28.6% vs. 25.8%) (p=0.0123,1df ), a weak sense of community belonging (44.1% vs38.9%) (p<0.0001, 1df ), not having a regular GP (21.9%vs. 18.6%) (p=0.008, 1df ), being in the younger agegroups (p<0.0001, 2df ), and being in the post secondaryeducation groups (p<0.0001, 3df ). No collinearity wasobserved between stress, community belonging, and ha-ving a regular GP (all r< 0.2).Association between sexual orientation and mooddisordersLGB Canadians were found to have 2.76 higher odds ofmood disorder diagnosis compared to heterosexuals(95% CI: 2.42–3.16) in the unadjusted model. In the fullyadjusted model, LGB had 2.93 higher odds of mooddisorder diagnosis compared to heterosexuals (95% CI:2.55–3.37). Table 3 summarizes weighted unadjusted andadjusted odds ratios for the association between sexualorientation and mood disorders.Effect modification by sex and ageEffect modification by sex and age was explored inseparate stratified analyses. Table 4 shows the resultsof these analyses, reporting the odds ratios for theassociation between sexual orientation and mood dis-orders by age group and sex. Lesbian and bisexualwomen had 2.60 higher odds of mood disorders (95% CI:2.17–3.12) compared to heterosexual females; gay andbisexual males had 3.5 higher odds of mood disorders(95% CI: 2.81–4.31) compared to heterosexual males.LGB respondents aged 18–29 were found to have thehighest odds for mood disorders at 3.75 (95% CI: 2.96–4.74) compared to heterosexual respondents in the sameage group.Table 2 Distribution of study sample by sexualorientationCharacteristicsSexual orientationHeterosexual LGBn=75000 (97.92%) n=1630 (2.72%)*Mood disorderYes 6232 (6.92%) 314 (17.05%)No 68768 (93.08%) 1316 (82.95%)SexMale 34648 (49.73%) 793 (50.24%)Female 40352 (50.27%) 837 (49.76%)**Self-perceived life stressNot very high 56879 (74.22%) 1161 (71.44%)Very high 17946 (25.78%) 465 (28.56%)*Community belongingStrong 47963 (61.16%) 926 (55.86%)Weak 26327 (38.84%) 687 (44.14%)**Regular GPYes 60944 (81.45%) 1299 (78.15%)No 14004 (18.55%) 328 (21.85%)*Age18–29 17337 (27.0%) 462 (32.71%)30–39 18064 (22.9%) 329 (19.37%)40–59 39599 (50.11%) 839 (47.92%)*EducationLess than secondary 9007 (10.11%) 166 (7.42%)Secondary 13363 (17.32%) 243 (14.48%)Other post-secondary 6562 (9.65%) 204 (14.47%)Post-secondary 45831 (62.91%) 1010 (63.63%)Note. Chi-square test: * p<.0001, ** p<.05.Table 3 Adjusted and unadjusted odds ratios for mooddisorder and sexual orientationCharacteristicUnadjusted(n=76,630)Adjusted1(n=76,386)OR 95% CIs OR 95% CIsSexual orientationLGB 2.76* 2.42–3.16 2.93* 2.55–3.37Heterosexual 1.0 1.0SexFemale 2.14* 2.02–2.27 2.03* 1.97–2.15Male 1.0 1.0Age18–29 0.70* 0.65–0.75 0.72* 0.67–0.7730–39 0.79* 0.74–0.85 0.85* 0.79–0.9140–59 1.0 1.0EducationLess than secondary 1.69* 1.56–1.84 1.92* 1.77–2.10Secondary 1.32* 1.21–1.45 1.51* 1.37–1.65Other post-secondary 1.11* 1.03–1.20 1.23* 1.14–1.33Post-secondary 1.0 1.0Regular GPYes 1.91* 1.75–2.08 1.75* 1.60–1.92No 1.0 1.0Community belongingWeak 1.61* 1.53–1.70 1.61* 1.52–1.70Strong 1.0 1.0Self-perceived life stressVery high 2.61* 2.46–2.76 2.50* 2.36–2.65Not very high 1.0 1.0Note. Wald test: * p<.0001.1 Adjusts for age group, sex, education, having a regular GP, communitybelonging, and life stress.Pakula and Shoveller BMC Public Health 2013, 13:209 Page 4 of 7http://www.biomedcentral.com/1471-2458/13/209Missing dataResults of regression analyses on a sample without mis-sing values (n=75,490) compared to the study samplewith missing values (n=76,386) yielded nearly identicalodds ratios, with slightly wider confidence intervals atthe upper end. Age, sex, and outcome distributions forthose with missing responses to the sexual orientationquestion (n=3,211) showed that missing respondentswere more likely to be male (p=0.0064, 1df ) and be inthe older age groups (p=0.0874, 2df ) compared to het-erosexual and LGB respondents. These respondents hadhigher rates of mood disorders compared to heterosexuals(9.5% vs. 6.9%), but lower compared to LGB (vs. 17.1%)(p<0.0001, 2df).DiscussionThree key findings emerge from this study regarding theassociation between sexual orientation and self-reportedmood disorder diagnosis. First, lesbian, gay and bisexualCanadians reported greater odds of mood disorder diag-noses compared to their heterosexual counterparts. Thiseffect persisted, and in fact increased slightly, after con-trolling for levels of stress, community belonging, havinga GP, and socio-demographic characteristics. Second, instratified analyses, both males and females in the LGBgroup had elevated odds of mood disorders compared toheterosexual males and females, with the highest oddsnoted among gay and bisexual males. Third, while in-creased odds of mood disorders for LGB respondentswere observed across all age groups, the highest odds ra-tios were noted among young LGB aged 18–29, withnearly quadruple odds compared to their same-age het-erosexual counterparts.The results of the study build on growing evidence ofincreased prevalence of self-reported mood disorders forLGB Canadians. The findings are consistent with inter-national studies reporting poorer mental health outcomes,such as depression, anxiety disorders, and suicide, amongLGB people [4,5,7-10,31]. Although it has been suggestedthat factors related to marginalization and stigma (e.g.,homophobia, heterosexism, disclosure reactions, and sex-ual discrimination) [19-23] contribute to elevated mooddisorder prevalence in the LGB community, the exact na-ture of the mechanisms and pathways that shape mentalhealth in these communities remain poorly understood.The stratified findings of effect modification by ageand sex are consistent with existing literature on theimportance of factors, such as sex, age, race, and sex-ual orientation, in understanding health inequalities inCanada [32]. The stratified results are also consistentwith literature reporting poorer mental health outcomesof young LGB people [6,8,33]. These findings point tothe possible mechanisms underlying the independent ef-fect of sexual orientation on mood disorder diagnosis,after controlling for known confounders. A number ofstudies discuss the mental health implications as youngpeople navigate the stages of sexual identity develop-ment [22,34]. For example, in one US study, negative so-cial reactions to disclosing one’s LGB identity wereassociated with subsequent substance use, while positivereactions were thought to serve as stress-buffering orresilience-building for LGB people [23]. The currentfindings show substantially higher odds of mood disor-ders among gay and bisexual males (compared to het-erosexual males), which point to important sex- andgender-based considerations regarding the mental healthinequalities experienced by LGB people.The current study has several limitations and strengths.The self-reported nature of the data may be subject to re-call and social desirability biases as well as the subjectiveinterpretation of the questions. While respondents wereasked to report mood disorders diagnosed by a health pro-fessional, this primary outcome was self-reported and thedate of the diagnosis is unknown. The proportion of LGBCanadians is also likely underestimated in the CCHS. TheCCHS asks about the sexual orientation of people aged18–59 only, thus excluding adolescents and seniors. Basedon estimates from the US, the proportion of people whochoose to self-identify as LGB is approximately 2% whilethose who report same sex behaviour ranges from 5–7%[35]. Similarly, about 2.7% of CCHS respondents self-identified as LGB. Furthermore, existing literature sug-gests that self-identification or the act of disclosure (“com-ing out”) is an indication of self-acceptance, reducingstress associated with concealing or denying one’s sexualTable 4 Adjusted odds ratios for mood disorders andsexuality stratified by sex and ageCharacteristicSexual orientation Adjusted1OR 95% CIsSex2Male GB 3.48* 2.81–4.31Heterosexual 1.0Female LB 2.60* 2.17–3.12Heterosexual 1.0Age318–29 LGB 3.75* 2.96–4.74Heterosexual 1.030–39 LGB 2.68* 1.91–3.76Heterosexual 1.040–59 LGB 2.53* 2.07–3.09Heterosexual 1.0Note. Wald test: * p<.0001.1Adjusts for age group, sex, education, having a regular GP, communitybelonging, and life stress.2Sex: female (n=41,189); male (35,441).3Age: 18–29 (n=17,799); 30–39 (n=18,393); 40–59 (n=40,438).Pakula and Shoveller BMC Public Health 2013, 13:209 Page 5 of 7http://www.biomedcentral.com/1471-2458/13/209orientation [23,34]. Survey respondents who chose to self-identify as LGB in the CCHS may therefore be more likelyto report better mental health outcomes than those whodid not self-identify (i.e., remain ‘closeted’), leading to anunderestimation of the true effect between sexual orienta-tion and mood disorders in the study. Additionally, al-though the study is strengthened by the use of a large,population-based survey sample, the sample size of LGBrespondents impaired our ability to conduct additionallystratified analyses (e.g., separate effects for gay, lesbian,and bisexual people). In particular, the study could notexamine multiple intersecting vulnerabilities, such as race,gender identity, or immigration status, which some otherstudies have suggested may also be important contributorsto mental health outcomes [32,36-38]. Finally, the cross-sectional design of the CCHS limits the ability to assesscausal relationships, although we acknowledge that afulsome investigation of these mechanisms may de-mand the use of an array of methods (qualitative andquantitative) to facilitate more nuanced explanations,particularly amongst hard-to-reach populations [39].ConclusionsThese findings point to mental health needs among LGBpeople and highlight the importance of accounting forparticular risk factors that are associated with being amember of a stigmatized sexual minority. In light of theprevalence and potential severity of mental health prob-lems, there is an urgent need to better understand – andact upon – the conditions and practices that contributeto the likelihood of LGB people experiencing mood dis-orders. Additional research to identify the pathways ofrisk and resilience is required in order to point towardspossible policy and programming interventions, inclu-ding novel efforts to intervene to prevent the emer-gence of mood disorders (e.g., interventions to help withstressful life events; interventions designed tailored toaddress social stigma, including heterosexism and homo-phobia). Finally, the scope of the problem also demandsresponses within the mental health care system to en-sure that the mental health treatment needs of LGB areresponded to appropriately (e.g., LGB-friendly approaches;low-threshold service provision).Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsBP conceived of the study design, and was responsible for the accuracy ofstatistical analyses and the composition of manuscript. JAS wrote andreviewed manuscript drafts, and provided significant scientific input to theinterpretation of the data and results. Both authors read and approved thefinal version of the manuscript. Research was conducted between October2011-March 2012.AcknowledgementsBP is the recipient of the CIHR Doctoral Research Award (Frederick Bantingand Charles Best Canada Graduate Scholarship) and Killam DoctoralScholarship. JAS holds the CIHR Applied Public Health Chair in ImprovingYouth Sexual Health. The authors thank Dr. Mieke Koehoorn for providinghelpful feedback and guidance on earlier drafts of the manuscript. Sincerethanks to Catherine Dick and Steven Thomas of Statistics Canada for theirassistance with remote data access.Received: 28 September 2012 Accepted: 4 March 2013Published: 8 March 2013References1. Health Canada: A report on mental illnesses in Canada. Ottawa; 2002. ISBNISBN H39-643/2002E.2. 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Faugier J, Sargeant M: Sampling Hard to Reach Populations. J Adv Nurs1997, 26:790–797.doi:10.1186/1471-2458-13-209Cite this article as: Pakula and Shoveller: Sexual orientation and self-reported mood disorder diagnosis among Canadian adults. BMC PublicHealth 2013 13:209.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitPakula and Shoveller BMC Public Health 2013, 13:209 Page 7 of 7http://www.biomedcentral.com/1471-2458/13/209

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