The depression connection: if you're gay, you're more prone to depression than those in the general population, experts say. And if you "party" by taking certain illegal drugs, your risk may jump.

Tom Johnstone has battled drug abuse for much of his life. He started taking ecstasy in high school, and by the time he turned 30 he was addicted to cocaine.

Now the gay Houston native is clean and sober and is facing a new battle: depression. Speaking from inside the Alternatives recovery clinic in the Silver Lake neighborhood of Los Angeles, Johnstone said he was diagnosed in 1999 with bipolar disorder, formerly known as manic-depressive illness, characterized by mood fluctuations from extreme highs to extreme lows. "My friends and I," Johnstone says, "we all have issues with depression."

It has been widely reported that the incidence of depression among gay men is higher than in the overall U.S. population. One often-cited study reports that more than 17% of American gay and bisexual men suffer from depression, compared with 9.5% of all adults. According to a biennial survey of high school students in Massachusetts, LGBT teenagers are about four times more likely than their straight peers to have attempted suicide in the prior year.

Measures are now being taken to address the issue. The Medius Institute for Gay Men's Health in New York City, which has been studying gays and depression, recently called for mental health exams to become part of regular checkups and recommended educational programs to teach gay men about the symptoms of mental illness. "I see really great doctors, but my experience is that I get a mental health exam [only] if I walk into the examination room and burst into tears," says Spencer Cox, founder and executive director of the institute. "The first step is to think of it as part of normal health care."

According to Cox, some common factors that cause depression among gays include lacking a romantic partner, experiencing antigay violence, not identifying as gay, or feeling alienated from the gay population. He suggests that gay and bisexual men face multiple epidemics--depression, drug abuse, violence, and HIV--that reinforce one another. "What we have to do is probably tackle each of these things with some understanding of how they're connected," Cox says.

Indeed, a number of recent studies have connected depression with use of ecstasy, a "club drug" that has been around for many years and is wildly popular among gay men. Johnstone believes his mental illness may have resulted from his many years abusing the drug.

He recalls first taking ecstasy with some high school friends at a beach outside of Houston. "I thought it was amazing," he recalls. "Euphoria." That night Johnstone drove home, walked into his parents' bedroom, and woke them up to tell them, "I found God in pill form."

Before long Johnstone and his friends were taking a half tablet every three days. Then he began "stacking"--taking two tablets at once. Within five years he was taking as many as five hits at a time. He gave up "X" in 1998, when he began using cocaine intravenously. But Johnstone, 38, has been clean since August 2006.

Now he blames his depression, at least in part, on ecstasy. "I think taking the amount of ecstasy I started taking at such a young age definitely has been a factor in my depression," says Johnstone, who sought help from Alternatives, a treatment facility that caters to gay, lesbian, bisexual, and transgender clients. "When I'm not on Prozac, I'm suicidal. I've always felt like there was a connection."

Physician David McDowell, founder of the Substance Treatment and Research Service at Columbia University, says the scientific evidence for a link between depression and ecstasy abuse is "very strong." "I don't mean to imply that it always causes depression; it does not," says McDowell, who maintains a private practice and has researched club drugs for 15 years. "But there is a definite correlation between it and feelings of depression as well as increased rates of depression."

Not everyone agrees. The cause-effect findings are challenged by some scientists, who see the studies linking ecstasy and depression as flawed. Because many people who use ecstasy also use other drugs, their depression can be tough to tie back to one drug. Others see the lingering debate as a chicken-or-egg exercise, arguing that undiagnosed depression could have driven people to use ecstasy as a way of self-medicating.

"There are people who use drugs and alcohol because of a mood disorder, and there are people who have a mood disorder because they used drugs and alcohol," says Jim Stolz, clinical services director of the Pride Institute, which runs multiple in-patient treatment centers nationwide focusing on LGBT clients. "The question is always, Which came first?"

As former ecstasy users get clean and learn about diagnoses of depression, they can become angry about what they've done to their lives. "People oftentimes carry a lot of anger, a lot of guilt, and a lot of shame that's directed at themselves," Stolz says. "Part of the program is learning to accept your past and learning to move forward."

Like crystal methamphetamine, ecstasy is a stimulant. The drug's promise of boundless energy, happiness, and closeness to others--and the popular myth that it threatens few bad side effects--often seduces gay men. "If you have the disease of depression, most likely if you're given a choice of different drugs, you're going to choose one of the stimulants rather than the downers," says Jim Mulligan, medical director at Seabrook House, a drug rehab center in New Jersey. "And if you don't have depression and you use these substances severely over long periods of time, yes, you now have produced a chemical depression. It's very hard to treat."

Self-acceptance and other good feelings result when ecstasy triggers users' nerve cells to flood the brain with serotonin, a chemical that plays a key role in regulating mood. With their supply of serotonin drained, users often become depressed in the days after using ecstasy while the brain replenishes its reservoir of the chemical. Weekend ecstasy users nickname this short-term despair "Black Monday" or "Suicide Tuesday."

But long-term or heavy use appears to change the brain's mood-controlling system permanently. A number of studies suggest that ecstasy causes depression and anxiety that lasts far longer than any initial withdrawal would. This long-term depression is the result of ecstasy damaging the brain's serotonin-producing neurons.

In March 2006, Danish researchers concluded that ecstasy causes depression in pigs, whose brains are similar to those of humans. In a 2003 study London Metropolitan University researchers tracked 519 people and found that those who had used ecstasy were at least four times more depressed than those not using ecstasy, even if they used other drugs. And Cambridge University researchers reported in 2005 that chronic ecstasy users with a certain genetic makeup experience more depression than others afterward.

Mike Rizzo, program director at Alternatives, considers it "absolutely" plausible that long-term use of ecstasy causes depression. "With ecstasy, you're creating a chemical imbalance in your body just by taking it," he says.

But Rizzo is not dwelling on it in his programs. If a patient is depressed, they address it as part of their recovery. "New coping mechanisms need to be learned," he says. "We offer a structured sober environment. Not only do we treat them medically, we treat them socially. Our clients will see a psychiatrist every other week. They see a psychotherapist on a weekly basis."

Johnstone moved out of Alternatives in mid December and found an apartment in Los Angeles. He's learning how to live both without drugs and with depression. And he wants other gay men to think twice before doing anything that could cause or add to their risk of depression. "The rumor was that you weren't going to pay any consequences for doing ecstasy," Johnstone recalls of his first time doing the drug. "I feel that's a real myth."

Henneman has also written for the San Francisco Chronicle, the Los Angeles Times, and San Francisco magazine. A hospital scorecard

Having to go to the emergency room with a serious injury is bad enough. But the pain you experience before you get there could be worsened by the homophobic environment you might encounter at the hospital.

To help gay and lesbian patients get the best medical treatment possible, the Human Right Campaign and the Gay and Lesbian Medical Association have teamed up to create the Healthcare Equality Index, which will provide information about how individual hospitals respond to the needs of LGBT individuals and their families. The annual report, the first of which is expected in spring 2007, also will promote best-practice models or "gold standard" policies for the health care industry.

"Too many times a gay man has been unable to comfort his partner, a transgender person has been ridiculed instead of treated, or a lesbian mom has been barred from seeing her child at the hospital," Human Rights Campaign president Joe Solmonese said in a statement. "We believe this project will create a patients' bill of rights for GLBT Americans so we no longer have to live in fear of these scenarios."