A Description of Common Mental Disorders in Men Who Have
Sex with Men (MSM) Referred for Assessment and Intervention
at an MSM Clinic in Cape Town, South Africa
Kevin Stoloff•John A. Joska•Dorothy Feast•
Glenn De Swardt•Johan Hugo•Helen Struthers•
James McIntyre•Kevin Rebe
Published online: 27 March 2013
? Springer Science+Business Media New York 2013
prevalence of common mental disorders (CMD), as compared
with heterosexual men. HIV infection is independently asso-
ciated with higher rates of CMD. Given this context, and the
high background community prevalence of HIV in South
aim of this research was to investigate neuropsychiatric
symptoms and disorders in MSM who were referred for
assessment and management of mental health problems, in an
MSM Clinic in urban Cape Town, South Africa. Twenty-five
men were screened using the MINI, AUDIT, DUDIT, and
IPDE Screener. Depression, suicidality, as well as alcohol and
drug use disorders were highly prevalent in this group (44, 56,
was suggestive of a high prevalence of personality disorders.
The high prevalence of neuropsychiatric disorders in this
sample supports the idea that integrated mental health services
are needed to address the complex needs of this population.
Adequate input into the mental health needs of this population
could reduce the potential for HIV acquisition and transmis-
sion, improve adherence to treatment and care, and ensure the
provision a comprehensive health service for MSM.
Mental health ? DUDIT ? MINI ? AUDIT ? IPDE
MSM ? HIV/AIDS ? South Africa ?
In several studies internationally, the prevalence of com-
mon mental disorders (including mood, anxiety, and sub-
stance use disorders) has been shown to be greater among
MSM than in heterosexual men. Data from the National
Co-morbidity Survey in the United States demonstrated
higher 12-month prevalences of anxiety disorders, mood
disorders and substance use disorders, as well as of suicidal
thoughts and plans in people with same-sex partners .
Sandfort et al.  in a Dutch study found increased
12-month prevalences of mood and anxiety disorders in
MSM. Herrel et al.  found an increased lifetime preva-
lence of suicidal behaviours in MSM in a study using data
collected from a twin registry. A meta-analysis by Meyer
 confirmed these findings.
HIV is highly prevalent in Southern Africa. Some studies
indicate even higher seroprevalence among MSM in the
region (between 10.4 and 33.9 %) [5, 6]. It is also well-
documented that common mental disorders are also highly
prevalent in people living with HIV (PLWHA) [7, 8]. The
consequences of untreated mental disorders on HIV are
numerous, include delayed initiation of ART, higher all-
cause morbidity and mortality, adverse immunological
outcomes, and decreased adherence to medication [9–13].
Given that MSM in general are reported to have higher
rates of CMDs, and that the HIV prevalence in this group is
higher than the general population, MSM in Cape Town
K. Stoloff ? J. A. Joska ? D. Feast
Department of Psychiatry and Mental Health, University
of Cape Town, Cape Town, South Africa
K. Stoloff (&)
Department of Psychiatry and Mental health, Groote Schuur
Hospital, Anzio Road, Observatory 7925, South Africa
e-mail: email@example.com; firstname.lastname@example.org
G. De Swardt ? J. Hugo ? H. Struthers ? J. McIntyre ? K. Rebe
Anova Health Institute, Johannesburg and Cape Town,
Centre for Infectious Diseases Epidemiology and Research,
School of Public Health and Family Medicine, University
of Cape Town, Cape Town, South Africa
AIDS Behav (2013) 17:S77–S81
may be at an even greater risk for the development of
CMD’s. Specific MSM factors may contribute to this,
including the consequences of living in a heteronormative
stigmatizing society, which leads to discrimination, isola-
tion, and distress and high levels of internalised homo-
phobia . Furthermore, PLWHA internalize AIDS
stigmas which leads to higher levels of depression .
There is little local South African data on the prevalence
of mental disorders in our MSM population.
It has been the experience of clinicians working at the
Ivan Toms Centre for Men’s Health (ITCMH) in Cape
Town, an MSM-targeted primary health care HIV and
sexually transmitted diseases clinic, that men with the triad
of MSM-specific relational and personality issues, HIV
seropositivity, and substance abuse constitute the most
challenging and difficult to treat patients.
In this study, we aimed to describe the psychopathology in
MSM who were referred to the mental health clinic at the
ITCMH. A working knowledge of mental disorders in this
group is needed to inform the development of appropriate
mental health services, allocation of resources and the devel-
ofassessmentandtreatmentof mentaldisorders isintegraltoa
comprehensive health plan. Not only do depression, anxiety
disorders and substance use disorders contribute a significant
disease burden, but in themselves impair quality of life.
Setting and Participants
This descriptive study was performed at ITCMH, which
provides sexual health, HIV and mental health services for
MSM in Cape Town, South Africa. Participants were
recruited from new referrals to the mental health clinic
between September 2010, and June 2011, and were referred
by medical staff at the clinic, as well as by external
healthcare providers. Participants were excluded from the
analysis if they were heterosexual, or if they had been
assessed previously in this clinic (Tables 1, 2).
A total of 25 participants were screened in clinical inter-
views, which were 90 min in duration, by the attending psy-
Project, a larger project aimed at establishing a screening pro-
tocol for common mental disorders in PLWHA, and was
approved by the Human Research Ethics Committee of the
Health Sciences Faculty of the University of Cape Town.
Consecutive new referrals were invited to participate in the
study, and participants provided written informed consent.
The initial part of the interview consisted of recording
basic demographic information, and the administration of
screening instruments, which was followed by a more
problem-focused, free-style interview process. Participants
were either treated by the attending psychiatrist, and fol-
lowed up if necessary, or were referred to external
The psychiatrists were trained in the use of the mental
health screening protocol. This consisted of four screening
(M.I.N.I.), which is a short structured diagnostic interview,
Table 1 Summary of demographic information
Home language (N = 25)
English14 (56 %)
Afrikaans 7 (28 %)
Xhosa2 (8 %)
Zulu 1 (4 %)
Employed11 (44 %)
Unemployed13 (52 %)
Level of education
Primary2 (8 %)
Secondary6 (24 %)
Tertiary 17 (68 %)
Single16 (64 %)
Married1 (4 %)
Common-law3 (12 %)
Divorce 2 (8 %)
Widowed2 (8 %)
18–35 12 (48 %)
36–509 (36 %)
51–65 4 (16 %)
Table 2 Prevalence of mental disorders (M.I.N.I.)
Current suicidality 14 (56 %)
Major depressive disorder, current11 (44 %)
Agarophobia5 (20 %)
Generalized anxiety disorder3 (12 %)
Social phobia3 (12 %)
Anti-social personality disorder2 (8 %)
Post traumatic stress disorder 2 (8 %)
Obsessive compulsive disorder1 (4 %)
Bipolar disorder, type 2, current mood episode 1 (4 %)
S78AIDS Behav (2013) 17:S77–S81
developed jointly by psychiatrists and clinicians in the
United States and Europe, for DSM-IV and ICD-10 psy-
chiatric disorders, by Sheehan et al. , and validated in
several studies in low to middle income countries (LMICs).
The Alcohol Use Disorders Identification Test (AUDIT),
which was developed by the World Health Organization
(WHO) as a simple method of screening for excessive
drinking, which has been validated in Sub-Saharan Africa
. It can help in identifying excessive drinking as the
cause of the presenting illness. The AUDIT was developed
and evaluated over a period of two decades, and it has been
found to provide an accurate measure of risk across gender,
age, and cultures (1.2, 10). It is a self-administered ques-
tionnaire, and total scores of 8 or more are recommended as
indicators of hazardous and harmful alcohol use, as well as
possible alcohol dependence.
The Drug Use Disorders Identification Test (DUDIT),
was developed as a parallel instrument to the AUDIT for
identification of individuals with drug-related problems.
International Personality Disorder Examination (IPDE)
screener is a self-administered screening instrument for
personality pathology . The IPDE Screening Ques-
tionnaire is a carbonless form that contains 77 DSM-IV or
59 ICD-10 items written at a 9 years of age reading level.
The patient responds either true or false to each item and
can complete the questionnaire in 15 min or less. The
clinician can quickly score the questionnaire and identify
those patients whose scores suggest the presence of a
personality disorder. For the screen positives, the IPDE
semi-structured clinical interview can be administered, in
order to make a diagnosis.
In addition to these screening instruments, a brief soci-
odemographic questionnaire was administered. Variables
such as age, employment status, marital status, home lan-
guage, level of education, and HIV status were obtained.
Data was initially captured in paper format, then entered
into Microsoft EXCEL?.
Data exploration took place to establish the current
diagnoses as recorded by the M.I.N.I., and the prevalence
of individual disorders was reported. Drug and alcohol
use was established by examining scores on both the
AUDIT and the DUDIT, and the prevalence of alcohol or
drug-related problems was then calculated, using the
internationally accepted cut-offs of 6 (DUDIT), and 8
The prevalence of suspected personality disorder was
established by using a cut-off of 3 for each personality dis-
order, as is recommended in the IPDE scoring manual. The
most prevalent personality disorder was then calculated.
The participants were mostly English-speaking (56 %),
single (64 %), and unemployed (52 %). The majority of
participants (68 %) had had tertiary education. Their mean
age was 37 years (range 18–64). Thirteen participants were
HIV positive (52 %).
Prevalence of Neuropsychiatric Disorders as Measured
by the M.I.N.I.
The alcohol and drug modules were omitted from the
M.I.N.I. for the purpose of this study, and alcohol and drug
use disorders were examined by the AUDIT and DUDIT.
The most prevalent disorder in the sample was major
(44 %). Only participants who were currently depressed
Suicidality was present in the past month in 14 partici-
pants (56 %), and in some cases this was not associated
with a current MDD.
Of the anxiety disorders, agoraphobia was present in five
participants (20 %), generalized anxiety disorder was
present in three participants (12 %), social phobia in three
participants (12 %), post-traumatic stress disorder in two
participants (8 %), and obsessive–compulsive disorder in
one participant (4 %).
Anti-social personality disorder was present in two
participants (8 %).
Prevalence of Alcohol and Drug Use Disorders
Using the recommended cut-off of 8 on the AUDIT, 48 %
of participants were identified as having an alcohol use
disorder. The mean AUDIT score was 9.16 (SD 9.026). On
the DUDIT, 56 % of participants were identified as having
a drug use disorder, using the recommended cut-off of 6.
The mean DUDIT score was 12.15 (SD 12.945).
Personality Disorder Screening
All participants interviewed screened positive for at least
one personality disorder. The most prevalent positive
screens were for narcissistic (20 or 80 %), borderline (19 or
76 %), and avoidant (19 or 76 %) personality disorders.
In this investigation of mental disorders in MSM in Cape
Town, we found high rates of depression, nearing 50 % of
the sample. A significant number of participants had
recently experienced suicidality. Rates of anxiety disorders
AIDS Behav (2013) 17:S77–S81S79
were lower. Around half of participants reported significant
alcohol and substance use symptoms. All participants
screened positive for at least one personality disorder.
Collectively the high prevalence of these disorders could
have substantial implications for the care and management
of MSM in Cape Town.
The high prevalence of common mental disorders in this
sample is consistent with the findings reviewed in the meta-
analysis by Meyer  in 2003, where she reported higher
rates of depression, anxiety and substance abuse among
MSM than in the heterosexual population.
While the results of this descriptive study are by no
means generalizable to the greater MSM population, the
high prevalence of depression, suicidality, and substance
use disorders, illustrates the clinical challenges in the
provision of a comprehensive and holistic health service in
this population. While no clear inferences can be made
from the descriptive data pertaining to personality, as the
IPDE Screener was used (which may have produced false
positives), the suggestion that the prevalence of maladap-
tive personality styles may be high in this group supports
what we have suspected clinically.
Given the high HIV prevalence in the MSM population
in Cape Town, the relationship between mental disorders
and HIV needs to be considered and understood. The
presence of these disorders in PLWHA adds substantially
to the burden of disease, and exerts many adverse effects
on health-related outcomes. These include delayed initia-
tion of ART, higher all-cause morbidity and mortality,
adverse immunological outcomes, and decreased adher-
ence to medication [9–13]. Substance and alcohol use
disorders have a particularly negative impact on adherence
to ART [19, 20]. Furthermore, some data suggest that
mental disorders in PLWHA are associated with increased
risky sexual behaviour, and consequent increased rate of
forward transmission of HIV [21–23].
These complex, interacting and overlapping risk factors
constitute a compelling argument for the need for co-loca-
ted HIV, MSM and mental health services, as this model
facilitates the required multidisciplinary team approach to
the provision of comprehensive, cost-effective health
USAID under the terms of Award No. 674-A-00-08-00009-00. The
opinions expressed herein are those of the authors and do not nec-
essarily reflect the views of USAID.
This work was supported by PEPFAR through
1. Gillman SE, Cochrane SD, Mays VM, Hughes M, Ostrow DG,
Kessler RC. Risks of psychiatric disorders among individuals
reporting same-sex sexual partners in the National Comorbidity
Survey. Am J Public Health. 2001;91:933.
2. Sandfort TG, de Graaf R, Bijl RV, Schnabel P. Same-sex sexual
behavior and psychiatric disorders: findings from the Netherlands
Mental Health Survey and Incidence Study (NEMESIS). Arch
Gen Psychiatry. 2001;58:85–91.
3. Herrel R, Goldberg J, Ramakrishnam V, Lyons M, Eisen S,
Tsuang MT. Sexual orientation and suicidality: a co-twin control
study in adult men. Arch Gen Psychiatry. 1999;56:867–74.
4. Meyer IH. Prejudice, social stress, and mental health in lesbian,
gay, and bisexual populations: conceptual issues and research
evidence. Psychol Bull. 2003;129(5):674–97.
5. Lane T, Raymond F, Dladla S, Rasethe J, Struthers H, McFarland
W, et al. High HIV prevalence among men who have sex with
men in Soweto, South Africa: results from the Soweto Men’s
Study. AIDS Behav. 2009;15(3):626–34.
6. Burrell E, Mark D, Grant R, Wood R, Bekker LG. Sexual risk
behaviours and HIV-1 prevalence among urban men who have
sex with men in Cape Town, South Africa. Sex Health. 2010;
7. Bing EG, Burnam MA, Longshaw D, Fleishman JA, Sherbourne
CD, London AS. Psychiatric disorders and drug use among
human immunodeficiency virus-infected adults in the United
States. Arch Gen Psychiatry. 2001;58(8):721–8.
8. Ciesla JA, Roberts JE. Meta-analysis of the relationship between
HIV infection and risk for depressive disorders. Am J Psychiatry.
9. Fairfield KM, Libman H, Davis RB, Eisenberg DM. Delays in
protease inhibitor use in clinical practice. J Gen Intern Med.
10. Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE,
Schuman P, Boland RJ. Mortality, CD4 cell count decline, and
depressive symptoms among HIV-seropositive women: longitu-
dinal analysis from the HIV Epidemiology Research Study.
11. Ironson G, Balbin E, Stuetzler R, Fletcher MA, O’Cleirigh C,
Laurenceau JP. Dispositional optimism and the mechanisms by
which it predicts slower HIV: proactive behaviour, avoidant
coping, and depression. J Behav Med. 2005;12(2):86–97.
12. Ammassari A, Trotta MP, Murri R, Castelli F, Narciso P, Noto P.
Correlates and predictors of adherence to highly active anti-ret-
roviral therapy: overview of published literature. J Acquir
Immune Defic Syndr. 2002;31(S3):123–7.
13. Nakimuli-Mpungu E, Mutamba B, Othengo M, Musisi S. Psy-
chological Distress and adherence to highly active anti-retroviral
therapy (HAART) in Uganda: a pilot study. Afr Health Sci.
14. Vu L, Tun W, Sheehy M, Nel D. Levels and correlates of
internalized homophobia among men who have sex with men in
Pretoria, South Africa. AIDS Behav. 2011;16(3):717–23.
15. Simbayi LC, Kalichman SC, Strebel A, Cloete A, Henda N,
Mqeketo A. Internalized stigma, discrimination, and depression
among men and women living with HIV/AIDS in Cape Town,
South Africa. Soc Sci Med. 2007;64:1823–31.
16. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J,
Weiller E, et al. The Mini-International Neuropsychiatric Inter-
view (M.I.N.I): the development and validation of a structured
diagnostic psychiatric interview for DSM-4 and ICD-10. J Clin
17. Myer L, Smit J, Roux LL, Parker S, Stein DJ, Seedat S. Common
mental disorders among HIV-infected individuals in South
Africa: prevalence, predictors, and validation of brief psychiatric
rating scales. AIDS Patient Care and STDS. 2008;22(2):147–58.
18. Loranger AW, Sartorius N, Andreoli A, Berger P, Bucheim P,
Channabasavanna SM, et al. The International Personality Dis-
order Examination. The World Health Organization/Alcohol,
S80AIDS Behav (2013) 17:S77–S81
Drug Abuse, and Mental Health Administration international
pilot study of personality disorders. Arch Gen Psychiatry. 1994;
19. Samet JH, Horton NJ, Meli S, Freedberg KA, Palepu A. Alcohol
consumption and anti-retroviral adherence among HIV-infected
persons with alcohol problems. Alcohol Clin Exp Res. 2004;
20. Lucas M, Stevenson D. Violence and abuse in psychiatric
in-patient institutions: a South African Perspective. Int J Law
21. Kalichman SC, Simbayi LC, Cain D, Jooste S. Alcohol expec-
tancies and risky drinking among men and women at high-risk for
HIV infection in Cape Town, South Africa. Addict Behav. 2007;
22. Kalichman SC, Simbayi LC, Kagee A, Toefy Y, Jooste S, Cain D.
Associations of poverty, substance use, and HIV transmission risk
behaviors in three South African communities. Soc Sci Med.
23. Simbayi LC, Kalichman SC, Jooste S, Mathirti V, Cain D, Cherry
C. Alcohol use and sexual risks for HIV infection among men and
women receiving sexual transmitted infection clinic services in
Cape Town, South Africa. J Stud Alcohol. 2004;65(4):434–42.
AIDS Behav (2013) 17:S77–S81S81