Khat use as risk factor for psychotic disorders: a cross-sectional and case-control study in Somalia

Khat - a controversial plant

Khat (Catha edulis) is a shrub or tree whose leaves have been chewed for centuries by people who live in the Eastern part of Africa and the Arabian Peninsula. It has recently turned up in North America and Europe, particularly among emigrants and refugees from countries such as Somalia, Ethiopia and Yemen. Khat contains a number of chemicals, among which are two controlled substances, cathinone (Schedule I) and cathine (Schedule IV). Both chemicals are stimulant drugs with effects similar to amphetamine. Chewing the leaves makes people feel more alert and talkative, and suppresses appetite. Chewing khat leaves releases cathinone, a stimulant that produces the feeling of euphoria. When cathinone is broken down in the body, it produces chemicals including cathine and norephedrine, which have a similar structure to amphetamine and adrenaline (epinephrine). Regular khat use is associated with a rise in arterial blood pressure and pulse rate, corresponding with levels of cathinone in the plasma. Moreover, regular khat chewers have gingivitis and loose teeth, but there appears to be no convincing unusual incidence of oral cancer. Among khat users in Yemen there is, however, a higher incidence of esophageal cancer compared with gastric cancer. Long term use or abuse can cause insomnia, anorexia, gastric disorders, depression, liver damage and cardiac complications, including myocardial infarction. Manic and delusional behavior, violence, suicidal depression, hallucinations, paranoia and khat-induced psychosis have also been reported. On the basis of the scientific data it seems clear that khat use has negative consequences on the economic development of a country and on the health of the society.

Prevalence of Khat chewing in college and secondary (high) school students of Jazan region, Saudi Arabia

Background

Khat is widely consumed among the youth of Jazan region of Saudi Arabia. However, its prevalence is not well documented.

Objective

This study was conducted to assess the prevalence and associated risk factors of khat chewing among college and secondary school students in Jazan region.

Methods

The study was conducted in May 2006 in the colleges and secondary schools in Jazan region. A sample of 10,000 students aged between 15 and 25 years was randomly selected. Students in each year of study were selected by systematic random sampling technique. Self-administered questionnaire was used for data collection.

Results

The overall prevalence of khat chewing in all the studied population was 21.4% (colleges 15.2% versus schools 21.5%). There were 3.8% female khat chewers and 37.70% male Khat chewers. Significant differences were found between khat chewers according to age, gender and residence (p < 0.05). The prevalence was different in different colleges and in different provinces of Jazan region.

Conclusion

The prevalence of Khat chewing seems to be high among male students and not remarkable among female students. The use of Khat is significantly associated with age, gender, residence and school and college education (p < 0.05) among students of Jazan region. Strong measures need to be taken for greater awareness among school and college students to reduce its prevalence.

Proconvulsant effect of khat (Catha edulis) in Sprague dawley rats

ETHNOPHARMACOLOGICAL RELEVANCE

Catha edulis (khat) is a plant whose fresh young leaves are used by an estimated five million people in eastern Africa and the Arabian Peninsula as a drug of recreation. The fresh leaves and shoots are rich in cathinone, a psychostimulant with effects similar to those of amphetamines. Psychostimulants produce a dose-related excitation of the central nervous system which can lead to seizures and convulsions. However there are no reports on studies of the effect of this herb on brain excitability and seizures. This knowledge is useful for doctors who may prescribe drugs whose side effects include lowering seizure threshold because there could be additive proconvulsant effect among khat users.

AIM OF THE STUDY

to determined whether khat lowers pentylenetetrazole (PTZ) seizure threshold.

METHODOLOGY

Male Sprague dawley rats were given fresh aqueous khat extract, old aqueous khat extract (3 g/kg bw), methylphenidate or saline and the timed intravenous (PTZ) seizure threshold test was used to study its effect on seizure threshold.

RESULTS

Fresh khat (3 g/kg) and methylphenidate (4 mg/kg) lowered PTZ seizure threshold.

CONCLUSION

Khat lowers seizure threshold.

Illicit cathinone (“Hagigat”) poisoning

INTRODUCTION

Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200 mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported.

METHODS

Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed.

RESULTS

Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was (1/2)-6 capsules (ingestion-32, sniffing-2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery.

CONCLUSION

Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Pattern of khat abuse and academic performance among secondary school and college students in jazan region, kingdom of saudi arabia (ksa)

BACKGROUND

Khat is a widely-abused psychoactive substance in East African countries, Yemen and Southwestern areas of the Kingdom of Saudia Arabia (KSA), especially in Jazan region. However, patterns of Khat consumption as well as its adverse consequences on academic work are not well studied.

OBJECTIVE

The study was conducted to assess the pattern of Khat abuse and its associated academic effect on Secondary School and College students in Jazan region, KSA.

METHODS

A cross-sectional study was conducted in May 2006, in Secondary Schools and Colleges in Jazan region, KSA. Students in each class were selected by systematic random sampling technique. Self-administered questionnaire was used for data collection. Data was processed and analyzed using the Statistical Package for Social Sciences (SPSS).

RESULTS

Most Khat sessions were conducted in homes (43.8%) and friend's houses (37.0%). The mean duration of a Khat session is 6.1 ±3.13 hours and 5.5% chew Khat for 12-18 hours. Most Khat sessions take place at the weekends (48.4%) usually after 8 p.m (69.8%).

CONCLUSION

Most chewing sessions took place at weekends usually in social gatherings after 8 p.m. with an average duration of about 6 hours. Smoking and educational problems were more prevalent among Khat chewers. Strong preventive and control measures including early interventions and increase of awareness need to be implemented. Recreational alternatives for young people and families especially at weekends and holidays have to be found.

Risk assessment of khat use in the Netherlands: a review based on adverse health effects, prevalence, criminal involvement and public order

In preparing a decision about the legal status of khat in the Netherlands, the Dutch Minister of Health requested CAM (Coordination point Assessment and Monitoring new drugs) to assess the overall risk of khat in the Netherlands. The present paper is a redraft of a report which formed the scientific basis of the risk evaluation procedure (October 2007). This report reviews the scientific data about khat available in the international literature. In addition, the report contains some information specific for the Netherlands (prevalence, availability of khat and public order aspects). The main psychoactive compounds in khat leaves are cathine and cathinone, which are some 2- to 10-fold less active than amphetamine. Acute health problems are rarely seen, and are usually related with malnutrition, social and financial problems. Khat has a low addictive potential. Chronic toxicity of khat is modest when used in low amounts, whereas at high levels, khat use is associated with adverse effects, like hypertension, heart rhythm disorders, insomnia and loss of appetite. In addition, khat users show a higher prevalence of cancers in the digestive tract. At population level, khat does not lead to specific health risks in the Netherlands, as its use is confined to East-African immigrants. A relationship between khat use and psychiatric disorders has been suggested, but the reports are contradictory, and such studies are presumably heavily confounded by posttraumatic and social stress. In the Netherlands (and other countries), khat use occasionally leads to minor disturbance of civil order in the public domain (loud talking, spitting), but is not related to criminal activities. Following the assessment, CAM estimated the overall risk potential of khat use in the Netherlands as very low. A similar conclusion may be drawn for countries with a comparable prevalence of khat use and khat related public order disturbance.

Khat induces G1-phase arrest and increased expression of stress-sensitive p53 and p16 proteins in normal human oral keratinocytes and fibroblasts

Khat is a psychostimulant plant used by over 10 million people daily, mainly in eastern Africa and the Middle East. Previous studies have suggested an association between khat use and oral lesions such as hyperkeratosis and oral cancer. This study investigated the effects of an extract of khat on primary normal human oral keratinocytes (NOK) and normal human oral fibroblasts (NOF). Low (sublethal) concentrations of khat inhibited the proliferation of both cell types in a dose-dependent and time-dependent manner. Both NOK and NOF treated with khat accumulated in the G1-phase of the cell cycle and showed increased expression of the stress-sensitive p53 protein after 24 h. Normal human oral keratinocytes showed a profound increase in p16(INK4A) (p16) after 24 h and showed morphological changes suggesting cell differentiation. Normal human oral fibroblasts showed growth inhibition and increased expression of p21(WAF1/CIP1) (p21) within 24 h. The concentrations of khat tested in this study were within the range of those found in the oral cavity of khat chewers. The results show that stress induced by khat modulates the cell cycle in oral keratinocytes and fibroblasts. It is further speculated whether khat could have similar effects in vivo, especially in keratinocytes.

Khat chewing from the pharmacological point of view: an update

Khat chewing is deeply rooted in the every day life of people living in the Horn of Africa and in South Arabia, where Catha edulis is endemic. Considered little more than an exotic habit producing just mild pharmacological effects, systematic investigations on its active principles have instead lead to the isolation and chemical characterization of cathinone, a compound structurally related to amphetamine. Three decades of intense experimental and clinical research on khat have depicted a consistently clear picture of its pharmacological and toxicological effects.

The consumption of khat and other drugs in Somali combatants: a cross-sectional study

BACKGROUND

For more than a decade, most parts of Somalia have not been under the control of any type of government. This "failure of state" is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control-to our knowledge the first account on this topic.

METHODS AND FINDINGS

Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e.g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%-57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%-76.5%), followed by smoking cannabis (10.7%, 99% CI 0%-30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%-24.4%), drinking alcohol (5.3%, 99% CI 0%-13.8%), inhaling solvents (1.8%, 99% CI 0%-5.1%), and eating hemp seeds (0.6%, 99% CI 0%-2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets.

CONCLUSIONS

Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.

Screening for posttraumatic stress disorder among Somali ex-combatants: a validation study

Background

In Somalia, a large number of active and former combatants are affected by psychological problems such as Posttraumatic Stress Disorder (PTSD). This disorder impairs their ability to re-integrate into civilian life. However, many screening instruments for Posttraumatic Stress Disorder used in post-conflict settings have limited validity. Here we report on development and validation of a screening tool for PTSD in Somali language with a sample of ex-combatants.

Methods

We adapted the Posttraumatic Diagnostic Scale (PDS) to reflect linguistic and cultural differences within the Somali community so that local interviewers could be trained to administer the scale. For validation purposes, a randomly selected group of 135 Somali ex-combatants was screened by trained local interviewers; 64 of them were then re-assessed by trained clinical psychologists using the Composite International Diagnostic Interview (CIDI) and the Self-Report Questionnaire (SRQ-20).

Results

The screening instrument showed good internal consistency (Cronbach's α = .86), convergent validity with the CIDI (sensitivity = .90; specificity = .90) as well as concurrent validity: positive cases showed higher SRQ-20 scores, higher prevalence of psychotic symptoms, and higher levels of intake of the local stimulant drug khat. Compared to a single cut-off score, the multi-criteria scoring, in keeping with the DSM-IV, produced more diagnostic specificity.

Conclusion

The results provide evidence that our screening instrument is a reliable and valid method to detect PTSD among Somali ex-combatants. A future Disarmament, Demobilization and Reintegration Program in Somalia is recommended to screen for PTSD in order to identify ex-combatants with special psycho-social needs.

Khat (Catha edulis) Chewing during Pregnancy in Yemen: Findings from a National Population Survey

AIMS

This study examines the prevalence of khat chewing among women during pregnancy and some of the risk factors for this habit in Yemen.

METHODS

Survey data on 7,343 ever-married women from the Yemen Demographic and Maternal and Health Survey (YDMHS), conducted in 1997 are used. Women who had a live birth during the 5 years preceding the survey were asked if they chewed khat during each of their pregnancies (=1) or not (=0). Associations between chewing khat and socio-demographic risk factors were assessed using odds ratios from binary logistic regression models.

RESULTS

About 40.7% of women surveyed reported chewing khat while pregnant during the 5 years before the survey. Old age, no education, rural residence, living in mountainous regions, and low wealth were significant risk factors for chewing khat.

CONCLUSIONS

Khat chewing during pregnancy is highly prevalent in Yemen. Socio-economically disadvantaged women were more likely to chew khat than other women.

Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors

BACKGROUND

There are few mental health data for Somali people. This is due to the absence of culturally validated appropriate assessment instruments and methodological challenges. We aimed to develop a culturally appropriate instrument, and address the methodological challenges and assess some risk factors for mental disorder among Somalis in London.

METHODS

Following a comprehensive process of cultural adaptation of the MINI Neuropsychiatric Interview, we assessed ICD-10 mental disorders among 143 Somalis recruited from GP registers and community sites. Associations with demographic and economic characteristics, sampling venues, cultural and migration related risk factors are reported.

RESULTS

A higher risk of mental disorders was found among Somalis who used Khat (OR = 10.5, 1.1-98.3) claimed asylum at entry to the UK (OR = 12.8, 2-81.4) and recruits from primary care rather than from community sites (OR = 5.9, 1.4-25.8). A lower risk of mental disorders was found amongst Somalis in employment (OR = 0.03, 0.01-0.61), and those receiving education in the UK and in Somalia (OR = 0.13, 0.02-0.92). Over a third of subjects had any mental disorder (36.4%, 28.4-44.4), mainly common mental disorders (CMD) (33.8%, 26-41.5) and post-traumatic stress disorder (PTSD) (14%, 8.8-20.8). CMD were found among 80% of those with PTSD.

CONCLUSION

Public health interventions for Somalis should focus on CMD as well as PTSD, khat use and mental health screening for suicide risk and mental disorders on arrival.

The potential adverse effects of habitual use of Catha edulis (khat)

The habit of Catha edulis Forsk (khat) chewing has prevailed for centuries among populations in the horn of Africa and the Arabian peninsula. Fresh leaves of Catha edulis are customarily chewed to attain a state of stimulation. The fact that cathinone has a closer structural similarity with amphetamine, and both share common pharmacodynamic features, led to the conclusion that cathinone is the most important active ingredient of Catha edulis, which causes the major pharmacological effects. Problems associated with repeated consumption of Catha edulis leaves are becoming evident. Literature surveys and clinical diagnostic studies revealed an association with prevalence of psychiatric morbidity. Repeated intermittent oral administration of Catha edulis to laboratory animals lead to development and expression of locomotor sensitisation. Catha edulis also leads to several peripheral effects that include increases in blood pressure and has been associated with the increased incidence of acute coronary vasospasm and myocardial infarction. Catha edulis also accounts for a number of gastrointestinal tract problems, oesophagitis, gastritis and delay intestinal absorption, as well as the development of oral keratotic white lesions at the site of chewing. Administration of Catha edulis extracts showed a deranged systemic capacity to handle oxidative radicals and induces cytotoxic effects in cells of liver and kidney, as well as induction of cell death in various human leukaemia cell lines and in peripheral human blood leukocytes.

Khat (Catha edulis)-an updated review

The habit of chewing fresh leaves and twigs of khat (Catha edulis) for their stimulating amphetamine-like effects is highly prevalent in East Africa and southwest on the Arabic peninsula. There is an extensive literature on khat providing information about its history, botany, production, geographical distribution, chemistry and pharmacology, and exploring the social, economic, medical, psychological and oral aspects related to its use. Some of this literature dates as early as the 11th century; however, most of it appeared after the first scientific description of khat by Peter Forskal in 1775. This review provides a panorama of khat and the various aspects of its use. A non-technical description of the plant chemistry and pharmacology is included. The medical, psychological and oral aspects are emphasized, and the current knowledge about the microbiological effects of khat is also presented.

Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia

Background

Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with Khat and alcohol consumption in Ethiopian youths.

Methods

A probabilistic national sample of 20,434 in-school and out-of-school youths aged between 15 and 24 years of age was selected and interviewed regarding their sexual behavior and substance use.

Results

Over 20% of out-of-school youth had unprotected sex during the 12-month period prior to interview compared to 1.4% of in-school youth. Daily Khat intake was also associated with unprotected sex: adjusted OR (95% CI) = 2.26 (1.92, 2.67). There was a significant and linear association between alcohol intake and unprotected sex, with those using alcohol daily having a three fold increased odds compared to those not using it: adj. OR (95% CI) = 3.05 (2.38, 3.91). Use of substances other than Khat was not associated with unprotected sex, but was associated with initiation of sexual activity: adj. OR (95% CI) = 2.54 (1.84, 3.51).

Conclusion

A substantial proportion of out-of-school youth engage in risky sex. The use of Khat and alcohol and other substances is significantly and independently associated with risky sexual behaviour among Ethiopian youths.

Repeated Catha edulis oral administration enhances the baseline aggressive behavior in isolated rats

The effects of repeated oral administration of the psychostimulant plant, Catha edulis and its active principle, cathinone on rats were studied using isolation induced aggression paradigm. The behavioral responses were videotaped and scored later by offline data analyses. Rats were decapitated at the end of the behavioral experiment and in the relevant brain regions, monoamines were assessed. The results demonstrate that isolation of male rats produces a baseline aggression. Treatments with the psychostimulant plant, Catha edulis or commercial S-(--)-cathinone enhanced significantly: The locomotor activities and the baseline aggression behaviors compared with vehicle treated rats. Neurochemical correlates revealed a significant depletion of serotonin (5-HT) and its corresponding metabolites (5-HIAA) in both the anterior and posterior striatum. There was also a reduction in the level of homovanillic acid (HVA) in the hippocampus. Additionally, elevation of dopamine level was observed in the nucleus accumbens, especially, in those rats treated with Catha edulis extract. Cathinone, on the other hand, increased the level of HVA in the posterior striatum and decreased HVA in the nucleus accumbens. In conclusion, the present data demonstrate that repeated administration of Catha edulis or S-(--)-cathinone enhances aggression in rats, presumably by decreasing the level of serotonin and its corresponding metabolites. Besides, the data obtained do not rule out the involvement of dopamine in aggression behavior.