Khat use and mental illness: A critical review

Epidemiology of Khat (Catha edulis) Chewing in Ethiopia: A Systematic Review and meta-analysis

In several countries, including Ethiopia, the shrub Catha edulis (khat) leaves are chewed for their stimulant properties. The present review summarizes evidence on the prevalence of khat use in Ethiopia and forwards recommendations for future action. PubMed, Embase, and Scopus were searched for studies examining the prevalence of Khat chewing among adolescent and/or adult populations in Ethiopia. A random-effects model was employed to estimate the pooled prevalence of khat chewing. Of the 568 articles identified, 26 were included in the review. The pooled prevalence of current and lifetime khat use was 19.55% (95% CI 14.62-25.64) and 26.14% (CI 17.66-36.87), respectively. The current prevalence of khat use was higher in men, 23.72% (CI 13.42-38.41), than in women 8.45% (CI 4.94-14.08). Lifetime prevalence of khat use was higher in men, 29.8% (CI: 22.80-37.99) than in women 13.02% (CI 8.96-18.56). The results of the meta-analysis demonstrated a higher odds of current (OR = 4.00, CI 2.80-5.73) and lifetime (OR = 2.84, CI 2.50-3.23) khat use in men than in women. Our review found a high prevalence of current (19.55%) and lifetime (26.14%) khat chewing in Ethiopia and demonstrated higher odds of current and lifetime khat use in men than in women. Awareness creation and integrated management of khat use problems at the primary health-care level is highly recommended.

The epidemiology of khat (catha edulis) chewing and alcohol consumption among pregnant women in Ethiopia: A systematic review and meta-analysis

The use of khat (Catha edulis) and alcohol during pregnancy is a serious public health problem that has been associated with a number of harmful outcomes for both the fetus and the mother's health. There has been no systematic review with meta-analysis to determine risk factors associated with khat and alcohol use among pregnant women in Ethiopia. Therefore, we aimed to determine the pooled prevalence and risk factors of khat and alcohol use during pregnancy in Ethiopia. This review has been registered in PROSPERO with protocol ID: CRD42023395115. Studies identified from PubMed, Google Scholar, the WHO African Index Medicus, the Cochrane Library, African Journal Online, and Science Direct. Articles published from January 1, 2000 to February 10, 2023 were included. We searched for articles that included any combination of the following key terms: "khat", "qat", "alcohol", "ethanol", "prevalence", "factors", "pregnant" and "Ethiopia". Two reviewers worked independently to screen studies and extract data. A funnel plot and Egger's regression test were used to test publication bias. A forest plot was used to present the pooled prevalence and odds ratio with a 95% confidence interval (CI) using the random effect model. I2 metrics were used to assess heterogeneity. The meta-analysis was carried out with Stata 14.0 software. Nine hundred sixty-two records were retrieved from different sources, and 23 studies were included in the final analysis. The pooled prevalence of khat use and alcohol drinking during pregnancy was 26.6% (95% CI 17.8, 35.5) and 31.65% (95% CI: 21.8, 41.5), respectively. Partner khat use (OR 5.9 [95% CI (2.4, 14.5)]) was associated factor for khat use during pregnancy. Low educational level (OR 2.54 [95% CI (1.8, 3.5)]), pre-pregnancy alcohol use (OR 3.5 [95% CI (2.6, 4.7)]), unplanned pregnancy (OR 2.7 [95% CI (1.8, 4.0)]), history of abortion (OR 2.3 [95% CI (1.4, 3.7)]), poor social support (OR 3.3 [95% CI (2.0, 5.3)]), and mental distress (OR 2.6 [95% CI (2.0, 3.3)]) were associated factors for alcohol drinking during pregnancy. This review indicated that the magnitude of khat and alcohol use during pregnancy in Ethiopia was high. Targeted interventions for groups of pregnant women at high risk of khat and alcohol use are urgently needed. Community-based health education interventions and point-of-sale warnings are essential to reduce the burden. Future studies should consider the influence of community-level factors on khat and alcohol use during pregnancy.

Is chewing khat associated with mental health disorders? A scoping review of the content and quality of the current evidence base

BACKGROUND

Khat (Catha edulis) is a plant commonly found in the horn of Africa whose leaves are chewed for their psycho-stimulant effects. Several studies have demonstrated the association between khat use and mental health problems. Nevertheless, evidence is mixed and inconsistent, warranting further review of available studies. This scoping review is aimed at investigating the content and quality of evidence base on the associations between khat use and mental health disorders and suggesting avenues for further research.

METHODS

We used a scoping review methodology to map the existing evidence using PubMed, SCOPUS, Embase, and CINAHL databases. Primary studies focusing on the association between any pattern of khat use and any form of mental health disorders are included. The review focused on all age groups, any study design, all geographical locations, and any publication year. The terms used for searching eligible studies include khat, mental disorders, and various alternative terminologies. Narrative review is employed to present findings.

RESULTS

7,121 articles were found, of which 108 were eligible, conducted across 12 different countries. The majority of the studies was done during the last ten years and the studies mostly employed cross-sectional design. About 10 different categories of mental health disorders have been identified as showing associations with khat use. Despite many contradictory findings between the studies, most of the evidence base suggests that khat use is associated with mental health disorders. Non-specific psychological distress is the most frequently mentioned mental health problem (reported in 26.9% of the studies). Khat use as a predictor variable is mostly assessed using a 'yes/no' category, and as a result, dose-dependent effects of khat use on mental health are not given much consideration.

CONCLUSION

Although most of the studies associate khat use with mental health disorders, the causal relationships are inconclusive given the cross-sectional design of the studies, and the presence of potential confounders and several forms of biases. Available studies also report contradictory findings. Further studies are recommended using prospective designs, standardized and valid measures of khat use, and focusing on specific types of mental health disorders.

Reducing Khat use among Somalis living in Kenya: a controlled pilot study on the modified ASSIST-linked brief intervention delivered in the community

BACKGROUND

During recent decades, the consumption of the stimulant khat (catha edulis) has profoundly changed in countries around the Horn of Africa, and excessive use patterns have emerged-especially evident among displaced Somalis. This is related to the development of severe somatic and psychiatric disorders. There are currently no preventive or interventional studies targeting khat use. This study's aim was to test screening and brief intervention (SBI) to reduce khat use among urban Somali refugees living in Kenya with limited access to public healthcare.

METHODS

In this controlled study, 330 male Somali khat users from the community were either assigned to SBI (161) or an assessment-only control condition (AC; 169); due to field conditions a rigorous experimental design could not be implemented. The World Health Organization's (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)-linked brief intervention was adapted to khat and Somali culture. Trained local counselors administered the intervention. The amount and frequency of khat use was assessed using the time-line-follow-back method. We compared the month before the intervention (t1) to the two months after it (t2, t3). Baseline differences in khat use frequency were corrected by partial matching and mixed effect models used to evaluate intervention effects.

RESULTS

SBI was well accepted and feasible for khat users. Over the complete observation period and from t1 to t2, khat use amount and frequency decreased (p < .001) and the intervention group showed a greater reduction (group x time effects with p ≤ .030). From t2 to t3, no further reduction and no group differences emerged.

CONCLUSION

The results provide preliminary evidence that khat use amount and frequency can be reduced in community settings by SBI, requiring little resources. Thorough assessment alone might have intervention-like effects. The non-treatment-seeking community sample and the non-professional counselors are distinct from SBI studies with other substances in other countries, but support the feasibility of this approach in khat use countries and especially in Somali populations with limited access to healthcare. Future studies that employ rigorous experimental design are needed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02253589. Date of first registration 01/10/2014, retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02253589 . First participant 16/09/2014.

Prevalence of mental distress and associated factors among university students in Ethiopia: a meta-analysis

BACKGROUND

Mental distress is an important public health problem and is becoming common health problems among university students.

AIMS

This study aimed to provide a pooled prevalence of mental distress and associated factors among university students in Ethiopia.

METHOD

We systematically searched PubMed, EMBASE and PsycINFO databases. A further search was performed at Google Scholar search engine for additional studies. All observational studies reporting the prevalence of mental distress and/or associated factors among university students in Ethiopia were included. Pooled prevalence with 95% confidence interval (95% CI) were calculated using random effects and quality effects models. Subgroup and sensitivity analyses were performed. Heterogeneity between studies and evidence of publication bias were assessed.

RESULTS

The pooled prevalence of mental distress was 35% (95% CI; 28%-43%). Being female, participating in religious programmes, having close friends, experiencing financial distress, alcohol use, khat use, conflict with friends, lack of interest in their field of study and a family history of mental illness were factors associated with mental distress among students. We found significant heterogeneity, but no evidence of publication bias.

CONCLUSIONS

More than one third of university students in Ethiopia have suffered with mental distress. The finding provides evidence that university students are at risk population for mental health problems and suggests the need for early intervention to prevent severe mental illness.

Exposure to DDT and HCH congeners and associated potential health risks through khat (Catha edulis) consumption among adults in South Wollo, Ethiopia

Khat (Catha edulis) chewing is widespread in the region of East Africa. Even low levels of organochlorine pesticides (OCPs) in khat could induce public health concern. In a market-based study, from five popular khat varieties, a total of 35 composite khat samples were analyzed for dichlorodiphenyltrichloroethane (DDT) and its main transformation products, and four hexachlorocyclohexane (HCH) isomers. Extraction was carried out by quick, easy, cheap, effective, rugged and safe method (QuEChERS). OCP concentrations were determined by head space solid phase microextraction coupled to gas chromatography-mass spectrometry (HS-SPME-GC-MS). Every sample contained β-HCH above the maximum residue limit set by the European Commission. For total DDT, this was the case for 25.7% of the samples. The ratios of (p,p'-DDD + p,p'-DDE) to p,p'-DDT were less than one for 85% of khat samples, demonstrating recent use of DDT in khat farmlands. Conversely, the ratio of β-HCH to total HCH varied from 0.56 to 0.96, implying historical input of technical HCH. Assuming a daily chewable portion of 100 g, dietary intakes of p,p'-DDT, total DDT and total HCH by adults ranged from 3.12 to 57.9, 6.49 to 80.2 and 39.2 to 51.9 ng (kg body weight)^-1 day^-1, respectively. These levels are below acceptable levels suggested by international organizations. Chewing khat showed lower non-cancer health risk, but showed relatively higher cancer risk in terms of OCPs. Because khat is chewed without being subjected to any treatment, uncertainties associated with estimated intakes and health risks should be low. Therefore, this practice is of great concern.

An updated review on synthetic cathinones

Cathinone, the main psychoactive compound found in the plant Catha edulis Forsk. (khat), is a β-keto analogue of amphetamine, sharing not only the phenethylamine structure, but also the amphetamine-like stimulant effects. Synthetic cathinones are derivatives of the naturally occurring cathinone that largely entered the recreational drug market at the end of 2000s. The former "legal status", impressive marketing strategies and their commercial availability, either in the so-called "smartshops" or via the Internet, prompted their large spread, contributing to their increasing popularity in the following years. As their popularity increased, the risks posed for public health became clear, with several reports of intoxications and deaths involving these substances appearing both in the social media and scientific literature. The regulatory measures introduced thereafter to halt these trending drugs of abuse have proved to be of low impact, as a continuous emergence of new non-controlled derivatives keep appearing to replace those prohibited. Users resort to synthetic cathinones due to their psychostimulant properties but are often unaware of the dangers they may incur when using these substances. Therefore, studies aimed at unveiling the pharmacological and toxicological properties of these substances are imperative, as they will provide increased expertise to the clinicians that face this problem on a daily basis. The present work provides a comprehensive review on history and legal status, chemistry, pharmacokinetics, pharmacodynamics, adverse effects and lethality in humans, as well as on the current knowledge of the neurotoxic mechanisms of synthetic cathinones.

Khat induced psychotic disorder: case report

Background

Khat (Catha edulis) is a stimulant leaf khat comes from a tree which grows in countries bordering the Red Sea which are along the east coast of Africa and in west Asia. The psycho- active component within these leaves is cathinone. In Ethiopia, Khat is chewed routinely by users for its euphoric effects and as a recreational drug, and chewing khat has an important role as well in both traditional and religious ceremonies. In this case report, we describe the case of a 33-year-old male patient presented with psychotic symptoms after prolonged and heavy khat chewing.

Case presentation

Findings on psychiatric evaluation encompassing detailed history and mental state examination suggest khat induced psychotic disorder severe in full remission; khat use disorder, severe, in early remission.

Conclusions

This case demonstrates that the use of excess khat above 2 bundles for prolonged duration can manifest with psychotic episodes. A small number of case studies had supported a causal relationship between heavy khat use and psychosis or psychotic symptoms. There have been suicidal attempts and homicidal acts in those who used excess and prolonged use of khat. In our case, the improvement attributed to stopping the khat rather than taking antipsychotics.

Therefore, we recommend an urgent social intervention to change the community norms regarding Khat use through psycho-education in media, institution and in person about the relationship between khat use and mental illness. In addition, we suggest the role of religious institutions on the management of khat use not be overlooked. Finally, this study makes a powerful argument for researchers and policy makers to do clinical study to settle a causal effect relation of khat on mental health.

The Experiences of People Who Quit Khat and the Health Care Professionals Who Support them

Background

This study aimed to explore the barriers and enablers to quitting khat from the perspective of users and the barriers and enablers to supporting users to quit from the perspective of healthcare professionals (HCPs).

Methods

The present qualitative study was conducted using semi-structured interviews and the Theoretical Domains Framework (TDF) to collect and analyse data.

Findings

Overall, 10 khat users and 3 professionals were interviewed. Beliefs about the consequences of continued use facilitated user’s decisions to quit. Social influences were both a barrier and an enabler. For professionals, the social influence of other colleagues and working together was key in enabling them to support clients. Social/professional role and identity was also an important enabler, as professionals saw supporting users to quit as an integral part of their role. A range of behaviour change techniques was identified as potential ways in which quitting attempts could be more successful, from the perspective of users and professionals.

Conclusion

The study reveals the complexity of khat chewing and quitting from the perspective of khat users, such as the varied influence of family and friends. It also identifies the many barriers and enablers that professionals experience when supporting individuals to quit, such as working with other professionals. There is little evidence for the effectiveness of current services provided for quitting khat or little information outlining how they were developed. Current services would benefit from evaluating the effectiveness of the interventions using established methodology. Recommendations have been provided for practice in the field of substance misuse.

Depression, Anxiety, Stress, and Associated Factors among Khat Chewers in Amhara Region, Northwest Ethiopia

Individuals with substance use disorder are prone to develop different psychiatric disorders. Substance abuse and associated problems are of current global concern that leads to mental health disorders which contributed about 14% of the global burden of the disease. It has become an epidemic in some parts of the African region with adolescents being the main victims of the ill health and social effects of substance use. This study is aimed at assessing the prevalence of depression, anxiety, and stress and associated factors among khat chewers in the Amhara region, 2019. A community-based cross-sectional study was done from February 14 to April 15, 2019. A purposive sampling technique was used to enroll the subjects. Data was collected using the face-to-face interview technique using the Depression Anxiety Stress Scale 21 (DASS-21) questionnaire. Descriptive statistics and bivariate and multivariate logistic regression were used to summarize the results. p value < 0.05 was considered statistically significant. A total of 478 participants were enrolled in the study with a response rate of 94.1%. The overall prevalence of depression, anxiety, and stress was 27.4%, 40.6%, and 18.8%, respectively. Around 43% of the respondents develop dependency from khat chewing. Working in a private sector, being self-employed, being jobless, spending 90 to 180 minutes and more, chewing 51-100 g and more, and chewing khat more than once per week were positively associated with stress. On the other hand, being a private sector worker, being jobless, completing secondary education, earning 1001-5000 ETB per month, chewing khat more than once per week, being khat dependent, and the presence of chronic illness were positively associated with anxiety. History of chronic illness and being khat dependent were positively associated with depression. The prevalence of depression, anxiety, and stress was high among khat chewers in the Amhara region. Special attention has to be given to khat chewers since khat chewing will double the burden of mental illness. Proper awareness and evaluation activities will reduce the impact of the problem.

A Systematic Review of Treatments for Problematic Khat Use

Khat, a psychostimulant cultivated and commonly used in Eastern Africa and the Arabian penin-sula, has a longstanding history of use embedded within the cultures of these regions. Due to changing patterns of use and the adverse effects of dependence, khat has become a growing pub- lic health concern. Despite extensive findings regarding the detrimental psychiatric, physical, and social consequences of khat dependence, research on interventions in this area is glaringly sparse. The present paper aims to summarize the consequences of chronic khat use and review existing research on interventions.

Involvement of CB2 Receptors in the Neurobehavioral Effects of Catha Edulis (Vahl) Endl. (Khat) in Mice

There is behavioral evidence for the interaction between crude khat extract and the endocannabinoid system, whereby the endocannabinoid system alters khat extract-mediated behavioral effects through modulation of the monoaminergic system. The objective of this study was to investigate the role of the endocannabinoid system on the neurobehavioral effect of khat extract in mice following concomitant administration of khat extract and the CB2R agonist, JWH133. Locomotor activity test, immunohistochemistry, and reverse transcriptase polymerase chain reaction technique were utilized to assess locomotor activity, tyrosine hydroxylase immunoreactivity, and expression of dopamine transporter mRNA gene. The results show sub-acute administration of khat extract alone increased locomotor activity in mice and co-administration of the CB2R agonist, JWH133, reduced khat extract induced hyperlocomotor activity. The data revealed that cell type specific deletion of CB2Rs on dopaminergic neurons increased the hyperlocomotor behavior of khat extract. Furthermore, the results revealed that khat extract attenuated MPTP induced motor deficits, which is enhanced by JWH133. Khat extract also increased expression of tyrosine hydroxylase positive cells and expression of dopamine transporter mRNA gene in wild type mice. Nevertheless, JWH133 did not alter the effect of khat extract on tyrosine hydroxylase immunoreactivity and dopamine transporter mRNA expression when given together with khat extract. Taken together, the results suggest that the CB2Rs selectively interact with khat extract-mediated locomotor effects and could be utilized as therapeutic target in central nervous system movement disorders associated with dopamine dysregulation.

Mental healthcare of asylum-seekers and refugees

Many health professionals feel ill-equipped to deal with the complex needs of asylum-seekers and refugees. This article offers an overview of the literature, and reviews the demography, epidemiology and causes of mental illness in refugee and asylum-seeker groups. It discusses the types of service configurations and service response that would be appropriate. It highlights the findings of the Royal College of Psychiatrists' consensus team and their position statement on the treatment of refugees and asylum-seekers. It finishes with some thoughts about what clinicians can do to improve their treatment. Clearly, there is a need for more training, education and service development.

The adverse consequences of mephedrone use: a case series

Aims and method

Mephedrone is a cathinone with amphetamine-like stimulant effects, and is a commonly used recreational drug. The adverse effects of mephedrone use have not been extensively studied. All individuals who self-presented between January and June 2010 to the emergency departments and acute mental health services in Edinburgh and Falkirk with adverse effects of self-reported mephedrone use were identified.

Results

Twenty cases were identified and analysed. Severe agitation was the most common presenting problem (70%), with 40% of individuals developing psychotic symptoms and a further 20% reporting low mood and suicidality. One person died by suicide.

Clinical implications

Mephedrone can produce amphetamine-like adverse psychological intoxication effects, particularly in those with a history of mental illness. Clinicians should consider advising patients on the adverse effects of mephedrone, where relevant.

Comorbid psychopathology and everyday functioning in a brief intervention study to reduce khat use among Somalis living in Kenya: description of baseline multimorbidity, its effects of intervention and its moderation effects on substance use

BACKGROUND AND AIMS

Migration and khat use were found to correlate with high rates of psychopathology. In this paper we aimed for assessing baseline multimorbidity and its interactions with a Brief Intervention.

METHODS

In the RCT, 330 male Somali khat users were assigned to treatment conditions (khat use is a predominantly male habit). The ASSIST-linked BI for khat users was administered. Using the TLFB Calendar, the PHQ-9, a Somali short version of the PDS and parts from the CIDI, khat use and comorbidity was assessed. With a regression analysis we tested for the influence of comorbidity and with mixed effect models group differences over time in sleep duration, khat use-time and everyday functioning.

RESULTS

We found high rates of baseline multimorbidity: 51% (N = 168) for depression, 22% (N = 74) for PTSD and 23% (N = 73) for khat-psychotic symptoms. Depression and khat-psychotic symptoms, but not PTSD symptoms decreased without group differences. Khat use-time decreased and functional time increased with significant time × group interactions (p ≤ 0.046). Depression and PTSD did not influence therapy success but in participants without comorbid psychopathology, more khat use reduction after the intervention was found (p = 0.024).

CONCLUSION

Somali khat users in Kenya are highly burdened by multimorbidity of depression, PTSD and khat-psychotic symptoms. The main effects for time and differences in healthy vs. mentally ill khat users indicate potential of unspecific support and the specific need for mental health care in combination with substance abuse treatment. The increase of everyday functioning promises more options for alternative activities, preventing excessive use and addiction.

Catha edulis Forsk. (Khat): Evaluation of its Antidepressant-like Activity

BACKGROUND

Catha edulis Forsk. (Khat) is traditionally used for treating various disorders. Nevertheless there are no reports of any scientific assessment of its psychopharmacological properties.

OBJECTIVE

Therefore, the current study was designed to evaluate the antidepressant-like activity of Khat ethanolic extract using established animal models of depression and stress.

MATERIALS AND METHODS

Ninety healthy male albino mice were used in this study. Forced swim, tail suspension and head poking tests were utilized to evaluate the antidepressant-like activity of the ethanolic extract of Khat (100, 200 and 400 mg/kg, i.p.) and escitalopram (standard drug) which were administered 30 min prior to the tests. Phytochemical analysis of the standardized extract was conducted using liquid chromatography-mass spectroscopy (LC-MS).

RESULTS

A significant decrease in the head-dipping behavior was noticed after administration of 100, 200 and 400 mg/kg of Khat extract. Moreover, the extract significantly decreased the immobility time in tail suspension and forced swim tests. The presence of cathinone and cathine were detected in the extract using LC-MS.

CONCLUSION

The current results suggest that the extract of Khat leaves has acute antidepressant properties and may have sedative effects.

SUMMARY

Antidepressant-like activity of Khat established in vivoThe extract decreased the immobility time in tail suspension and forced swim testsLiquid chromatography-mass spectroscopy data revealed the presence of cathinone and cathine in Khat extract. Abbreviations used: LC-MS: Liquid chromatography-mass spectroscopy; NIST: National institute of standard technology; SSRI: Serotonin reuptake inhibitors; FST: Forced swim test; TST: Tail suspension test.

Managing interactions between cognitive enhancers and other psychotropics

Polypharmacy is common in psychiatry. Usage of cognitive enhancers is increasing in the psychiatric population. Many clinicians are not familiar with these new psychoactive compounds. This paper reviews the potential drug-drug interactions when these cognitive enhancers are used together with psychotropic drugs and their confounding effects on diagnosis and clinical management.

Projection neurons in the cortex and hippocampus: differential effects of chronic khat and ethanol exposure in adult male rats

BACKGROUND

Recent evidence suggests that many individuals who chew khat recreationally also drink ethanol to offset the stimulating effect of khat. The objective of this study was to describe the separate and interactive effects of chronic ethanol and khat exposure on key projection neurons in the cortex and hippocampus of young adult male rats.

METHODS

Young adult male Sprague Dawley rats were divided into six treatment groups: 2 g/kg khat, 4 g/kg khat, 4 g/kg ethanol, combined khat and ethanol (4 g/kg each), a normal saline control, and an untreated group. Treatments were administered orally for 28 continuous days; brains were then harvested, sectioned, and routine hematoxylin-eosin staining was done. Following photomicrography, ImageJ® software captured data regarding neuron number and size.

RESULTS

No differences occurred in counts of both granular and pyramidal projection neurons in the motor cortex and all four subfields of the hippocampal formation. Khat dose-dependently increased pyramidal neuron size in the motor cortex and the CA3 region, but had different effects on granular neuron size in the dentate gyrus and the motor cortex. Mean pyramidal neuron size for the ethanol-only treatment was larger than that for the 2 g/kg khat group, and the saline control group, in CA3 and in the motor cortex. Concomitant khat and ethanol increased granular neuron size in the motor cortex, compared to the 2 g/kg khat group, the 4 g/kg khat group, and the 4 g/kg ethanol group. In the CA3 region, the 4 g/kg ethanol group showed a larger mean pyramidal neuron size than the combined khat and ethanol group.

CONCLUSION

These results suggest that concomitant khat and ethanol exposure changes granular and pyramidal projection neuron sizes differentially in the motor cortex and hippocampus, compared to the effects of chronic exposure to these two drugs separately.

Subchronic oral administration of crude khat extract (Catha edulis forsk) induces schizophernic-like symptoms in mice

Background

Chewing fresh leaves of the khat plant (Catha edulis forsk) is a deep rooted and widespread habit in East Africa and the Middle East. Although a body of knowledge exists about the adverse effects of khat on health, data are sparse with regard to the consequences of long-term khat chewing in resulting schizophrenic like symptoms.

Methods

A crude extract of khat at different doses (100 mg/kg (K (khat)100), 200 mg/kg (K200) and 400 mg/kg (K400)) were administered for experimental group of mice whereas standard (ketamine (KT) 10 mg/kg- positive controls (KT10)) and vehicle (2 % v/v Tween-80 in distilled water – negative control groups (CON)) were administered for control groups of mice daily for two months to evaluate subchronic oral administration of crude khat extract to induce schizophrenic-like symptoms in mice. Mice were subjected to a battery of behavioural tests and parameters like locomotor activity, total time spent in social interaction and level of cognition among different groups of mice were measured and analyzed.

Results

Khat at all doses significantly increased (p < 0.001) the mean locomotor activity score of mice compared to CON. However, the mean locomotor activity score of mice treated with khat was significantly lower (p < 0.001) compared to the mean locomotor activity score of KT10 mice (p < 0.001).

The mean total time score (in seconds) spent in social interaction, mean total time score (in seconds) spent in sniffing and following the partner was significantly higher (p < 0.001) in CON groups of mice compared to khat and ketamine treated groups. Moreover, in spatial memory task, the mean latency score (in seconds) to find the platform of khat and ketamine treated mice was significantly higher (p < 0.05) when compared to CON.

Conclusions

Subchronic oral administration of khat showed an enhanced locomotor activity, reduced social interaction and impaired cognitive function, which demonstrated that long-term use of khat is associated with schizophernic-like symptoms.

Regional research priorities in brain and nervous system disorders

The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.

Bibliometric analysis on global Catha edulis (khat) research production during the period of 1952-2014

BACKGROUND

Publication of scientific articles related to khat (Catha edulis) in peer-reviewed journals is considered a measure of research productivity. The principal objectives of this study were to quantify the research contribution related to khat at the global level, as well as to determine its relative growth rate, collaborative measures taken, productivity at the institutional level, and the most prolific journals publishing on the topic.

METHODS

On the basis of title words related to khat, publications were identified for all data in Scopus bibliographic database's history up to December 31, 2014. The research productivity for the top 10 countries was evaluated in relation to the population size and gross domestic product (GDP) in 2013.

RESULTS

The criteria were met by 651documents published in 51 countries. The largest number of articles associated with khat was from the UK (15.2 %), followed by Yemen (10.3 %), the USA (9.7 %) and Ethiopia (9.1 %). Ethiopia, Yemen, and Kenya had the highest productivity of publications after standardization by population size and GDP. Furthermore, Yemen achieved the highest number of collaborations, by having researchers from 19 countries. Ethiopia followed, having researchers from 16 countries.

CONCLUSIONS

This bibliometric study provides a demonstration for the worldwide research activity regarding khat. The number of articles related to khat has increased rapidly over the last 10 years. The present study is a good starting point to evaluate research activity in the field of khat. Although the data shows a promising increase in the research activity, the quantity of khat-related research is still too little compared to the massive use of khat in certain countries.

Before the ban--an exploratory study of a local khat market in East London, U.K

BACKGROUND

Khat is a green leaf with amphetamine-like effects. It is primarily used among people in Africa, the Middle East and in the diaspora communities from these countries. Prior to the prohibition of khat in the UK on 24 June 2014, there was almost no information available on key aspects of the local khat market.

METHODS

A cross-sectional study was conducted in 2012 using snowball sampling, Privileged Access Interviewing and area mapping in order to identify khat sale establishments. Data was collected via face-to-face interviews using mixed methods for data collection. This included information about the establishments selling khat, khat pricing and its use among different ethnic minority groups, in addition to the potential sale of khat to children and risk assessment (e.g., use of pesticides on khat).

RESULTS

Five out of seven sellers identified agreed to participate. Sellers described their khat sale establishments as 'community centres' which included, for example, a restaurant basement. The sellers' history of selling khat ranged between 1-15 years and khat's sale took place between 2pm-10pm. Miraa (e.g., Lara) from Kenya was the most popularly used khat variety, sold in pre-wrapped bundles of approximately 250 g costing £3 each and delivered four days a week. Harari (e.g., Owdi) from Ethiopia was sold in 200 g, 400 g and 1 kg bundles, priced between £5 and £20 and delivered two days a week. The primary benefit of khat use was reported to be social interaction. The customers were predominantly adult males of Somali origin. Most sellers claimed a self-imposed ban on sales to children under 18 years old. Khat bundles had no labelling describing variety or weight and sellers had no knowledge of the use of pesticides on khat and did not advertise the risks associated with khat use.

CONCLUSIONS

Khat selling establishments were businesses that did not adhere to trade standards regulations (e.g., labelling khat bundles). They claimed to provide a community service (facilitating social interaction) to their predominately Somali customers. Without a better understanding of the dynamics of the khat market there is a risk that both health and social needs of the vulnerable populations involved in the market continue to go unaddressed. Future research should track changes in the now illicit khat market in order to evaluate the social and public health implications following the recent changes to the current U.K. regulatory environment regarding khat.

Catha edulis chewing effects on treatment of paranoid schizophrenic patients

BACKGROUND

The current study's aim is to evaluate the possible interaction effects of khat chewing on treatment of paranoid schizophrenic patients.

PATIENTS AND METHODS

In the study group, 42 male subjects suffered from paranoid schizophrenia and were classified according to their khat chewing habits into two subgroups: either khat-chewer subgroup (SKc; n=21; r=11, h=10) or non-khat-chewer subgroup (SNKc; n=21, r=11, h=10). Each subgroup was further subdivided according to type of treatment into r (risperidone) and h (haloperidol). Healthy male subjects (37) were subdivided into healthy khat-chewer as positive controls (HKc, n=17) and healthy non-khat-chewer as negative controls (HNKc, n=20). Plasma dopamine, 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid, 5-hydroxytryptamine (serotonin), 5-hydroxyindoleacetic acid, epinephrine, and norepinephrine were estimated.

RESULTS

ANOVA and post hoc analysis showed that dopamine was illustrating significant elevation in all khat chewing groups. DOPAC was illustrating significant decrease in all khat chewing groups with an interesting outcome showing significant increase in DOPAC in SNKcr group due to risperidone effect. Homovanillic acid, serotonin, hydroxyindoleacetic acid, and norepinephrine were illustrating significant elevations in all khat chewing groups. Epinephrine was illustrating significant elevation in all chewers than non-chewers groups. Unexpected significant decrease in epinephrine in the SNKcr group indicated that risperidone drug is decreasing epinephrine through indirect mechanism involving calcium.

CONCLUSION

Khat chewing in schizophrenic patients is contraindicated because it aggravates the disease symptoms, attenuates all used treatment medications, and deteriorates all biochemical markers of the patients.

Effect of Khat on apoptosis and related gene Smac/DIABLO expression in the cerebral cortex of rats following transient focal ischemia

BACKGROUND

The leaves of the Khat shrub contain the major alkaloid compounds (cathinone) and cathine. These compounds can induce apoptosis and exacerbate the acute cerebral infarction, but the underlying mechanism is poorly understood. The present study aimed to investigate the effects of Khat treatment on the expression and cellular localization of Smac/Diablo (second mitochondrial activator of caspase) in the cortex of ischemic rat brain.

METHODS

Adult male Sprague-Dawley rats were administered Khat (3g/kg) twice daily for 4 weeks, then underwent left middle cerebral artery occlusion (MCAO) for 2h and reperfusion for 3, 6 and 12h, respectively. The infarction area was evaluated with 2,3,5-triphenyltetrazolium chloride (TTC) staining. Apoptosis was assessed by terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling (TUNEL). Smac/DIABLO expression levels in experimental and control groups were examined by immunohistochemistry and Western blot.

RESULTS

Khat significantly exacerbates the neurological damage compared with control (p<0.05). In addition, Khat-treatment significantly increased the number of TUNEL-positive cells 3h (p<0.01) and 12h (p<0.05) after reperfusion. Ischemia/reperfusion enhanced the release of Smac/DIABLO from the mitochondria to the cytosol after reperfusion. Such release of Smac/DIABLO was elevated after the rats were pretreated with Khat.

CONCLUSIONS

Our results indicate that Khat treatment can induce apoptosis through enhancing the release of Smac/DIABLO from the mitochondria to the cytosol after transient focal ischemia which may be an important mechanism of Khat neurotoxicity. Therefore, Khat chewing should be avoided by people who have cerebrovascular problems.

Herbal delivery system for treatment of obesity administration of encapsulated khat-extracts on body weight of rats

SUMMARY

Obesity is one of the most important problems worldwide. Khat (Catha edulis), an evergreen shrub, is thought to reduce body-weight. Its effect is more prominent when khat leaves are chewed. Thus, anti-obesity effects of khat and its associated side effects may depend on the release rate of its active constituents. The present study aimed to investigate the effect of a selected low dose of dried-khat, extracted, formulated as controlled release delivery systems on the body weight (BW), food intake (FI), cholesterol (CS) and triglyceride (TG) levels in rats. Khat extract (KE) was microencapsulated (KE235) and formulated into a parenteral implant (InjKE235). The effects of KE, KE235 and InjKE235 on BW, FI, CS and TG in rats were investigated. The results showed that microcapsules sustained the khat alkaloid release with T50% 1.58 h for KE235 and 14.41 days for InjKE235. KE and KE235 caused maximum reduction in BW, FI, CS and TG during the first to third weeks but rebound gradually thereafter. On the contrary, InjKE235 exhibited a sustained reduction in BW, FI, CS and TG levels for 2 months. The T50% of KE, KE235 and InjKE235 correlated with the reduction in BW, CS and TG but not with FI. In conclusion, the subcutaneous injection and sustained release rate of khat extract play an important role in enhancing the anti-obesity effect in SD rats.:

Concurrent use of khat and tobacco is associated with verbal learning and delayed recall deficits

AIMS

The present study assessed whether cigarette smokers who are also regular khat users would demonstrate greater impairments in verbal learning and recall compared to both non-smokers who are khat users and control subjects.

DESIGN

An independent-measures, between-subjects design with two covariates.

SETTING

An out-patient, university research center in Taiz, Yemen.

PARTICIPANTS

Subjects were 175 Yemeni college students (90 men, 85 women) ranging in age from 18 to 38 years. Seventy-five subjects were self-reported chronic cigarette smokers and khat users, 48 non-smoking subjects were self-reported to be chronic khat users and 52 non-smoking subjects reported no current use or history of khat use.

MEASUREMENTS

Verbal learning and verbal memory recall was assessed by subject performance on the Arabic version of the Rey Auditory Verbal Learning Test (RAVLT).

FINDINGS

Statistically significant differences (P < 0.05) were observed in RAVLT acquisition learning trials 2-5 and on delayed recall measures between concurrent khat and cigarette users compared to both the khat-only group and the control group of non-users of khat and cigarettes. On each of these trials, concurrent users recalled fewer words, demonstrating a slowed rate of verbal learning. This same pattern of performance was also seen on delayed recall measures. Khat use alone did not affect immediate or delayed recall of previously learned words.

CONCLUSIONS

Khat users who smoke cigarettes have a lower rate of verbal learning and delayed recall of previously learned verbal material than khat users who do not smoke cigarettes. This may be due to pre-existing differences between these groups of subjects.

Leaf of paradise?: the intricate effects of khat in Madagascar

Purpose

–Khat is a bushy plant whose leaves are chewed for a mild amphetamine effect. The purpose of this paper is to investigate khat's multiple effects, broadly defined to include impacts on producers, traders, and consumers, as well as on the biophysical environment, in northern Madagascar.

Design/methodology/approach

– This primarily ethnographic study (conducted from 2004 to 2010), includes observation, semi-structured interviews, and orally administered questionnaires.

Findings

– Khat's effects include strain on the household budgets of consumers, but increased earnings to producers and traders. In addition, there is some evidence of consumers’ strained primary social relationships, yet khat chewing is also positively linked with new forms of urban multiethnic identity.

Research limitations/implications

– To evaluate a drug's overall effects, it is critical to understand it within wide-ranging political, economic, biological, and cultural contexts. Many studies of drugs focus on only one component. While this makes for more manageable research designs, it obscures the complex interplay of numerous factors. This impedes general understanding and furthermore makes it difficult to design broadly effective, multisector intervention strategies.

Originality/value

– This analysis reveals the intricacy of khat's effects in Madagascar while programmatically proposing a model for doing research with policy implications on other psychotropic substances.

Khat (Catha edulis): A systematic review of evidence and literature pertaining to its harms to UK users and society

The use of khat ( Catha edulis) has been associated with a large number of physiological and societal harms, leading to calls for it to be controlled in the UK. The evidence of these harms is often equivocal, limited by confounding factors, or entirely anecdotal: high-powered, quality-controlled studies are lacking. Regardless, the body of relevant literature indicates that the once socially-regulated use of khat has been eroded. Some individuals have developed excessive consumption patterns, either using khat daily or in binge-sessions, though daily consumption is not necessarily problematic per se. The majority of users seem to use khat in moderation, where the associated harms appear low. For excessive users, harms associated with khat are greater, particularly relating to mental health. Social harms also seem to be largely related to excessive khat use rather than khat use itself. Even in cases of excessive khat use, however, causal relationships between chewing and harms have not been described. More research is required to establish the role of khat in liver disease, coronary problems, cancers of the digestive tract and incidents of domestic violence. Studies should consider the likeliness that certain users are more vulnerable to developing patterns of excessive khat use due to an interwoven set of factors such as social health determinants and pre- and post-migration experiences.

Gender differences in patterns and correlates of khat and tobacco use

INTRODUCTION

Although research suggests gender differences in patterns of tobacco use, whether gender moderates concurrent use of tobacco and other substances remains unclear. In some parts of Africa and the Middle East, tobacco is often accompanied with khat (Catha edulis), a widely used substance in these regions. The concurrent use of tobacco and khat may represent a public health burden spreading to other countries in Europe and North America.

METHOD

A total of 189 participants (69 women) khat users and smokers in Yemen were asked to complete questionnaires that focused on patterns of khat and tobacco use. Chi-square tests, analyses of variance, and correlational analyses were conducted.

RESULTS

Reported frequency and intensity of khat and tobacco use were greater among men than in women. Also, reported number of cigarettes smoked during a khat session was higher among men than among women, whereas frequency of waterpipe use during the session was greater among women than among men. Smoking status (daily or occasional) was positively associated with khat use in women only. Age of onset of khat use was inversely related to the number of cigarettes smoked during a khat session and with intensity of khat chewing. The majority of participants reported that they had thought about and have attempted to quit khat and tobacco use.

CONCLUSIONS

The results provide evidence for gender differences in patterns of concurrent use of tobacco and khat. Identifying determinants of tobacco and khat use may be useful in reducing the risk of their negative health outcomes.

Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a natural psychostimulant that has pharmacological effects similar to that of amphetamine. The behaviour of khat chewing is embedded within a cultural context. Meanwhile khat chewing is associated with psychological and physiologically burden, as a 'dependence producing' substance.

AIMS OF THE STUDY

To assess the applicability of the construct of substance dependence syndrome (DSM-IV, 1994) to khat chewing and to examine psychosocial and behavioural correlates of this syndrome including tobacco use.

MATERIALS AND METHODS

A sample of 204 khat chewers was recruited during random visits to khat sale outlets. A face to face interview that assessed socio-demographic, psychosocial dependence, substance dependence syndrome and behavioural characteristics was conducted. Descriptive, exploratory psychometric and multivariate analyses were employed.

RESULTS

Approximately a third (31%) of khat chewers reported symptoms consistent with dependence syndrome including increased khat chewing (13%) and cessation attempts (19%) while 17% reported withdrawal symptoms including depression (61%), increase in appetite (74%) and interrupted sleep (58%). Thirty-eight percent reported continued khat chewing despite impacts on their health. Psychometric assessment of the DSM-IV criteria for khat chewing dependence identified two factors; factor 1 consisted of bio-behavioural items and factor 2 withdrawal items, accounting for 67% of the variance and Cronbach's alpha coefficient at 0.78. In multivariate logistic regression modelling, there was an association between intensity of psychological khat dependence (SDS-Khat) and nicotine dependence with the likelihood of exhibiting khat chewing dependence syndrome (p=0.0005, OR=1.51, 95%CI=1.33-1.71; p=0.043, OR=2.87, 95%CI=1.03-7.98, respectively).

CONCLUSIONS

The substance dependence syndrome criteria are applicable to khat chewing and associated with increased intensity of nicotine and psychological khat dependence. The applicability of khat dependence syndrome and exploration of its dimensions and associated factors should be extended in future research. Concurrent validation of these findings using specific objective measures for self-report khat chewing is also recommended.

Working memory and speed of information processing in chronic khat users: preliminary findings

To date there are very few laboratory data available regarding the long-term effect of the psychostimulant khat on human neurocognitive functioning. The purpose of the present study was to assess whether chronic khat users would demonstrate impairments in working memory and speed of information processing compared to control subjects. Working memory was assessed using the forward and backward digit span test. Speed of information processing was assessed using the Digit Symbol Substitution Test. Results of the present study indicate that chronic khat use may have a long-term deleterious effect on working memory, particularly on digit backwards measures of short-term/working memory. The finding is consistent with results seen by several investigators in samples of methamphetamine users.

Khat use among Somali mental health service users in South London

PURPOSE

Khat use has been suggested to be associated with psychosis, but its prevalence and associations among mental health service users have not been described in either traditional use countries or countries with immigrant populations from traditional use countries. We aimed to investigate the clinical and demographic associations of khat use in a sample of Somali users of mental health service users in South London.

METHODS

We used an electronic case register of 150,000 mental health patients to investigate the associations of khat use among all 240 Somali patients in the database. We used logistic regression to generate adjusted estimates for a range of exposure variables and used multiple imputation as a principled approach to missing data.

RESULTS

Khat use or non-use was recorded for 172 patients (72% of the total), of whom 80 (47%) were current users. Khat use was very strongly associated with ICD-10 primary diagnosis of schizophrenia, psychosis or drug and alcohol disorder (compared to ICD-10 F43 stress-related disorders and other non-psychotic disorders), male gender, harmful or dependent use of alcohol, and detention under the Mental Health Act.

CONCLUSIONS

Recording and monitoring of khat use need to be more consistent in clinical settings, and further studies are required to investigate the much higher rates of use among those with psychotic disorders compared to non-psychotic disorders.

A pilot study on community-based outpatient treatment for patients with chronic psychotic disorders in Somalia: Change in symptoms, functioning and co-morbid khat use

Background

In Low and Middle Income Countries, mental health services are often poorly developed due to the lack of resources and trained personnel. In order to overcome these challenges, new ways of care have been suggested such as a focus on community-based services. In Somalia, the consumption of the natural stimulant khat is highly prevalent, aggravating mental illness. At the same time, mental health care is largely unavailable to the vast majority of the population. In a pilot project, we tested possibilities for effective measures in community-based out-patient mental health care.

Methods

Thirty-five male patients with chronic psychotic disorders and their carers were involved in a 10-months follow-up study. All of them abused khat. Seventeen outpatients experiencing acute psychotic episodes were recruited from the community and received an intensive six week home-based treatment package. Additionally eighteen patients with chronic psychotic disorders in remission were recruited either following hospital discharge or from the community. In a second phase of the study, both groups received community-based relapse prevention that differed in the degree of the family’s responsibility for the treatment. The treatment package was comprised of psycho-education, low-dose neuroleptic treatment, monthly home visits and counseling. The Brief Psychiatric Rating Scale (BPRS) was applied three times. Additionally, we assessed functioning, khat use and other outcomes.

Results

Of the 35 patients enrolled in the study, 33 participated in the 10-month follow-up. Outpatients improved significantly in the first six weeks of treatment and did not differ from remitted patients at the start of the second treatment phase. In the preventive treatment phase, we find heterogeneous outcomes that diverge between symptom and functioning domains. With the exception of depressive symptoms, symptoms in all patients tended to worsen. The outpatient group had higher BPRS positive and negative symptom scores compared to the remitted group. Levels of functioning in 20 out of 33 patients significantly improved, with small differences between groups. Most patients experienced improvements in basic functioning, such as communication, self-care etc. Khat use could only be reduced in the group of outpatients.

Conclusions

Community-based out-patient mental health treatment for chronic psychotic disorders has demonstrated positive effects in Somalia and is both feasible and practical, despite facing formidable challenges, e.g. controlling khat intake.

Validation of self-reported khat chewing amongst khat chewers: an exploratory study

ETHNOPHARMACOLOGICAL RELEVANCE

Khat chewing amongst the UK communities originating from Yemen and the East African coast is suggested to create dependency through its main stimulant components (cathinone, norephedrine and norpseudoephedrine) on the central nervous system.

AIMS OF THE STUDY

To validate self-reported khat chewing behaviours by measuring levels of cathinone, norephedrine and norpseudoephedrine in saliva and to explore their associations with self-reported khat chewing dependency.

MATERIALS AND METHODS

Face-to-face interviews were conducted amongst 30 male UK-resident khat chewers. Saliva samples were collected from each participant and high-performance liquid chromatography (HPLC) employed to extract and quantify the levels of the biomarkers.

RESULTS

The mean (SD) for cathinone and the composite norephedrine and norpseudoephedrine levels were 33.93 (±39.20) and 29.28 (±26.32)μg/mL respectively. These biomarkers were significantly associated (p≤0.05) with khat chewing dependency.

CONCLUSIONS

Validation of self-reported khat chewing is possible. Khat chewing dependency correlates significantly with biomarker levels in saliva. Replication is required.

Khat (Catha edulis) and ethanol co-dependence modulate seizure expression in a pentylenetetrazol seizure model

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a plant with psychostimulant properties whose parts, mainly leaves and twigs, are chewed for its euphoriant effects. Khat use and ethanol abuse are increasingly becoming global health concerns especially among many disadvantaged social groups. The present studies were undertaken to investigate seizure susceptibility and responses following chronic co-administration of khat and ethanol.

MATERIALS AND METHODS

Juvenile male Sprague-Dawley (SD) rats were administered khat, ethanol or combined khat and ethanol twice daily for 28 days by gavage. Khat-treated animals received 2 g/kg or 4 g/kg body weight continuously for the study period. Ethanol-treated animals received 20% ethanol at a dose of 4 g/kg body weight. The convulsant, pentylenetetrazol (PTZ), was administered intraperitoneally at a dose of 40 mg/kg body weight. Seizure responses were recorded.

RESULTS

Twice-daily dosing of khat did not produce inhibition of weight gain. Khat alone, combined khat and 20% ethanol, but not 20% ethanol alone, significantly reduced the latency to seize. Khat treatment at 2 g/kg but not 4 g/kg body weight also significantly increased the duration of seizures. Conversely, combined khat and ethanol reduced the duration of seizures compared to controls. Ethanol alone reduced the seizure severity while khat alone, and combined khat and ethanol, produced close to the maximum seizure severity.

CONCLUSIONS

These data suggest that combined moderate to high dose khat and ethanol co-dependence produce a greater deleterious CNS effect than either drug alone. Future studies will address neurochemical effects, in addition to neuroadaptations, resulting from coabuse of these drugs.

Khat chewing in persons with severe mental illness in Ethiopia: a qualitative study exploring perspectives of patients and caregivers

People with severe mental illness (SMI) in Ethiopia chew khat despite advice from their physicians to desist. We wanted to better understand their reasons for khat chewing, including any benefits that they might gain. A qualitative study was conducted involving patients with SMI and their caregivers in Butajira. Reasons given by patients as well as caregivers were more or less congruent: social pressure, a means for survival by improving function, combating medication side effects, to experience pleasure and curbing appetite. These findings will be of value to health workers, caregivers and policymakers alike in improving care and understanding for this patient group. Furthermore, our study indicates a role for future research to explore potentially beneficial effects of khat in this population.

Psychoses, PTSD, and depression in Somali refugees in Minnesota

INTRODUCTION

Initial clinical observation of Somali patients seen at a busy inner-city community clinic (CUHCC) suggested that, in addition to the expected pictures of Posttraumatic Stress Disorder (PTSD) and depression previously seen in the clinic's Southeast Asian refugee population from 1980 to 2000, there was an unusually high number of young Somali men presenting with acute psychotic disturbances.

OBJECTIVES

The aim of this study of health care utilization of Somali refugees (N = 600) seen in the mental health unit of the clinic from 2001 to 2009 was to investigate the major patterns of psychiatric disorders in this outpatient population and compare these findings with a cohort of non-Somali patients (N = 3,009) seen at the same outpatient clinic during the years 2007-2009. If the results supported the initial clinical observations that the rate of psychoses was higher among young Somali men than non-Somali men attending CUHCC clinic, then several areas of further research would recommend itself. First, since this study was not a study of prevalence of mental illness in the Somali community, the next step would be to undertake a study of community prevalence of mental illness among different age and gender cohorts. Second, further research should look into likely causative and contributory risk factors to explain the development of psychoses among Somali young men.

METHODS

Somali and non-Somali patients were diagnosed according to DSM-IV-R criteria. Main outcome measures (diagnoses, age cohort, sex) were analyzed by Chi-square tests. Patterns of illness and adjustment varied significantly by age and gender cohorts, reflecting the relevance of age and gender at time of trauma on different trauma and loss experiences and cultural and religious shaping of subsequent adjustment and symptoms.

RESULTS

The study confirmed that almost half of the Somali male patients are under age 30, 80% of whom presented with psychoses, compared with the rate of psychosis (13.7%) in the non-Somali control group of same-aged males at the clinic. The older male, and the majority of Somali female patients, show predominantly depressive and PTSD symptomatology.

CONCLUSIONS

War trauma experienced in childhood, early malnutrition from famines, head trauma, and excess Khat use in male adolescents provide partial explanations for the large number of young psychotic Somali men seen in the clinic from 2001 to 2009.

Cultural psychiatry and epidemiology: researching the means, methods and meanings

This article describes my developing interest in cultural psychiatry. This is both a challenging and yet a privileged opportunity to reflect on my research and clinical work over the last 25 years. I describe cultural and interpersonal influences on my thinking and interests, and the development of my research career moving from health services research of specialist services, to primary care research to public mental health research. Specifically, social and cultural influences on risks and responses to mental illness are discussed, as are pathways to care, the recognition of mental illness, and public health and cultural psychiatry research.

Multi residue analysis of pesticides in wheat and khat collected from different regions of Ethiopia

The present study investigated the presence and level of pesticide residues in wheat and khat samples collected from various localities of Ethiopia. The khat samples from Galemso and Aseno had p,p'-DDT concentrations ranged from 141.2 to 973.0 μg/Kg and 194.3-999.0 μg/Kg, respectively. Diazinon was detected in all the khat samples from BadaBuna (173.9-686.9 μg/Kg) but not in any of the samples from Galemso and Aseno. Diazinon was detected in all the wheat samples obtained from both Arsi and Bale (125.8 and 125.6 μg/Kg, respectively) and aldrin levels in these samples were below the quantification limit. Khat may be a contributing factor in the pathological diseases found among khat users.

The epidemiology of addiction in Sub-Saharan Africa: a synthesis of reports, reviews, and original articles

Use of alcohol and other psychoactive substances is associated with serious social and public health problems, but the extent of the problem in Sub-Saharan Africa is not well known. We set out to review epidemiological publications on alcohol and other psychoactive substances in Sub-Saharan Africa by performing a systematic search of electronic databases and paper records. Ten Sub-Saharan African countries are among the 22 in the world with the highest increase in per capita alcohol consumption. Cannabis, tobacco, and khat are widely used, and use of cocaine, stimulants, and heroin is increasing. More epidemiological research and implementation and evaluation of interventions is needed. Collaboration between African researchers and those in developed countries could help. 

A good chew or good riddance--how to move forward in the regulation of khat consumption

AIMS

To review the status of khat, the most recent plant based psychoactive substance to reach a global market, and consider policy making processes in general and the framework of drug control in particular.

MATERIALS AND METHODS

Desk review of literature on khat and wider drug policy processes.

RESULTS

The risk assessment and classification of psychoactive drugs is a contested arena where political, economic and moral agendas collide, leaving countries that have banned khat, with significant social costs. To best manage the risks arising from the increasing availability of khat it is therefore suggested to draft a regulatory framework with clear objectives and guiding principles.

CONCLUSIONS

Given that medical risks of khat use are modest, the objective of the regulatory framework should be the protection of consumers and community. This is best achieved by establishing processes for the quality control of khat imports, and by regulating access and availability. It should therefore not be considered as a drug to be controlled but as a licit substance that needs to be regulated.

Introduction to the special issue: the changing use and misuse of khat (Catha edulis)--tradition, trade and tragedy

Within the last decade the hitherto little known psychoactive substance of khat has emerged as a regional and international issue. In the Horn of Africa khat production has spurred an economic boom, but dramatic increases in consumption have raised public health concerns. Given the complexity of the topic spanning multiple academic disciplines and fields of professional practice, the need for a systematic overview is urgent. To facilitate the exchange of information, prompt interdisciplinary research and alert international organisations and governments, the authors organised an international and interdisciplinary khat conference in 2009. This special issue of the Journal of Ethnopharmacology contains articles written by different conference speakers that present the current state of knowledge and the challenges for future research and politics.

The stimulant khat--another door in the wall? A call for overcoming the barriers

AIM

In this article, we comment on the current international discourse on khat, we highlight pitfalls and and suggest balanced national international regulatory actions.

METHOD

A brief an focussed review of the available literature on khat and health and examples from our own research are provided.

RESULTS

The use patterns of catha edulis (khat) have changed throughout the last decades. During this period khat has had a remarkable economic boom and developed from a niche crop to the backbone of the regional economy. Now it contributes to the livelihoods of millions of people. Today, khat use is often the proverbial "Door in the wall" for large parts of the populations in African and Arab countries beyond the traditional user groups. Its use is often excessive and not restricted by social regulation mechanisms. Under such conditions, problematic khat use patterns develop rapidly, exemplified by the growing group of binge users, and it gets even prevalent among especially vulnerable groups such as children, people with mental disorders or pregnant women. The currently existing scientific evidence suggests that problematic use patterns not the use per se can be linked to numerous health consequences.

CONCLUSION

This paper argues that changed patterns of khat use are a burden for some of the most underdeveloped countries in the world. But the debate around khat is stuck between extreme poles arguing for prohibition or for de-regulation. Here, we call for a balanced action of governments and international organizations leaving behind the decades of debilitating debate pro vs. contra scheduling and banning khat leaves. Instead, regulation and harm-reduction measures are urgently needed. We suggest a number of steps that should be taken immediately to better understand current khat use patterns, to address noxious excesses and to relieve suffering.

Validity and reliability of a Severity of Dependence Scale for khat (SDS-khat)

AIMS OF THE STUDY

(1) To assess psychological khat dependence and (2) to assess the validity and reliability of the Severity Dependence Scale (Gossop et al., 1995) amended for khat use (SDS-khat), in a sample of UK-resident male adult Yemeni khat chewers.

MATERIALS AND METHODS

A cross-sectional study using a face to face structured interview schedule was conducted amongst purposively sampled UK-resident adult Yemeni male khat chewers, aged 18 years and above, selected during random visits to places of khat sale. A factor analysis with principal components extraction was conducted to explore the construct validity of the proposed SDS-khat. Reliability of the proposed scale was assessed using test-retest and internal reliability tests. The concurrent validity of the proposed SDS-khat was assessed in relation to individual measures and a composite index of khat chewing behaviours using univariate analyses.

RESULTS

Two hundred and four Yemeni male adult khat chewers were interviewed. The mean score of the proposed SDS-khat was 5.52 (SD ±4.03). Forty nine percent of respondents (95% CI=43-55%) with ≤5 scores were more likely not psychologically dependent. A single factor, uni-dimensional solution identifying the five items making up the scale accounted for 52.33% of variance. The internal reliability was good (Cronbach's alpha coefficient=0.76) and the test retest intraclass correlation coefficient (ICC) was 0.93 (95% CI=0.80-0.97). Many individual aspects of the khat chewing were significantly related to the scale. Assessment of the proposed SDS-khat's concurrent validity with individual items of khat chewing identified several significant relationships (p≤0.05) whilst the composite index of khat behaviour also identified a significant relationship (OR=14.40, 95% CI=6.71-30.89). The proposed SDS-khat also correlated with self-reported reasons for khat chewing (p≤0.001, OR=3.54; 95% CI=1.80-6.96).

CONCLUSIONS

In this sample of Yemeni khat chewers the SDS-khat is recommended as a valid and reliable research tool for measuring psychological dependence upon khat. Further validation in other samples is indicated.

Khat use and neurobehavioral functions: suggestions for future studies

Although there is a rich body of research available regarding the effect of acute and chronic khat dosing in animal models, research on the behavioral and cognitive effects of khat in human subjects is not extensive and several of the available studies have been done only in the context of observational and single-case studies. In light of the absence of a substantial literature on the neurobehavioral deficits associated with khat use and to provide a context that could be used to identify themes for future research we review previous research that has focused on other stimulant drugs. This review highlights multiple areas of neurocognitive deficit that have been identified in previous studies of individuals who have been chronic users of stimulants, such as amphetamines and methamphetamines. The review highlights a substantial body of evidence demonstrating a wide range of learning and memory impairments including deficits that persist during abstinence from active drug use. This review does not imply a similar khat effect, but due to some similarities pharmacologically between the active components of khat (cathinone and cathine) and amphetamines, future studies examining these same domains of cognitive functioning in chronic khat users and abstinent khat users appears to be warranted, if possible using some of the same or similar laboratory measures.