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

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.

Process and Outcome of Community Engagement Event on Substance Use and Addiction Risks Facing Their Immigrant Communities in Regina, Saskatchewan

Canada is a significant destination for immigrants who are drawn from different ethnic and cultural backgrounds some of whom have a hidden risk for substance use disorders due to acculturation stress and are not screened for risks of substance use or addiction when considering medical admissibility. Not surprisingly, healthcare providers in Regina are reporting a noticeable increase in substance use among immigrants. These immigrants experience barriers in seeking substance use prevention and treatment services due to diverse challenges: stigma, shame, and lack of knowledge of existing services. Considering the discussed challenges and risks of substance use disorders in immigrant communities, creating a safe space for discussing these topics is urgent. To understand and address these challenges, a connection grant from the Saskatchewan Health Research Foundation (SHRF) to mobilize immigrant communities in Regina to explore substance use issues and their impact on the community was sought and received. Subsequently, a Zoom knowledge-sharing event brought settlement agency stakeholders together to deliberate issues on substance use and addiction faced by immigrants in Regina, Saskatchewan. The Zoom session included presentations on immigrants and substance use from the clinical, community, and lived experience perspectives of immigrants. Because of the challenges and risks, this community consultation process revealed that acculturation stress and the ease of obtaining socially acceptable substances fuel substance use and addiction among immigrants in Regina; this is further exacerbated by the lack of programming available to prevent and reduce the risks of substance use in this population. A team of knowledge keepers with lived experiences, service providers, and researchers was assembled to explore substance use and addiction among immigrants. This manuscript reports the process of community engagement to identify solutions to this budding issue. The strengths, challenges, and lessons learned are identified.

Substance (mis)use among refugees as a matter of social ecology: insights into a multi-site rapid assessment in Germany

BACKGROUND

Previous research concluded that substance (mis)use is increasing among forcibly displaced populations. Nevertheless, little research has been conducted within a social ecological framework aimed at identifying and understanding the factors affecting substance (mis)use embedded in the post-migration context in high-income countries. The present study aims to develop an understanding of the links and underlying mechanisms between refugees' social ecological determinants and substance (mis)using behavior.

METHODS

Rapid assessments (RAs), including 108 semi-structured interviews and 10 focus group discussions with key persons from various professional, and personal backgrounds, were carried out in German urban and rural areas. The RA approach of interviewing key persons and not solely refugees that (mis)use substances allowed us to gather multi-perspective knowledge on this sensitive topic. Qualitative content analysis was applied, aiming at identifying determinants of substance (mis)use embedded in the post-migration context of refugees and understanding the underlying mechanisms.

RESULTS

One main result of the data suggests that the link between refugees' countries of origin and their post-migration substance (mis)use is not as direct as often assumed. It is observed that refugees' prospects and opportunities in receiving countries (e.g., work permits) undermine this commonly reproduced link. Further determinants are related to living conditions in German refugee shelters and social relations with peers and families. The influence of refugees' living conditions can be summarized as potentially increasing substance availability and distress, whereas family separation produces a loss of control and responsibility, increasing the risk for substance (mis)use. Peers' influence on substance (mis)use was reported to reflect a search for a sense of belonging.

CONCLUSIONS

Given that refugees who (mis)use substances have limited to no control over the factors identified in our study to be associated with substance (mis)use, common treatment and prevention approaches are challenged. Furthermore, we recommend aiming for a holistic comprehension of refugees' substance (mis)use by expanding the focus beyond individuals to the social ecological context in any attempt, including prevention, treatment, research, and policy.

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.

HOW MISUSE OF ANTIMICROBIAL AGENTS IS EXACERBATING THE CHALLENGES FACING SOMALIA'S PUBLIC HEALTH

Background

In contrast to most developed countries, antimicrobial resistance (AMR) has continued to be a serious challenge to public health in the majority of resource-limited countries in Africa.

Materials and method

A comprehensive review of all available literature reporting on antimicrobial resistance patterns, antimicrobial drug usage in both human and animals, as well as national AMR regulations in Somalia was undertaken.

Results

The review observed that successful AMR control and surveillance among resource-poor nations are affected by a lack of infrastructural and institutional capacities, poor investment in human and material resources, as well as non-adherence to available policies. The humanitarian crisis affecting Somalia has persisted for too long, leading to loss of lives, productivity and dilapidation of public health infrastructures. Somalia like most countries has adopted the One Health approach in developing their soon-to-be gazetted National Action Plan on AMR, which covers both human health, animal health and the environment. Although there are many other similar policy documents and guidelines regulating the usage and administration of antimicrobials in the country, evidence of the implementation indicates there is still a need for more effort.

Conclusion

AMR constitute a significant public health problem in Somali, and there is urgent need for gazetting and enforcement of the newly developed national policy. In addition, there is also the need for collaboration with the major stakeholders to develop workable solutions to combat the hazards posed by AMR in the country.

Contribution of Illicit Drug Use to Pharmaceutical Load in the Environment: A Focus on Sub-Saharan Africa

Illicit drug abuse and addiction are universal issues requiring international cooperation and interdisciplinary and multisectoral solutions. These addictive substances are utilized for recreational purposes worldwide, including in sub-Saharan Africa. On the other hand, conventional wastewater treatment facilities such as waste stabilization ponds lack the design to remove the most recent classes of pollutants such as illicit drug abuse. As a result, effluents from these treatment schemes contaminate the entire ecosystem. Public health officials are concerned about detecting these pollutants at alarming levels in some countries, with potential undesirable effects on aquatic species and increased health hazards through exposure to contaminated waters or recycling treated or untreated effluents in agriculture. Contaminants including illicit substances enter the environment by human excreta following illegal intake, spills, or through direct dumping, such as from clandestine laboratories, when their manufacturer does not follow accepted production processes. These substances, like other pharmaceuticals, have biological activity and range from pseudopersistent to highly persistent compounds; hence, they persist in the environment while causing harm to the ecosystem. The presence of powerful pharmacological agents such as cocaine, morphine, and amphetamine in water as complex combinations can impair aquatic organisms and human health. These compounds can harm human beings and ecosystem health apart from their low environmental levels. Therefore, this article examines the presence and levels of illicit substances in ecological compartments such as wastewater, surface and ground waters in sub-Saharan Africa, and their latent impact on the ecosystem. The information on the occurrences of illicit drugs and their metabolic products in the sub-Saharan Africa environment and their contribution to pharmaceutical load is missing. In this case, it is important to research further the presence, levels, distribution, and environmental risks of exposure to human beings and the entire ecosystem.

An Assessment of Health Priorities Among a Community Sample of Somali Adults

Somali immigrants are one of the largest African populations to resettle in the United States since 1990. There is an emerging literature base of disease-specific studies among Somali immigrants. However, we are aware of no studies on the health priorities for Somalis from the community's perspective. Somali adults in Minnesota completed a survey conducted by a community-based participatory research partnership on individual and community health priorities. Data were reported as counts and frequencies. 646 participants completed the survey. The most important health issues for individuals and their families were health behaviors (22.7%), diabetes (18.2%), and hypertension (14.4%), while those of the community were diabetes (22.5%), hypertension (18.8%) and weight (15.9%). This study found a significant overlap of health priorities among Somali individuals and their families compared to the community. These health priorities underscore the need to focus on non-communicable diseases among Somali immigrants.

A systematic review on risk factors for khat chewing among adolescents in the African continent and Arabian Peninsula

INTRODUCTION

Khat is a flowering plant with stimulant effect on the nervous system and produce psychological dependence. Despite its harmful effects, the ingestion of khat has been part of cultural norms and the legality of khat varies by region.

OBJECTIVE

This systematic review aimed at critically evaluating the available evidence on the risk factors of khat chewing among adolescents.

METHODS

A systematic review was conducted on published research studies from five databases Scopus, PubMed, Science-direct, Ovid and google scholar using keywords khat chewing OR qat chewing AND associated factors OR risk factors OR contributing factors AND adolescents OR teenagers. Articles included were either cross-sectional, cohort, case-control or qualitative studies which were published between the year 1990 till present. Excluded articles were the non-English written articles, descriptive studies and irrelevant topics being studied.

RESULTS

Out of 2617 records identified and screened, six were included for the analysis and interpretation of the data. All included studies were cross-sectional study design. All six studies reported having family members who chewed khat significantly predict khat chewing among adolescents, followed by five articles for friends or peers who also chewed khat and four articles for male gender. Smoking was also found to have the highest odds (OR = 18.2; 95% CI: 12.95-25.72) for khat chewing among adolescents.

CONCLUSION

The review highlights the crucial role of family members, friends or peers and male gender to predict khat chewing among adolescents. Effectiveness of health promotion programs to educate and reduce khat chewing among adolescents will require active participation of family members and friends.

Khat Use Patterns, Associated Features, and Psychological Problems in a Khat-Treatment-Seeking Student Sample of Jimma University, Southwestern Ethiopia

Background: Khat (Catha edulis) is a traditionally used substance in African and Arab countries that contains the amphetamine-like alkaloid cathinone. Khat use among Ethiopian students is a growing concern. This study aims to describe khat use, psychological problems, and motivation to change and to determine associated factors of khat use among students from Jimma University seeking psychological assistance.

Methods: In a cross-sectional study, a sample of 717 students from Jimma University, southwestern Ethiopia, who seek assistance to reduce khat use were recruited. The study used Amharic and Afaan Oromoo language versions of common psychological instruments and employed them as part of a comprehensive tablet computer-delivered self-report assessment battery, comprising the SRQ-20, the PCL-5, the LEC-5, the AUDIT, and the SOCRATES-khat. In addition, socio-demographic, economic variables, and functioning problems due to severe mental disorders were assessed. The analysis relied on the data of the 575 included participants and used clinical cut-off values to describe this treatment-seeking sample and hierarchical regression models to determine variables associated with khat use.

Results: The sample showed high khat use in the past month (M = 31.55 bundles, SD = 28.53, on M = 15.11 days, SD = 8.54); 17.0% showed highly problematic use. The sample was extremely burdened with comorbid psychiatric problems: 21.6% reported functioning problems due to past mental disorders, 60.2% scored above the cut-off for current common mental disorders, 37.9% screened positive for PTSD, and 47.1% reported hazardous alcohol use. Small to medium intercorrelations between variables were detected, and in hierarchical regression models, higher motivation to change khat use was associated with higher use of the substance.

Conclusions: This study clearly shows the need to develop research instruments, screening methods, and assistance services for khat-using students at Jimma University. Study participants' high mental health burden shows the need for targeted intervention programs that go beyond brief interventions for khat use. Furthermore, the study highlights challenges for implementing such services: the barriers to utilization for females and khat users without comorbid mental health problems.

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.

An assessment of khat consumption habit and its linkage to household economies and work culture: The case of Harar city

Background

This study investigates khat consumption habits and its linkage to the economy of a household and works culture in its ‘homeland,’ Harar. Khat consumption habit includes practices that are performed before, during, and after consuming khat. In Harar, it has permeated the local economy, social, political and spiritual lives. To evaluate how khat consumption habit is related to the economy of a household, this study compares the living standard and characteristics of khat consumers and non-consumers.

Methods

Both qualitative and quantitative approaches were used. Cluster sampling and lottery methods were used to identify respondents. Data were gathered through individual interviews and non-participant observation.

Results

The results of the study indicate that khat consumption habit affects the economy of the consumer household by negatively influencing their income usage and time management. Consumer households have significant, additional burdens on their income and time. The average monthly expenditure of a household on khat ceremonies is 1,800 ETB (30% of their income) and consumers spend an average of 112.5 hours monthly on khat related activities only. The habit of khat consumption also negatively associated with the work culture of consumers, as they leave for lunch break early and come back to work late.

Conclusion

Khat consumption habit does have a linkage to the bad economic situation of consumer households. It places a significant financial and time burdens on individuals, and as a result society. The work and saving culture of khat consumers are negatively affected. Khat consumption forces many into a cycle of borrowing and indebtedness. Concerned bodies should not underestimate the impacts of khat consumption on individuals and society.

Toxic effect of khat (Catha edulis) on memory: Systematic review and meta-analysis

BACKGROUND

People use khat (Catha edulis) for its pleasant stimulant effect of physical activity, consciousness, motor, and mental functions. Although there are reports assessing the effect of khat on memory, there was no study based on formal systematic review and meta-analysis.

OBJECTIVE

We have therefore conducted this meta-analysis to determine the level of evidence for the effect of khat (C. edulis Forsk) on memory discrepancy.

METHODS

MEDLINE, Cochrane Library, PubMed, Academic Search Complete, SPORTDiscus, ScienceDirect, Scopus, Web of Science, and Google Scholar were searched to retrieve the papers for this review. Keywords utilized across database search were khat, cat, chat, long-term memory, short-term memory, memory deficit, randomized control trial, and cross-sectional survey. The search was limited to studies in humans and rodents; published in English language.

RESULT

Finding of various studies included in our meta-analysis showed that the effect of acute, and subchronic exposure to khat showed that short-term memory appears to be affected depending on the duration of exposure. However, does not have any effect on long-term memory.

CONCLUSION

Although a number of studies regarding the current topic are limited, the evidenced showed that khat (C. edulis) induced memory discrepancy.

Disarming Ex-Combatants' Minds: Toward Situated Reintegration Process in Post-conflict Colombia

Collective violence in the context of armed conflict impacts the economy, health systems, and social stability of affected countries. This is considered a complex phenomenon with interwoven biological, psychological, social, cultural, and political factors. However, most of the research on this topic still lacks suitable established integrative approaches to assess multilevel perspectives. Social, cognitive and affective mental processes (SCAMP) are critical factors that should be considered in multilevel approaches. In this article, we critically discuss some of the classically isolated approaches used in violence research, the absence of successful interventions for ex-combatants reintegration, and the specific neglect of SCAMP in these interventions. We present the case of post-conflict Colombia as a unique opportunity to study the different roots of collective violence, and we call for a more robust and situated approach to understanding of and intervention in this multifaceted phenomenon. In addition, we suggest a two-stage approach for addressing ex-combatants’ reintegration programs, which considers the situated nature of post-conflict scenarios and the urgent need for evidence-based interventions. This approach focuses on the comprehensive scientific assessment of specific factors involved in violence exposure and the subsequent design of successful interventions. The implementation of this approach will contribute to the effective reintegration of individuals who have been exposed to extreme violence for more than 50 years.

Alcohol and Cannabis Use and Sexual Risk Behaviors in the Malawi Defence Force

Substance abuse is a public health priority in the context of the HIV epidemic, especially in military communities. This cross-sectional study quantified alcohol and cannabis use in the Malawi Defence Force and investigated its associations with condom use, transactional sex, multiple sexual partners, and sexual violence. Participants were 944 male and female service members ≥ 18 years old. Data were collected in 2013 using a computer-assisted self-interview. Twenty-four percent of men and women screened positive for hazardous and harmful drinking [Alcohol Use Disorders Identification Test (AUDIT) score ≥ 8]. About 6% reported using cannabis in the past year and 10% reported using cannabis prior to 1 year ago. Multivariable models found elevated adjusted odds of transactional sex and multiple sexual partners for men with an AUDIT score ≥ 8, and men who reported ever using cannabis. The adjusted odds of experiencing sexual violence were also elevated for men who reported ever using cannabis. These findings add to the growing concern that substance use may perpetuate the HIV epidemic in Sub-Saharan Africa by increasing risky sexual behaviors. A comprehensive military HIV prevention response should include substance use education and appropriate care and treatment for individuals screening positive for hazardous and harmful drinking.

Development of the Khat Knowledge, Attitudes and Perception Scale

INTRODUCTION AND AIMS

Khat (Catha edulis) is a stimulant plant widely used in East Africa and the Arabian Peninsula. Tobacco is often co-used with khat and its use has expanded to other parts of the world. Chronic khat use is associated with negative health consequences. There is a lack of research to develop a tool to assess attitudes toward khat use. This study aimed to develop a brief tool to assess attitude and perception related to khat (i.e. the Khat Knowledge, Attitudes and Perception Scale).

DESIGN AND METHODS

Four-hundred and three participants in Yemen (151 concurrent users of khat and tobacco, 141 khat-only users and 92 non-users of khat and tobacco) were asked about knowledge and attitudes related to khat. A principle component analysis with Promax rotation, Scree-plot and Cronbach's α coefficients was performed to examine psychometric properties of the Khat Knowledge, Attitudes and Perception Scale.

RESULTS

Principle component analysis revealed five factors: negative beliefs, positive beliefs, idleness, weight control and family issues. Internal consistency of items in negative beliefs, positive beliefs, idleness, weight control and family issues were 0.88, 0.62, 0.62, 0.72 and 0.53, respectively. Greater negative beliefs was inversely correlated with positive beliefs but positively associated with idleness, weight control and family issues. Concurrent users and khat-only users had lower scores on negative beliefs than non-users. Concurrent users had higher scores on positive beliefs than khat-only and non-users.

DISCUSSION AND CONCLUSIONS

These results provide initial support of the usefulness of the Khat Knowledge, Attitudes and Perception Scale.

Tobacco consumption and nicotine dependence in Bengo Province, Angola: A community-based survey

There is concern about the potentially increasing use of tobacco in Angola. However, information on the frequency and determinants of this use is not systematised. This study aimed to estimate the prevalence of tobacco consumption and nicotine dependence among smokers in an Angolan population and considering individual socio-demographic and behavioural characteristics. A community-based survey with 2,472 respondents (age range: 15-64 years) was conducted in 2013-2014 in the country's Bengo Province. The collection methodology for assessing each type of tobacco consumption and its daily quantification followed the World Health Organization STEPwise approach to chronic disease risk factor surveillance. The Fagerström Test for Nicotine Dependence was also used to assess smokers. Mean values for prevalence of tobacco use and nicotine dependence were estimated by sex and by previously defined variables. Daily smoking (6.1%) was found to be higher for males (10.0%) them among females (2.6%), and the amount of ex-smokers (7.5%) was higher them smokers. Only 0.2% of those surveyed reported use of smokeless (chewing) tobacco. One-third of ever-smokers reported having started smoking daily before age 18. Nicotine dependence levels were classified as very low or low in 83.6% of the smokers. Daily smoking prevalence increased with age, and was higher in rural areas and among individuals with no formal education, lower incomes, and alcohol consumption. This population presented a low smoking prevalence, along with a low number of daily smoked cigarettes and low levels of nicotine dependency, despite the low prices of, and easy access to, manufactured cigarettes. These two factors conjugated with the current absence of an Angolan policy for tobacco control, enhance the susceptibility for rising overall tobacco use in the near future.

Problematic khat use as a possible risk factor for harmful use of other psychoactive substances: a mixed method study in Ethiopia

BACKGROUND

Substance use disorders along with neuropsychiatric disorders contributed about 14% of the global burden of disease. Harmful alcohol use, is a known contributor for many harms (accidents, suicide, violence, and complication of other psychiatric and medical disorders). In the Western countries, alcohol and nicotine are gateway drugs to cannabis use, and cannabis use is a risk factor for other illicit drugs such as cocaine and heroin. Khat use is another psychoactive substance which is common in East African and Arabian Peninsula. But there is a knowledge gap regarding the position of khat use or problematic khat use in sequential progression of different psychoactive substances. Therefore, we aimed to understand and investigate the relationship of problematic khat use and other psychoactive substances in Ethiopia.

METHODS

Exploratory mixed methods study was employed. Quantitative cross sectional survey was done among 102 khat users, and 4 focus group discussions and 11 in-depth interviews were conducted to understand the pathways between khat use and other psychoactive substances use in 2014. Non random sampling (purposive and snowballing) was employed for both quantitative and qualitative studies. Khat users from khat cafeterias, shops, and from other open markets of khat in Addis Ababa were invited to participate.

RESULT

Currently significant majorities of khat users (86.3%) used at least one other psychoactive substance after they started khat use. The prevalence of harmful drinking was 53.9% among khat users. Problematic khat use was a significant predictor of harmful drinking (p < 0.05). About one from ten respondents engaged to risky sexual behavior pushed by the effect of khat after chewing.

CONCLUSION

The proportion of psychoactive substances use especially harmful drinking among khat users was observed higher compared to other cross sectional surveys conducted among general population. In Ethiopia, intervention and policy on harmful alcohol use could consider problematic khat use as one possible risky factor. A rigorous methodology which could test gateway hypothesis of problematic psychoactive substances use could be warranted.

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.

Stopping khat use: Predictors of success in an unaided quit attempt

INTRODUCTION AND AIMS

Despite the adverse effects of khat use and chewers interest in cessation, there are few studies that have reported on the outcome of khat cessation attempts, and limited resources available for potential quitters. We used electronic diaries to monitor the outcomes of an unassisted quit attempt among daily and near daily khat consumers, and examine predictors of success.

DESIGN AND METHODS

Sixty participants between the ages of 18 and 35 years who regularly chewed khat and who were attempting to quit were purposively recruited from an Ethiopian University campus. Real-time prospective daily recording of khat use was obtained for an average of 10 days prior to quit day (range 6-13) and 28 post-quit days (range 9-31), using an electronic diary.

RESULTS

Almost all (95%) achieved initial abstinence. Of these, 80% reached at least seven continuous days of abstinence; 7% maintained continuous abstinence for 28 days post-quit. While 93% lapsed (average 11 days post-quit, SD = 7), only a smaller proportion relapsed (41%: chewed for at least three consecutive days after at least 5 days of abstinence). No demographic factors were predictive of successful abstinence.

DISCUSSION AND CONCLUSIONS

Regular khat chewers have difficulties in maintaining abstinence despite having motivation and desire to quit. This implies that treatment aids may be needed to assist chewers' in their quit attempts. Controlled experimental trial through the use of available low cost quit aids and behavioural resources is crucial in order to increase success rates for those seeking to desist from khat use.

Cultural translation of refugee trauma: Cultural idioms of distress among Somali refugees in displacement

Westernized approaches to mental health care often place limited emphasis on refugees' own experiences and cultural explanations of symptoms and distress. In order to effectively assess community mental health needs and develop interventions grounded in local needs, mental health programs need to be informed by an understanding of cultural features of mental health, including cultural idioms of distress (CIDs). The current study aims to explore CIDs among Somali refugees displaced in Kenya to understand mental health needs in cultural context and serve the community in a culturally responsive and sensitive manner. This research was conducted as a two-phase qualitative study. First, key informant interviews with Somali mental health stakeholders generated a list of 7 common Somali CIDs: buufis, buqsanaan, welwel, murug, qaracan, jinn, and waali. Typologies of each CID were further explored through four focus group interviews with Somali community members. The findings from a template analysis revealed Somali lay beliefs on how trauma and daily stressors are experienced and discussed in the form of CIDs and how each term is utilized and understood in attributing symptoms to associated causes. This study highlights the need to incorporate colloquial terms in mental health assessment and to adopt a culturally relevant framework to encourage wider utilization of services and religious/spiritual support systems.

Mephedrone and 3,4-Methylenedioxypyrovalerone (MDPV): Synthetic Cathinones With Serious Health Implications

This article presents information on the predominant synthetic cathinones used in the Western world, mephedrone and methylenedioxypyrovalerone (MDPV). Synthetic cathinones are commonly used drugs of abuse in the United States and Europe, with numerous cases of patient harm and death. Patients exhibit many neurological, cardiovascular, and muscular adverse events and frequently require therapy to control psychotic or agitated states and acute kidney injury resulting from myopathy or rhabdomyolysis. There are potential genetic polymorphisms and drug interactions that might accentuate risk, but there are no studies evaluating to what extent this occurs or if it is clinically relevant. Clinicians should be aware of the known pharmacology, pharmacokinetics, and reports of effects to detect potential issues and treat patients presenting with these adverse effects.

Cannabis use among Navy personnel in Sri Lanka: a cross sectional study

BACKGROUND

Prevalence of cannabis use among military populations vary. There is evidence that drug use is associated with combat exposure and PTSD. The objective of the study was to assess the prevalence of cannabis use among Sri Lanka Navy (SLN) personnel and to identify any relationship with cannabis use and combat exposure.

METHODS

This cross sectional study was carried out among representative samples of SLN Special Forces (Special Boat Squadron) and regular forces deployed in combat areas. Both Special Forces and regular forces were selected using simple random sampling. Personnel who had served continuously in combat areas during the 1 year period prior to end of combat operations were included in the study. Cannabis use was defined as smoking cannabis at least once during the past 12 months.

RESULTS

The sample consisted of 259 Special Forces and 412 regular navy personnel. Prevalence of cannabis use was 5.22% (95% CI 3.53-6.9). There was no significant difference in prevalence of cannabis use among Special Forces personnel compared to regular forces. Cannabis use was significantly higher in the age group 18-24 years [OR 4.42 (95% CI 2.18-8.97)], personnel who were never married [OR 2.02 (95% CI 0.99-4.12)], or had an educational level less than GCE O'Level [OR 4.02 (95% CI 1.17-13.78)]. There was significant association between cannabis use and hazardous alcohol use [adjusted OR 5.47 (95% CI 2.65-11.28)], PTSD [adjusted OR 4.20 (95% CI 1.08-16.38)], GHQ caseness [adjusted OR 2.83 (95% CI 1.18-6.79)] and multiple somatic complaints [adjusted OR 3.61 (95% CI 1.5-8.7)]. Cannabis use was not associated with smoking. Risk of cannabis use was less in those who had seen dead or wounded [adjusted OR 0.42 (95% CI 0.20-0.85)]. Experiencing hostility from civilians was the only combat exposure that significantly increased the risk of cannabis use [adjusted OR 4.06 (95% CI 1.06-15.56)].

CONCLUSIONS

Among Sri Lanka Navy personnel exposed to combat cannabis use was significantly associated with hazardous alcohol use but not smoking. PTSD and other adverse mental health outcomes were associated with an increased risk of cannabis use. Exposure to combat was not associated with increased risk of cannabis use.

Use of a bibliometric literature review to assess medical research capacity in post-conflict and developing countries: Somaliland 1991-2013

OBJECTIVES

Effective healthcare systems require high-quality research to guide evidence-based interventions and strategic planning. In low- and middle-income countries, especially those emerging from violent conflict, research capacity often lags behind other aspects of health system development. Here, we sought to bibliometrically review health-related research output in Somaliland, a post-conflict self-declared, autonomous nation on the Horn of Africa, as a means of assessing research capacity.

METHODS

We reviewed articles on health-related research conducted in Somaliland between 1991 and 2013 that included a description of the experimental design, and articles were published in either a peer-reviewed journal or as part of a scholarly programme receiving formal review. We did not include policy or social science research that did not enrol or interact with subjects from Somaliland. Using online databases, all studies meeting minimum eligibility criteria were reviewed in regard to Somaliland-based co-authorship, topic of research and specific measures of quality.

RESULTS

A total of 37 studies were included in this review. Of these, only 19 (51%) included co-authorship by Somaliland-based researchers. Of the 21 studies reporting ethical approval, 16 (64%) received approval from the Somalia or Somaliland Ministry of Health, while five received approval from a university or national commission. More than two-thirds of published research was limited to a few areas of investigation with most (19, 51%) following basic cross-sectional study designs. The number of articles published per year increased from 0 to 1 in the years 1991-2007 to a maximum of 8 in 2013.

CONCLUSIONS

Research activity in Somaliland is extremely limited. Investigators from high-income countries have largely directed the research agenda in Somaliland; only half of the included studies list co-authors from institutions in Somaliland. Leadership and governance of health research in Somaliland is required to define national priorities, promote scholarly activity and guide the responsible conduct of research. The methods used here to assess research capacity may be generalisable to other low- and middle-income countries and post-conflict settings to measure the impact of research capacity-building efforts.

Concurrent tobacco and khat use is associated with blunted cardiovascular stress response and enhanced negative mood: a cross-sectional investigation

OBJECTIVES

Khat (Catha edulis), an amphetamine-like plant, is widely used in East Africa and the Arabian Peninsula and is becoming a growing problem in other parts of the world. The concurrent use of tobacco and khat is highly prevalent and represents a public health challenge. We examined for the first time associations of the concurrent use of tobacco and khat with psychophysiological responses to acute stress in two sites in Yemen.

METHODS

Participants (N = 308; 135 women) included three groups: users of khat and tobacco, users of khat alone, and a control group (nonsmokers/nonusers of khat). These individuals completed a laboratory session in which blood pressures (BP), heart rate, and mood measures were assessed during rest and in response to acute stress.

RESULTS

Concurrent use of khat and tobacco was associated with attenuated systolic BP, diastolic BP, and heart rate responses to laboratory stress (ps < 0.05) and with increased negative affect relative to the control group (ps < 0.05).

CONCLUSIONS

Results demonstrated blunted cardiovascular responses to stress and enhanced negative affect in concurrent khat and tobacco users. These findings extend previous studies with other substances and suggest that adverse effects of khat use may lie in its association with the use of tobacco.

Khat Use, PTSD and Psychotic Symptoms among Somali Refugees in Nairobi - A Pilot Study

In East-African and Arab countries, khat leaves are traditionally chewed in social settings. They contain the amphetamine-like alkaloid cathinone. Especially among Somali refugees, khat use has been associated with psychiatric symptoms. We assessed khat-use patterns and psychiatric symptoms among male Somali refugees living in a disadvantaged urban settlement area in Kenya, a large group that has not yet received scientific attention. We wanted to explore consume patterns and study the associations between khat use, traumatic experiences, and psychotic symptoms. Using privileged access sampling, we recruited 33 healthy male khat chewers and 15 comparable non-chewers. Based on extensive preparatory work, we assessed khat use, khat dependence according to DSM-IV, traumatic experiences, posttraumatic stress disorder (PTSD), and psychotic symptoms using standardized diagnostic instruments that had been adapted to the Somali language and culture. Hazardous use patterns like chewing for more than 24 h without interruption were frequently reported. All khat users fulfilled the DSM-IV-criteria for dependence and 85% reported functional khat use, i.e., that khat helps them to forget painful experiences. We found that the studied group was heavily burdened by traumatic events and posttraumatic symptoms. Khat users had experienced more traumatic events and had more often PTSD than non-users. Most khat users experience khat-related psychotic symptoms and in a quarter of them we found true psychotic symptoms. In contrast, among control group members no psychotic symptoms could be detected. We found first evidence for the existence and high prevalence of severely hazardous use patterns, comorbid psychiatric symptoms, and khat use as a self-medication of trauma-consequences among male Somali refugees in urban Kenyan refugee settlements. There is a high burden by psychopathology and adequate community-based interventions urgently need to be developed.

Factors associated with Khat use among youths visiting HIV testing and counseling centers in Gamo Gofa, Southern Ethiopia

Background

The use of khat among youths can be harmful leading to decreased academic performance, increased risk of contracting HIV and other sexually transmitted diseases or other psychiatric symptoms. It is believed to be one of the factors associated with unprotected risky sexual behavior predisposing the youth for HIV infection and transmission.

Methods

A cross-sectional study was conducted in South West Ethiopia. A total of 410 participants were recruited in the study using stratified sampling technique. Data were collected by using interviewer administered structured questionnaire. Multiple logistic regression and Cox regression were used to assess the association of independent variables with the outcome variable.

Result

Khat use was positively associated with male gender (OR 2.9; C.I. 1.4 to 6.0), alcohol use (OR 4.8; C.I. 2.1 to 10.6), no education level (OR 2.6; C.I. 1.1 to 6.2) and not having communication with parents about khat chewing (OR 2.6; C.I. 1.1 to 6.2).

Conclusion

Strategies should be designed to increase awareness of factors associated with khat use among youths and their parents in order to reduce the prevalence of khat use and its adverse social and health consequences.

Khat chewing habit among school students of Jazan region, Saudi Arabia

BACKGROUND

The use of Khat leaves (Catha edulis) in Jazan, southwest of KSA, is prevalent among all segments of the population.

OBJECTIVE

This study was conducted to assess the prevalence and predictors of Khat chewing among intermediate and secondary school students of Jazan region.

METHODOLOGY

A cross-sectional survey was conducted in late 2011 in Jazan region. A random sample of 3923 students was selected from 72 intermediate and upper secondary schools representing the different educational sectors of the region. A structured self-administered questionnaire was used for data collection. Descriptive statistics, a chi-squared test and logistic regression were performed to examine the prevalence, associations and predictors of Khat chewing.

RESULT

The overall Khat chewing prevalence among students was 20.5% (95% C.I.: 19.27-21.79). The prevalence was significantly higher among males, at 33.1% (95% CI: 31.16-35.08), than among females 4.3% (95% C.I.: 3.39-5.31) ( P <0.001). Univariate analysis revealed that gender, age, academic performance, friends' smoking and Khat chewing, and students' smoking status were associated with a significantly high risk of Khat chewing ( P <0.001 for all). The multivariate logistic regression analysis suggested that the most important independent predictors of Khat chewing among the students in our sample were students' smoking status (OR = 13.02, P <0.001), friends' use of Khat (OR = 5.65, P <0.001), gender (OR = 4.62, P <0.001), and friend's use of tobacco (OR = 1.43, P <0.001).

CONCLUSION

A significant percentage of students chew Khat. The abuse of Khat is significantly associated with gender, peer influence, and cigarette smoking. Intervention programs are needed to create awareness among school students and to reduce the prevalence of the habit and its unfavorable consequences.

Does perpetrating violence damage mental health? Differences between forcibly recruited and voluntary combatants in DR Congo

As a consequence of the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are constantly involved in various forms of violence. Findings concerning the impact of perpetrating violence on mental health are contradictory, ranging from increasing to buffering the risk for mental ill health. The present study investigated the impact of perpetrating violence on mental health. In total, 204 forcibly recruited and voluntary male combatants (mean age = 24.61 years) from different armed groups in the eastern DRC took part in the study. In a semistructured interview, respondents were questioned about appetitive aggression and posttraumatic stress disorder (PTSD) as well as self-experienced violence and self-perpetrated violent offending. A multivariate analysis of variance (η(2) = .23) revealed that voluntary combatants perpetrated more violent acts (η(2) = .06) and showed higher appetitive aggression η(2) = .03). A moderated multiple regression analysis (R(2) = .20) showed that perpetrating violence was positively related to PTSD in forcibly recruited combatants, but not in voluntary combatants. Thus, perpetrating violence may not necessarily qualify as a traumatic stressor. Further studies might consider assessing the combatant's perception of committing violent acts.

Effects of chronic khat use on cardiovascular, adrenocortical, and psychological responses to stress in men and women

BACKGROUND

Khat is a psychostimulant plant widely used in Africa and its use has been growing rapidly in Europe and North America.

OBJECTIVES

We investigated effects of chronic khat (Catha edulis) use on cardiovascular, adrenocortical, and psychological responses to acute stress.

METHODS

Chronic khat users and nonusers were compared on physiological measures and mood reports in a cross-sectional, mixed design. Measurements were conducted during 24-hour ambulatory monitoring and during a laboratory session. A total of 152 participants (58 women) were recruited by flyers posted around Sana'a University campus and the surrounding community in Sana'a, Yemen. Salivary cortisol and self-report measures were collected during a 24-hour ambulatory period prior to a lab testing session. In addition, blood pressures (BP), salivary cortisol, and mood measures were assessed during rest and in response to acute mental stress.

RESULTS

Khat users exhibited enhanced evening and attenuated morning cortisol levels, reflecting a blunted diurnal pattern of adrenocortical activity compared to nonusers. Khat users reported greater negative affect during the ambulatory period and during the laboratory session. In addition, they exhibited attenuated BP responses to stress.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These novel results demonstrate altered adrenocortical activity and increased dysphoric mood among khat users. The extent to which these associations are due to effects of chronic khat use per se or instead reflect predisposing risk factors for khat use is yet to be determined.

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.

Prevalence and determinants of khat (Catha edulis) chewing among high school students in eastern Ethiopia: a cross-sectional study

BACKGROUND

Use of psychoactive drugs such as khat leaves (Catha edulis) alter moods and emotional state and lead to adverse effects on the health and social life of users. Ethiopia is a major producer and exporter of khat in east Africa and the majority of the khat comes from the eastern part of the country, however, no studies have been conducted to investigate the habit in this area. This study was conducted to assess the prevalence and predictors of khat chewing among high school students in Harar, eastern Ethiopia.

METHODOLOGY

The study was conducted among 1,890 secondary school students in Harar town in April 2010. A structured self-administered questionnaire was used for data collection. Descriptive statistics and logistic regression were performed to examine the prevalence and predictors of khat chewing.

RESULT

The overall prevalence of khat chewing among the sample was 24.2% (95% CI 22.2%-26.2%). About 28.5% of females and 71.5% of males had chewed khat. Older age (OR 1.31; 95% CI 1.16-1.49), male gender (OR 2.10; 95% CI 1.50-2.93), Muslim religion (OR 1.88; 95% CI 1.17-3.04), having friends who chewed khat (OR 7.93; 95% CI 5.40-11.64), and availability of someone with a similar habit in the family (OR 1.50; 95% CI 1.07-2.11) were found to be independent predictors of chewing.

CONCLUSION

A significant proportion of students chew khat. The use of khat is significantly associated with age, gender, Muslim religion, peer influence and habit of family and other relatives among students. Measures such as educational campaigns need to be instituted to create awareness among school adolescents and their parents in order to reduce the prevalence of the habit and its adverse social and health consequences.

Exposure to violence and PTSD symptoms among Somali women

Posttraumatic stress disorder (PTSD) symptoms, exposure to traumatic stressors, and health care utilization were examined in 84 women attending a primary health care clinic in Mogadishu, Somalia. The Somalia-Posttraumatic Diagnostic Scale was used in this active warzone to measure symptoms. Nearly all women reported high levels of confrontations with violence; half described being exposed to a potentially traumatizing event. Nearly one third had significant PTSD symptoms. Compared to those who did not, women who reported exposure to a traumatic stressor reported more confrontations with violence (7.1 vs. 3.3; p < . 001), health complaints (3.8 vs. 2.9; p = .03), and nearly 3 times as much (p = .03) health service utilization. A potentially traumatizing event was found to be a simplified proxy for assessing mental health distress in women attending a primary health care facility in highly insecure, unpredictable, resource-limited settings.

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.

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.

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.

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.

Trauma, khat and common psychotic symptoms among Somali immigrants: a quantitative study

AIM OF THE STUDY

To investigate the relationship between (i) khat use and (ii) traumatic events, with measures of common psychotic symptoms and symptoms of anxiety and depression. To undertake this work in a Somali population of emigrants who have sought asylum in a non-conflict zone country.

MATERIALS AND METHODS

A secondary analysis of data on a population sample of 180 Somali men and women.

RESULTS

Frequency of khat use was not associated with common psychotic symptoms or with symptoms of anxiety and depression, nor with traumatic events in this population. Traumatic events were related to low levels of psychotic symptoms and high levels of symptoms of anxiety and depression.

CONCLUSIONS

Khat use is not inevitably linked to psychotic symptoms in population samples of Somali men and women. The contrasts between these findings and those from studies in conflict zones and studies of people with mental health problems using khat suggest further investigations are necessary. These should take into account environmental and physiological interactions.

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.

Antismoking messages and current cigarette smoking status in Somaliland: results from the Global Youth Tobacco Survey 2004

BACKGROUND

Tobacco is a leading cause of death globally. There are limited reports on current cigarette smoking prevalence and its associated-antismoking messages among adolescents in conflict zones of the world. We, therefore, conducted secondary analysis of data to estimate the prevalence of current cigarette smoking, and to determine associations of antismoking messages with smoking status.

METHODS

We used data from the Somaliland Global Youth Tobacco Survey (GYTS) of 2004 to estimate the prevalence of smoking. We also assessed whether being exposed to anti-smoking media, education and having discussed with family members on the harmful effects of smoking were associated with smoking. Logistic regression analysis was used to assess these associations. Current smoking was defined as having reported smoking cigarettes, even a single puff, in the last 30 days preceding the survey (main outcome).

RESULTS

Altogether 1563 adolescents participated in the survey. However, 1122 had data on the main outcome. Altogether, 15.8% of the respondents reported having smoked cigarettes (10.3% among males, and 11.1% among females). Factors that were associated with reported non-smoking were: discussing harmful effects of smoking cigarettes with their family members (OR = 0.61, 95% CI 0.52, 0.71); being taught that smoking makes teeth yellow, causes wrinkles and smokers smell badly (OR = 0.62, 95% CI 0.52, 0.74); being taught that people of the respondent's age do not smoke (OR = 0.81, 95% CI 0.69, 0.95); and having reported that religious organizations discouraged young people smoking (OR = 0.70, 95% CI 0.60, 0.82). However, exposure to a lot many antismoking messages at social gatherings was associated with smoking. Exposure to antismoking print media was not associated with smoking status.

CONCLUSION

A combination of school and home based antismoking interventions may be effective in controlling adolescent smoking in Somaliland.

Drug consumption in conflict zones in Somalia

The authors discuss the public health implications of a new study on the use of khat and other drugs by Somali combatants.