Khat and health Facts, Addiction effects and Health

Implications Dr. Jibril I.M Handuleh, MBBS

Assistant Clinical Lecturer in PsychiatryAmoud University Mental Health Initiative Lead

Amoud UniversityBorama, Somalia

Learning Objectives

• At the end of this session participants should be able to:

Define substance dependence and abuse Define Qat and its effects on healthRecognize signs and symptoms of khat related

mental health conditionsUnderstand Qat related mental health problems in

Borama, Somalia and among Somali diaspora

Amoud University-THET- King’s College London Mental Project

2011• Outpatient service• Community based Psychiatry• School mental health • Maternal mental health • Forensic(legal) Psychiatry

New scopes-planned for 2012-13 Amoud University

• Child and adolescent mental health friendly clinic

•Khat clinic-the first in Somalia to open in November 2012!

Khat• A stimulant plant Catha delis, mainly grown in

Ethiopia, Kenya, Yemen, Somalia, Sudan,& Madagascar.

• In ancient times, it was used for relieving the symptoms of depression.

• The young bud of leaves contain amphetamine like substances

• Cathinone - α aminopropiophenone • Cathine – D- norpseudoephedrine

Why might people use Khat?• To enhance social interaction • To help concentrate during prayers• Other reasons include: to improve

performance, stay alert and to increase work capacity

• Students chew khat in an attempt to improve mental performance before exams.

• Yemeni khat chewers for minor ailments such as headaches, colds, body pains, fevers, arthritis and also depression

Effects of khat

• Modes of action: enhance dopamine and norepinephrine in the brain

• Subjective experiences: euphoria, excitement, increased energy levels, increased alertness, increased ability to concentrate, improvement in self-esteem and an increase in libido.

• Unpleasant after effects: insomnia, numbness, lack of concentration, low mood

Effects of khat (2)

Objective signs:• Minor reactions - over-talkativeness,

overactivity, insomnia, anxiety, irritability, agitation and aggression.

• Serious reactions – Schizophreniform psychosis– Manic like episode

IS QAT A SUBSTANCE ABUSE OR A HABIT?

What is substance abuse?

• Clear evidence use Physical or Psychological harm

– Failure to fulfil major obligations

– Recurrent use leading to physical dangers

– Recurrent legal problems

– Social or interpersonal problems

What is substance dependence?Three or more of the following occurring in the same 12

month period 1. Tolerance:

– a need for markedly increased amounts of the substance – markedly diminished effect with continued use of the

same amount of the substance 2. Withdrawal:

– the characteristic withdrawal syndrome for the substance– the same (or a closely related) substance is taken to

relieve or avoid withdrawal symptoms

What is substance dependence? (2)

3.Loss of control over use

4.Compulsive use

5.Long time spent on obtaining & using it

6.Giving up important activities

7.Continued use despite hazard to health

Khat and the other health problems

• Gastrointestinal- oral cancers ,ulcers, constipation, liver diseases, GIT cancers

• Cardiovascular – irregular heart beats , heart attacks, hypertension

• CNS- strokes • Impotence• Co morbid conditions- Diabetes, other substances, smoking etc.

Drug of abuse

• WHO classified it into substance I abuse in 1980.

• It is illegal in many countries • Legal in East Africa and Yemen

Borama mental health and Qatcase example from Somalia

• Qat contributes to mental health disorders• It reduces medication compliance• Exacerbates mental health disorders• Usual presentations : paranoid, mania,

anxiety like features, depression and general health problems

• They only respond to depots

• Higher expenditure on medications compared to others

• Longer stay in rehabilitation• They tend to come back to illness• Families have tremendous burden with

patients having Qat as a cause of their sickness.

• Poor response to medications

How common is Qat?

Common addictions in Somalia

Mental health disorders-Borama community Outreach

2011-2012

PATIENT WITH QAT INDUCED PSYCHOSIS

AMOUD MENTAL HEALTH PROJECT GLOBAL MENTAL HEALTH PARTNERSHIP

Dr. Jibril Handuleh1 and Dr. Susannah Whitwell2 health

1Amoud Mental Health Project, 2South London and Maudsley NHS Foundation Trust

METHODS RESULTS

ACKNOWLEDGMENTS

We thank to the deans of Amoud medical and Amoud Nursing schools, all the colleagues in KTSP mental health group and the nurses /social workers in Borama and all who have offered assistance to the project.

The objective of the project was to establish mental health services in Borama that previously had no psychiatric services. Amoud teaching hospital intended to develop clinical and education support for psychiatry

The Amoud mental health had outstanding results even outside our project targets and they include

• Outpatient treatment of over 500 mentally ill clients within the first six months• 2 training sessions for nurse tutors • 2 training sessions for midwives on maternal mental health• 1 training on school mental health for school teachers in working with ministry of

education office in Borama.• 3 training sessions for prison authorities on forensic mental health• Treating of inmates in prison• Community mobile clinics to reach out poor people who had no access to care

people from the war torn South-Central Somalia.• Borama local government , Amoud University, Borama hospital director, Borama

Diaspora communities in Denmark and Norway sponsored mental health unit in Borama hospital

FURTHER ACTIVITIES

The 2 nurses and two doctors working in the project continue to receive mental health e-supervision from KTSP volunteers through www.medicineafrica.com

In Borama , the mental health project was able to introduce outpatient service , community outreach and working mental health unit in the teaching hospital within a year which shows how a partnership in global health can make difference.

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Sh.Osman

Halane

Sheeddheer

Ahmed Gurey

The Amoud mental health project is a novel project that established mental services in Borama, Somaliland as a global mental health partnership linking Amoud University teaching hospital and the King’s THET Somaliland Partnership (KTSP). The project is designed and implemented by Amoud University with academic support from King’s and financial assistance from THET. It was the first time people of Borama got access to mental health care

Fig 4: patients seen between May and November 2011 in Borama

The project was designed in December 2010 by the project manager working with KHP team to establish educational and patient care service. The components of this project were

•Outpatient mental health unit•Forensic mental health service in Borama prison•Maternal mental health service• Mobile community team• Outreach school mental health awareness program in Borama high schools

Dr Jibriil Handuleh’s experience of setting up this service

“I had to set up this project to get service for Borama residents who had to travel to distant location to receive mental health service.

The secret of achieving this project comes from the fact I got local community support , Amoud medical school commitment and the dedication from the KTSP team.As a junior doctor, the mental health project manager heavily relied on the KTSP support and guidance during the proposal to the project implementation.

Community people who assisted with project included women association, religious leaders , local government of Borama and academics from different fields at Amoud University in the set up of the service”

Fig1: King’s THET Somaliland Partnership

CONCLUSIONS

Fig2: Midwives learning about psychiatry

Fig3: Dr Jibril with clients in the mental health outpatient unit

INTRODUCTION

Somali diaspora

• The Somali community in commonly consume Qat in the west.

• It is related to mental illness in that community. They also use other illicit substances like cocaine etc

• Lots of crime and law enforcement contact• Somalis, second minority group with highest

number of inmates in Britian, 2012.

Research on Qat in Somalia and on Somalis globally

• There are several papers written on Qat and its mental health problems

• Khat is actively written in many countries particularly in Europe, North America, Asia and in Africa.

Some papers on khat 1.Mental disorders among Somali refugeesDeveloping culturally appropriate measures and assessing socio-cultural risk factors• Kamaldeep Bhui, Tom Craig, Salaad Mohamud, Nasir Warfa, Stephen A. Stansfeld,

Graham Thornicroft,Sarah Curtis and Paul McCrone2.Traumatic events, migration characteristics and psychiatric symptoms among Somali refugeesPreliminary communication• Kamaldeep Bhui, Abdisalama Abdi, Mahad Abdi, Stephen Pereira,

Mohammed Dualeh, David Robertson,Ganesh Sathyamoorthy and Hellena Ismail3.Khat use as risk factor for psychotic disorders: a cross-sectional and case-control

study in Somalia.• Odenwald M, Neuner F, Schauer M, Elbert T, Catani C, Lingenfelder B, Hinkel

H, Häfner H, Rockstroh B.

Acknowledgements

• Maskaxmaal Reading Club, Borama,Somaliland, Northern Somalia

• Amoud University, Somalia • Borama Hospital, Somalia• Patients & Qat dealers who agreed their

photos for the presentation• Towfiq community volunteers, Somalia

Where Qat addicts may end up !

Thanks for listening