Khat and health Facts, Addiction effects and Health Implications

Dr. Jibril I.M Handuleh, MBBSAssistant Clinical Lecturer in PsychiatryAmoud University Mental Health Initiative LeadAmoud UniversityBorama, Somalia

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Learning ObjectivesAt 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- Kings College London Mental Project 2011Outpatient serviceCommunity based PsychiatrySchool mental health Maternal mental health Forensic(legal) Psychiatry

New scopes-planned for 2012-13 Amoud University

Child and adolescent mental health friendly clinicKhat clinic-the first in Somalia to open in November 2012!

KhatA 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 - aminopropiophenone

Cathine D- norpseudoephedrine

Why might people use Khat?To enhance social interaction To help concentrate during prayersOther reasons include: to improve performance, stay alert and to increase work capacityStudents 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 khatModes of action: enhance dopamine and norepinephrine in the brainSubjective 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 psychosisManic 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 obligationsRecurrent use leading to physical dangersRecurrent legal problemsSocial or interpersonal problems

What is substance dependence?Three or more of the following occurring in the same 12 month period Tolerance: a need for markedly increased amounts of the substance markedly diminished effect with continued use of the same amount of the substance

Withdrawal: the characteristic withdrawal syndrome for the substancethe same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

What is substance dependence? (2)Loss of control over useCompulsive use Long time spent on obtaining & using itGiving up important activitiesContinued use despite hazard to health

Khat and the other health problemsGastrointestinal- oral cancers ,ulcers, constipation, liver diseases, GIT cancersCardiovascular irregular heart beats , heart attacks, hypertensionCNS- strokes ImpotenceCo morbid conditions- Diabetes, other substances, smoking etc.

Drug of abuseWHO 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 disordersIt reduces medication complianceExacerbates mental health disorders Usual presentations : paranoid, mania, anxiety like features, depression and general health problemsThey only respond to depots

Higher expenditure on medications compared to othersLonger 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

Chart1

45212110

36161214

29121711

96112

53185

7451

13642

3211

12132

401135

0021

Sh.Osman

Halane

Sheeddheer

Ahmed Gurey

Sheet1

Sh.OsmanHalaneSheeddheerAhmed Gurey

Schizophrenia45212110

Bipolar disorder36161214

Depression29121711

Acute Psychosis96112

Qat induced Psychosis53185

Anxiety disorders7451

Childhood disorders13642

Delirium3211

Dementia12132

Epilepsy401135

Organic Psychosis0021

Source: Amoud mental health project*

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

METHODSRESULTS

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 includeOutpatient treatment of over 500 mentally ill clients within the first six months2 training sessions for nurse tutors 2 training sessions for midwives on maternal mental health1 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 healthTreating of inmates in prisonCommunity 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 ACTIVITIESThe 2 nurses and two doctors working in the project continue to receive mental health e-supervision from KTSP volunteers through www.medicineafrica.comIn 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.

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 Kings THET Somaliland Partnership (KTSP). The project is designed and implemented by Amoud University with academic support from Kings and financial assistance from THET. It was the first time people of Borama got access to mental health careFig 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 unitForensic mental health service in Borama prisonMaternal mental health service Mobile community team Outreach school mental health awareness program in Borama high schools

Dr Jibriil Handulehs 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: Kings THET Somaliland Partnership

CONCLUSIONSFig2: Midwives learning about psychiatry Fig3: Dr Jibril with clients in the mental health outpatient unitINTRODUCTION

Chart1

45212110

36161214

29121711

96112

53185

7451

13642

3211

12132

401135

0021

Sh.Osman

Halane

Sheeddheer

Ahmed Gurey

Sheet1

Sh.OsmanHalaneSheeddheerAhmed Gurey

Schizophrenia45212110

Bipolar disorder36161214

Depression29121711

Acute Psychosis96112

Qat induced Psychosis53185

Anxiety disorders7451

Childhood disorders13642

Delirium3211

Dementia12132

Epilepsy401135

Organic Psychosis0021

THET CONFERENCE LONDON 2012- THE SUCCESS STORY OF BORAMA POSTER FROM BORAMA AT IMPERIAL COLLEGE LONDON*

Somali diasporaThe 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 contactSomalis, 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 factorsKamaldeep Bhui,Tom Craig,Salaad Mohamud,Nasir Warfa,Stephen A. Stansfeld,Graham Thornicroft,Sarah CurtisandPaul McCrone

2.Traumatic events, migration characteristics and psychiatric symptoms among Somali refugeesPreliminary communicationKamaldeep Bhui,Abdisalama Abdi,Mahad Abdi,Stephen Pereira,Mohammed Dualeh,David Robertson,Ganesh SathyamoorthyandHellena Ismail

3.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,Hfner H,Rockstroh B.

AcknowledgementsMaskaxmaal Reading Club, Borama,Somaliland, Northern SomaliaAmoud University, Somalia Borama Hospital, SomaliaPatients & Qat dealers who agreed their photos for the presentationTowfiq community volunteers, Somalia

Where Qat addicts may end up !

Thanks for listening

*Source: Amoud mental health project*THET CONFERENCE LONDON 2012- THE SUCCESS STORY OF BORAMA POSTER FROM BORAMA AT IMPERIAL COLLEGE LONDON*