A study on Khat use among Somalis.

[OdaySomali]

Use of khat and posttraumatic stress disorder as risk factors for psychotic symptoms: A study of Somali combatants.

Journal of Social Science & Medicine. Vol. 69 (2009), pp. 1040–1048.

Michael Odenwald, Harald Hinkel, Elisabeth Schauer, Maggie Schauer, Thomas Elbert, Frank Neuner and Brigitte Rockstroh.

 

The chewing of the khat leaves, which contain the amphetamine-like cathinone, is a traditional habit in

Somalia. Our objective was to explore the effects of khat use and Posttraumatic Stress Disorder (PTSD) on

paranoid symptoms and to test a potential causal chain. We report on a cross-sectional study in Somalia

that was conducted in 2003. Trained local staff interviewed 8723 personnel of armed groups in seven

regional convenience samples. Of them, 8124 were included in the analysis. We assessed current khat

use, PTSD symptoms, functional drug use and paranoid ideation using items from the Composite

International Diagnostic Interview (CIDI) and the Somali version of the Posttraumatic Stress Diagnostic

Scale (PDS). Applying the causal steps approach, in a series of logistic regression models, we used PTSD as

independent and paranoia as outcome variable; the quantity of khat use was defined as mediator

variable and functional drug use as moderator. The results showed that respondents with PTSD used khat

more frequently. Khat chewers with PTSD reported a higher intake compared to khat chewers without

PTSD. Among excessive khat chewers with PTSD, paranoia was most frequent. The greatest amount of

khat use was among respondents with PTSD who indicated that they found drugs help them to forget

war experiences. The proposed mediated moderation model was supported by the data, i.e. besides the

direct effects of PTSD and functional drug use on paranoia, the amount of khat use appeared to be

a mechanism, by which paranoia is caused. We conclude that in our data we have uncovered a relationship

between khat, PTSD and paranoia. Khat is functionally used by respondents with PTSD. Findings

support a dose effect: the more khat consumption and when a respondent has PTSD, the higher the odds

for paranoid ideation. However, the proposed causal chain needs to be confirmed in longitudinal studies.

Demobilization and reintegration programs in Somalia need to be prepared to deal with complex

psychological problems.

 

Amphetamine-type drugs are an especially dangerous type of

substance to be functionally used to cope with stress or PTSD. They

have been shown to induce psychotic symptoms in experimental

settings in humans (Bell, 1973) and animals (Kalivas & Stewart,

1991) and they exacerbate psychotic states in psychiatric patients

(Angrist, Rotrosen, & Gershon, 1980). These drugs induce lasting

changes in the brain and in behavior (Baicy & London, 2007).

Amphetamine-type stimulants and stress lead to cross-sensitization

in animal models for psychosis (Kalivas & Stewart,1991). Crosssensitization

of amphetamine use and stress to the re-emergence of

psychotic symptoms has recently been identified among humans in

a highly controlled prison environment (Yui et al., 2001). Also khatinduced

psychotic states have been described in over 20 case

reports (Warfa et al., 2007) and, recently, community-based studies

showed that khat use is associated with severe psychiatric problems

(Bhui et al., 2006). Furthermore, khat use has been identified

by caretakers as one of the main cause of relapse among psychotic

patients in Ethiopia (Bimerew, Sonn, & Korlenbout, 2007). While

moderate khat chewing may elicit psychotic symptoms only in

especially vulnerable individuals, excessive and prolonged use

seems to be noxious particularly when started early in life (Advisory

Council on the Misuse of Drugs, 2005). Excessive abuse has

become a common phenomenon among combatants in Somalia

during the course of the ongoing conflict (Odenwald, Hinkel, et al.,

2007). In a cross-sectional study in Hargeisa, Somaliland, 16% of

former combatants were severely impaired in their everyday

functioning due to psychiatric problems, consisting mostly of

 

psychotic disorders and associated excessive khat abuse (Odenwald

et al., 2005). This study revealed a significant relationship between

the amount of khat use and the number of traumatic events

experienced. In another study with 64 Somali ex-combatants, we

found a prolonged khat use among respondents with PTSD and that

8 of 14 individuals with PTSD also had co-morbid psychotic features

(Odenwald, Lingenfelder, et al., 2007). In this context, it is important

to acknowledge that a substantial number of ex-combatants

with PTSD have secondary co-morbid psychotic symptoms, which

mostly consist of auditory hallucinations, paranoid and referential

delusions and which are related to more severe PTSD symptoms

and to more behavioral problems (Braakman, Kortmann, & van den

Brink, 2009). Recently, early trauma exposure was identified as

a risk factor for the development of schizophrenia and PTSD was

linked to the development of psychosis on different levels (Seedat,

Stein, Oosthuizen, Emsley, & Stein, 2003). Studies on the effects of

stimulant use on co-morbid psychotic features among individuals

with PTSD are lacking.

Methods

Design, sampling and participants

 

Our data originate from a study among personnel of armed

groups, which was conducted as a small part of a preparatory

 

Given that the

country remains in armed conflict, it was not possible to apply

random sampling methods. Thus, we drew seven large convenience

samples in seven parts of the country. The use of convenience

samples does not allow for the estimation of biases, and thus

prevalence estimates must be interpreted with caution. However,

in this study we assumed that selection biases would still allow us

to study the associations of variables.

The seven parts of Somalia with the highest estimated military

staff density were selected for interviews, including major population

centers and rural areas: In the North of Somalia, we included

Somaliland and Puntland; in central Somalia, Hiran; and in southern

Somalia Bay/Bakol, Mogadishu and Kismayo. Mogadishu was

divided in two samples according to the ‘‘green line,’’ which divided

the town between main factions at the time of the interviews.

Mogadishu South included the Lower Shabelle region with the town

of Merka. For a more detailed description of sampling methods,

please refer to Odenwald, Hinkel, et al. (2007). In every region, we

aimed to assess a minimum of 600 respondents, including as many

factions and armed groups as possible, with the request that

a minimum of one unit within the overall structure be completely

assessed. We had no access to basic information concerning the

units (e.g. actual size of units) chosen for this assessment.

Interviews were conducted between August and December

2003. The interviewers went directly into a compound used by the

respective militia or units to conduct the individual interviews in

a place that provided as much privacy as possible, e.g. in a separate

room.

 

Respondents’ socio-demographic characteristics are reported in

Table 1. In our sample, we had 882 women (10.9%) and 7242 men

(89.1%). 758 of the women were from northern Somalia (85.9%). On

average they were 37.312.6 years of age and 67.5% were married.

Less than half of them had completed primary education and even

less had received any vocational training. Only about two thirds

reported combat experience.

 

Khat chewing during the last week was reported by 2955

participants (36.4%, 99% CI 35.0%–37.8%). Khat chewing was

reported more frequently in the South of the country (26.2%, 99% CI

24.4–27.6 vs. 50.7%, 99% CI 47.8–52.2; p <.001). Only 12 women

(1.4%, 99% CI 0.3–2.3) in contrast to 2943 men (40.6%, 99% CI 38.5–

41.5) reported khat use in the previous week (p< .001), three of

them in northern Somalia. On average, participants consumed

3.6 8.3 bundles of khat in the previous week (99% CI 3.4–3.8). The

12 khat chewing women, had consumed the same amount of khat

as male chewers in the week before the interview (female vs. male:

12.8 19.1, 99% CI 0.0–27.0 vs. 9.7 11.3, 99% CI 9.2–10.2; p ¼ .907).

 

PTSD was found in 456 subjects (5.6%, 99% CI 4.9–6.3); in the

North of the country, PTSDwas seldomly found (2.1%, 99% CI 1.5–2.5

vs. 10.6%, 99% CI 9.5–12.5; p< .001). Only 16 females were found

with PTSD (female vs. male: 1.8%, 99% CI 0.7–3.0 vs. 6.1%, 99% CI

5.3–6.7; p< .001). Of them, 4 were from the North. Khat chewing

was more frequent among subjects with PTSD (66.2%; 99% CI 60.5–

71.9 vs. 34.6%, 99% CI 28.8–40.4; p <.001), and khat chewers with

PTSD consumed higher quantities than khat chewers without PTSD

(18.8 16.3 bundles, 99% CI 16.8–20.8 vs. 8.7 ,10.2, 99% CI 8.4–9.0;

p <0.001).

 

Paranoid ideation was found in 396 respondents (4.9%, 99% CI

4.3–5.5). In the North, we found paranoid ideation more seldomly

(1.8%, 99% CI 1.3–2.3 vs. 9.2%, 99% CI 7.8–10.4; p < .001). Only 12

female respondents reported paranoid ideation, less than among

males (1.4%, 99% CI 0.3–2.3 vs. 5.3%, 99% CI 4.6–6.0; p< .001).

Among respondents with PTSD, this rate was 26.1% (99% CI 20.8–

31.4), among those without PTSD it was 3.6% (99% CI 3.0–4.2;

p <.001). Among khat chewers, this rate was with 8.9% (99% CI 7.5–

10.3) higher than among non-khat chewers (2.6%, 99% CI 2.0–3.2;

p <.001).

 

[OdaySomali]

In total, 1577 subjects (19.4%, 99% CI 17.9–20.1) affirmed that

khat or other drug use would help to forget their stressful war

experiences. This proportion was smaller in the North of the

country (5.3%, 99% CI 4.5–6.1 vs. 39.3%, 99% CI 36.8–41.1; p <.001).

Of them, 18 were female (female vs. male: 2.0%, 99% CI 0.8–3.2 vs.

21.5%, 99% CI 19.8–22.2; p< .001). Among all respondents, subjects

with PTSD (456) more frequently indicated that khat or drugs help

them to forget stressful war experiences compared to subjects

without PTSD (7667; 77.6%, 99% CI 91.9–82.1 vs. 16.0%, 99% CI 13.9–

16.1; p< .001). This was also the case if we restricted our analysis to

only those respondents with lifetime combat exposure (5286;

79.7%, 99% CI 73.5–84.5 vs. 22.3%, 99% CI 20.5–23.5; p < .001), to

current khat users (2.955; 95.3%, 99% CI 91.8–98.2 vs. 40.5%, 99% CI

37.6–42.5; p <.001) or to current khat users with lifetime combat

exposure (2261; 96.0%, 99% CI 92.8–99.2 vs. 48.6%, 99% CI 45.1–

50.8; p < .001).

 

We report on a large cross-sectional study with personnel of

armed groups in Somalia, which uncovered the effects of khat

use and PTSD on psychotic symptoms in ex-combatants. Our data

support the hypothesis that PTSD and khat use have distinguishable

effects on paranoia. This result contradicts the opinion

among experts who argue that in studies with khat using

migrants all psychopathology can be explained by exposure to

stress (Pennings et al., 2008). Our data furthermore support the

hypothesis that PTSD causes the use of higher quantities of khat.

The increasing quantity of khat use appears to be one possible

mechanism by which paranoia is caused, but especially among

those individuals with PTSD, who functionally use it to cope with

unpleasant emotions and symptoms. However, our data stem

from a cross-sectional study and cannot be considered a proof of

this specific causal chain that we proposed. Our data can be

interpreted in the light of several possible causal chains, e.g.

alternatively that paranoid individuals use khat in order to

maintain themselves alert, as this is one of the traditional functions

of khat use during religious ceremonies. However, based on

the literature review above, we believe that the most plausible

direction of causality is that paranoia is the outcome and PTSD

and khat use increase its risk. Still, several hypothesis are

possible within this causal chain, e.g. is it only because of their

higher khat use that they are more likely to develop psychotic

symptoms or because PTSD renders individuals more vulnerable

for the psychotomimetic effects of khat? These different possible

causal hypotheses should be tested against each other in future

qualitative and quantitative studies, including experimental and

longitudinal designs. The numeric values of all point estimates

must be interpreted with caution because we only used

screening instruments and the sampling methods that were used

would not allow for estimation of biases.

 

Our findings are in line with a general ‘dose-response effect’

hypothesis, i.e. an increased risk for the development of paranoia

exists in subjects with PTSD and further increases when more khat

is consumed. Our findings are in accordance with the literature, as

excessive khat use has previously been found to promote psychotic

disorders (Odenwald, 2007;Warfa et al., 2007) and PTSD may have

co-morbid psychotic features (Braakman et al., 2009). Furthermore,

it is consistent with our previous work, which already had suggested

the possibility of an association between khat use, trauma

and psychosis (Odenwald et al., 2005).

 

In the literature it is well ackowledged that in the Somali culture

the khat session per se is a source of social support to cope with

experienced trauma. Here we describe that khat itself is used to

cope with trauma. These data add another piece of evidence in

favor of the hypothesis that traditional patterns of khat consumption

have changed profoundly. Results indicate that khat use has

a new function, i.e. to modify emotions related to experienced wartrauma

and to cope with symptoms of PTSD. This result corresponds

well to the literature on PTSD and stimulant use, which

shows its functional use for depression (Brady et al., 1998). In this

sense, khat use needs to be acknowledges as an important part of

the local patterns of coping but also as an additional source of

distress when it becomes compulsive and causes additional

psychopathology. Our findings also point at inter-individual

differences in khat’s effects.We would presume that the difference

between those respondents with PTSD who find khat helpful and

those who don’t might be related to the current psychiatric

symptom characteristics. For instance, those with co-morbid

depression might be more likely to experience positive effects (i.e.

cheering-up) while those with chronic hyperarousal or with

a tendency to react with psychotic features might find the effects

unpleasant.

 

Our data revealed that there are clear gender differences. Men

presentmore frequentlywithPTSDthanwomenandweremore likely

to use khat andweremore oftenparanoid. This result is in accordance

with traditional practices, i.e. that khat is a predominantly male drug.

However, it is likely that answers might be biased by the possibility

that women are less likely to disclose khat use thanmen.

In northern Somalia the subgroup with PTSD and very high khat

use is hardly represented in our sample. Among the regular armed

forces in northern Somalia, persons with mental health problems

would not be tolerated, are more likely to have been released from

service and, thus, would not be part of the interviewed population.

This explains the percentage ‘‘drop’’ in the last quartile in Fig. 3. In

contrast, in southern Somalia therewas active fighting, state failure

and no social welfare system. In this situation, an armed group,

which is usually defined by ethnic kinship, takes on the responsibility

of caring for severely ill members.

 

Our data have high relevance for future DDR activities in the

region. The international community needs to be prepared for

a large number of ex-combatants suffering from drug abuse and

complex psychiatric disorders that reduce their ability to reintegrate

into civil society. Thus, special attention should be paid to the

development of adequate psycho-social and medical support. In

our eyes, there is substantial evidence to justify the allocation of

scarce resources to mental health programs. We believe the international

community needs to seriously invest in research activities

that increase the knowledge on reintegration of ex-combatants.

The reported data also might contribute to the understanding

of psychotic disorders in general: The behavioral sensitization

paradigm is thought to provide insight into the neural substrate of

both drug-induced and idiopathic psychosis (Kalivas & Stewart,

1991); while developed in laboratory context, it has recently

proved validity for the explanation of psychotic symptom relapse

in humans (Yui et al., 2001). Based on these studies and our

findings, we speculate that the latent vulnerability for the development

of psychotic disorders might not just be triggered but

even acquired by early onset or excessive khat use in combination

with the exposure to traumatic stress and or the development of

PTSD.

..

[OdaySomali]

Very interesting.

[Carafaat]

OdaySomali, ik heb gehoord dat je Khat handelaar bent. maxaa ka jira?

[Bluelicious]

Mannen jullie weten toch dat khat meer kapot maakt dan je lief is. Dit onderzoek verbaasd me niet.

 

Carafaat - OdaySomali is tegen khat zie je niet *** hij zich inzet om de Somalische mensen voorichting te geven, hoezo is hij dan een handelaar.