General public teaching on Khat abuse

1. Khat and health
Facts, Addiction effects and Health
Implications
Dr. Jibril I.M Handuleh, MBBS
Assistant Clinical Lecturer in Psychiatry
Amoud University Mental Health Initiative Lead
Amoud University
Borama, Somalia

2. Learning Objectives
• At the end of this session participants should
be able to:
Define substance dependence and abuse
 Define Qat and its effects on health
Recognize signs and symptoms of khat related
mental health conditions
Understand Qat related mental health problems
in Borama, Somalia and among Somali diaspora

3. Amoud University-THET- King’s
College London Mental Project
2011
• Outpatient service
• Community based Psychiatry
• School mental health
• Maternal mental health
• Forensic(legal) Psychiatry

4. 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!

5. 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

6. 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

7. 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

8. Effects of khat (2)
Objective signs:
• Minor reactions - over-talkativeness,
overactivity, insomnia, anxiety, irritability,
agitation and aggression.
• Serious reactions
–Schizophreniform psychosis
–Manic like episode

9. IS QAT A SUBSTANCE ABUSE OR A HABIT?

10. 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

11. 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
1. Withdrawal:
– the characteristic withdrawal syndrome for the
substance
– the same (or a closely related) substance is taken to
relieve or avoid withdrawal symptoms

12. 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

13. 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.

14. Drug of abuse
• WHO classified it into substance I abuse in
1980.
• It is illegal in many countries
• Legal in East Africa and Yemen

15. Borama mental health and Qat
case 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

16. • 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

17. How common is Qat?

18. Common addictions in Somalia

19. Mental health disorders-
Borama community Outreach
2011-2012

20. PATIENT WITH QAT INDUCED
PSYCHOSIS

21. AMOUD MENTAL HEALTH PROJECT
GLOBAL MENTAL HEALTH PARTNERSHIP
Dr. Jibril Handuleh1
and Dr. Susannah Whitwell2
health
1
Amoud Mental Health Project, 2
South 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.
0
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2 0
3 0
4 0
5 0
6 0
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

22. 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.

23. 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.

24. Some papers on khat
1.Mental disorders among Somali refugeesDeveloping culturally appropriate measures and a
• Kamaldeep Bhui, Tom Craig, Salaad Mohamud, Nasir Warfa, Stephen A. Stansfeld,
Graham Thornicroft,Sarah Curtis and Paul McCrone
2.Traumatic events, migration characteristics and psychiatric symptoms among Somali refuge
• Kamaldeep Bhui, Abdisalama Abdi, Mahad Abdi, Stephen Pereira,
Mohammed Dualeh, David Robertson,Ganesh Sathyamoorthy and Hellena 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, Häfner H, Rockstroh B.

25. 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

26. Where Qat addicts may end up !
Thanks for listening