Elsevier

Journal of Ethnopharmacology

Volume 132, Issue 3, 1 December 2010, Pages 549-553
Journal of Ethnopharmacology

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

https://doi.org/10.1016/j.jep.2010.07.027Get rights and content

Abstract

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.

Introduction

Khat (Catha edulis) has many names including kat, qad, and miraa. It is a plant substance; the leaves and twigs are chewed for its psychomotor stimulant effects (Toennes et al., 2003). Khat is and has been used as a culturally sanctioned stimulant in many parts of East Africa and the Arabian Peninsula, in particular in public and private social gatherings. Although an illegal substance in the US, its legal use among some migrant communities in Europe and elsewhere has caused alarm among policy makers and health care professionals. US drug enforcement agencies report ‘that the adverse effects of khat chewing include anorexia, tachycardia, hypertension, insomnia, and gastric disorders; chronic khat abuse can result in physical exhaustion, violence, and suicide and depression; it is also reported to produce manic behaviors, hyperactivity, and hallucinations; there are some reports of khat induced psychosis. Widespread frequent use of khat can impact on economic productivity because it tends to reduce worker motivation’ (http://www.justice.gov/dea/concern/khat.html). Such advice may highlight population health risks, and encourage stricter classifications of khat as an illegal or dangerous substance.

In contrast to this view, there is an emerging consensus among international health agencies that ‘khat has a low abuse potential; and that the harmful effects of khat are related to excessive use, associated with adverse social conditions related to displacement and social marginalization’ (Fitzgerald, 2009). Certainly, in case reports it is linked with exacerbations of established psychoses; this raises alarm about regulation among practitioners and policy makers working with people who have mental health problems and use drugs (Warfa et al., 2006, Warfa et al., 2007). However, a systematic review of the literature suggested that the case report evidence distorted the scientific debate and was not reflecting the population based risk of psychosis among people consuming khat, and therefore should not be used as the basis for regulation (Warfa et al., 2007).

Nonetheless, recent work among Somali people in war zones shows that khat use appears to correlate strongly with measures of psychosis and that the two may be linked (Odenwald et al., 2007). Confounding factors include that Somali people are likely to be chewing khat for cultural and social reasons, and that they live in or have fled from the civil war in Somalia; khat may be therefore be used as a cheap drug of choice to cope with adversity due to an unsafe and fragmented and dangerous society in which non-state armies and militia are determining the rules by which people live. Victims and perpetrators of violence may therefore be under immense psychological pressures to secure their safety and escape harm, whilst surviving local regimes. Furthermore, in war torn societies, and specifically in Somalia, people will have experienced traumatic events.

It is argued that traumatic events can lead to post traumatic syndromes and, as an external and environmental stressor, may lead to mental distress (Breslau, 2009). Khat use might then add to the risk of mental distress and specific mental disorders. Studies among Somali refugees show that psychosis measures on standardized instruments appears to correlate with the use of khat (Odenwald et al., 2007, Odenwald et al., 2009); drug use in general, and khat use specifically, has been shown to be higher in conflict zones (Odenwald et al., 2007). There may also be differing strengths of khat in conflict zones, and child soldiers may be especially vulnerable to the effects of trauma and the effects of an early onset of use; the latter may be more likely to lead to intractable mental health problems later.

These previous studies reporting associations between khat use and psychosis were undertaken in particular contexts: war torn society, conflict, failures of security and safety, and high rates of traumatic events perhaps also leading to co-morbid PTSD, and perhaps anxiety and depression also; furthermore, the most vulnerable are young people, and perhaps young combatants. Convenience samples may also carry significant and multiple risk factors for mental disorders if compared with a more inclusive population sample. Nonetheless, the findings perhaps should be of relevance to Somali people who are khat chewers in Somalia, but perhaps do not apply to those who have fled Somalia, through other neighbouring East African countries, to reside in Europe and the US. The environmental context in these countries is quite different, with greater levels of safety and security, the absence of overt war; there is also less chance of being exposed to torture as part of inter-tribal warfare. Yet, there may be alternative stressors such as refugee camps and long delays before their legal status as refugees is confirmed. It is also unclear if research in true population samples would produce the same findings as research in samples at risk of mental disorders because of multiple adversities.

This paper aims to investigate the relationship between khat use and traumatic events with common psychotic symptoms. In this study we focus on symptoms of psychosis rather than psychotic illness diagnoses. There is a growing interest in new conceptualizations of common psychotic symptoms (van Os et al., 2009) and theories about the mechanisms that explain a higher incidence of psychotic disorders among migrants (Swinnen and Selten, 2007, Cantor-Graae and Selten, 2005, van Os et al., 2009). Psychotic disorders also have a multi-factorial aetiology and thus no single risk factor is thought to be sufficient to trigger a single episode or lead to a persistent psychotic disorder (van Os and Kapur, 2009), hence understanding the role of khat, or trauma, in psychosis requires a more complex explanation that is compatible with the proposed mechanisms by which psychosis is triggered.

In a systematic review of research in 10 countries, van Os et al. (2009) have shown that sub-clinical symptoms of psychoses are found with a median prevalence of 5% and a median incidence of 3%. Risk factors that shift the prevalence of these common, and often pre-clinical, psychotic symptoms are likely also to be risk factors future psychosis and more persistent diagnosed psychotic conditions over the life course (Dominguez et al., 2009). Furthermore, psychotic symptoms occur in some personality disorders, notably borderline personality disorder, which is associated with experience of early trauma and may make individual vulnerable to react to stressful situations with psychotic symptoms (Glaser et al., 2010). Therefore in the context of migrant communities, with a different first language, exposed to multiple traumatic events that can impact on personality development, and in the face of harsh economic realities and adversities involved in resettlement following migration, a study of psychotic symptoms may be enlightening and reflect social and environmental stressors interacting with khat use.

There are additional advantages to studying common psychotic symptoms. These are that psychotic symptoms are more common than diagnosed psychotic conditions, and therefore are more likely to yield analyes with adequate statistical power. Secondly, symptoms are simpler phenomena and do not require as complex judgments about the cultural validity about diagnoses (Bhui et al., 2003). These benefits are especially useful where subjects are considered ‘hard to reach’, less willing to be involved in research (Warfa et al., 2006), and/or where there are no routinely collected data that enumerate a population sample across a large number of geographical regions. Therefore studies of common psychotic symptoms (CPS) or pre-clinical or at risk mental states are more likely to yield findings from smaller sampling frames, whilst allowing investigations of risk factors that remain of relevance to the future risk of psychotic disorders, and are especially valuable where there are methodological concerns about diagnosing psychotic conditions across cultural and ethnic groups (see Bhui et al., 2003, Bhui et al., 2006).

Section snippets

Methods

Within this context this study undertakes a secondary analysis of data on a population sample of Somali men and women living in South London (Bhui et al., 2003). These data include measures of current khat use, past traumatic events, and standardized measures of symptoms of psychosis and anxiety and depression. The data have not previously been investigated using a theoretical framework of common psychotic symptoms that are found in the population. Indeed, the notion of common psychotic

Results

Data were available on 91 men and 89 women (see Table 1 for a summary; see Bhui et al., 2003 for a detailed demographic breakdown). Khat was used by 42.6% of subjects (75/176) on a weekly basis (mean frequency 1.3, range 0–7, N = 176 subjects). The amount of money spent on khat, amongst those acknowledging khat use, ranged between 0 and £3 a week, with a mean of £1.75 per week. The reported frequency of khat use correlated strongly with subjects reports of the amount of money spent on khat a week

Discussion

This study of a population sample of Somali people shows that khat use is moderate, and that it is not, at least in a non-conflict zone, associated with common psychotic symptoms or with anxiety and depression symptoms. The study also demonstrated that khat use in this population was not related to traumatic experiences, although traumatic experiences were more likely to be associated with low level psychotic symptoms and high level anxiety and depressive symptoms. As expected, our population

Conclusions

These findings emphasise the need for the treatment of anxiety and depression that are far more common than psychotic disorders and slightly more common than psychotic symptoms; the findings suggest that trauma may lead to low levels of psychotic symptoms that are not easily diagnosed as psychotic disorders, these may confuse and confound clinical assessment and treatment plans and may be responsible for the numerous case reports proposing that khat causes psychotic disorders (Warfa et al., 2007

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