Khat dependence : Risk factors, consequences and treatment

Abstract

Khat use has a long standing tradition in many African countries and the Arabian Peninsula. The tender leaves are chewed over hours, mostly in social settings and their stimulating effect increases concentration and productivity and leads to talkativeness and a flow of ideas. The traditional use for spiritual occasions or labor lost its relevance since mid of the 19th century with expanding trade, progressive urbanization and migration. It was replaced by motives like reduction of psychological burden, relaxation, increasing feelings of cultural identity, entertainment and fun, pressure to perform, peer pressure and social interaction. Various factors account for the development of excessive use patterns related to a number of harmful consequences for physical and mental health. There is no international regulation on khat use despite the evidence for a need for harm reduction. To date, there are no studies on khat-specific interventions. In the present thesis, an established WHO Brief Intervention (ASSIST) was adapted for Khat use and tested for its efficacy in a randomized controlled trial with Somali refugees in Kenya. The intervention group as well as the control group were interviewed in three times of measurement concerning khat use, comorbid psychological symptoms and potential environmental factors influencing therapy success. We found that the amount and frequency of khat use was reduced more after the intervention but also in the control group which refers to the success of the adapted intervention as well as the effects of unspecific active factors (article 1). The prevalence of comorbid symptoms of depression and PTSD was extremely high in this sample. The symptoms were reduced in both groups and we found that multiply mentally burdened participants benefit less from the intervention respective consume reduction (article 2). A lack of alternative activities, environmental khat cues and a lack of alternative coping strategies were shown to be the most relevant factors when reducing khat use (article 3). These results are in line with current recommendations for not treating khat users as a homogenous group. An adequate treatment of khat use requires adapted intervention strategies, especially in highly burdened countries like Kenya, Ethiopia and Somalia. Comprehensive information about risks related to problematic khat use should be the first step with focus on vulnerable groups. Trained lay persons from the community could reach many people efficiently, for example with low-threshold Brief Interventions. Using motivational strategies and increasing competence in coping strategies could prevent excessive use and reduce the need of intense treatment through highly skilled persons.