Khat and the Psychiatrist
Yemen has been in the news recently, due to its deteriorating security situation. I’ve long had a fascination with the Middle East, and this country is known not just for its fantastic architecture, but also for its people’s fondness for chewing khat.
Khat (Catha edulis) is a slow growing evergreen shrub that grows wild in countries bordering the Red Sea and along the East coast of Africa. Its appeal is that chewing its fresh leaves and tops leads the user toward a state of amphetamine-like euphoria and stimulation. There are several names for the plant, depending on its origin: chat, qat, qaad, jaad, miraa, mairungi, cat and catha. In most of the Western literature, and this posting, it is referred to as khat.
The habit of khat chewing probably predates the use of coffee, but it has become increasingly popular of late and it is estimated that three quarters of Yemeni adults chew the leaves each afternoon, with a similar social role to that of tea, cigarettes or alcohol. Khat chewing commands a dominant place in social functions and its use so widespread that withdrawal from khat can result in social isolation.
Yemeni homes are constructed specially to provide a warm reception room for khat chewing. For the urban chewer, khat sessions usually begin soon after lunch with men and women meeting separately; the habit is mostly practiced by males.
Drs Wijdan Luqman and T. S. Danowski describe the drug’s effects:
The chewing session starts with slightly euphoric behaviour and a friendly sense of humour. The leaves are plucked off the twigs, chewed, and stored against one or the other cheek. The mixture of saliva and extract from the leaves is swallowed. As new leaves are taken, the cheek bulges out. The euphoric effects appear shortly after the chewing begins ….. The session and the friendly atmosphere last about 2 h. These are followed by a mood of zeal that lasts another 2 h, and during this interval current subjects and problems are discussed. This in turn is supplanted by a serious mood and may be accompanied by irritability.
They also note:
The act of communal chewing promotes interpersonal interactions. For example, as passengers on public transport we observed spontaneous eruptions of group conversations among previously-mute Yemenis once khat chews began.
As you approach cruising altitude, the brain slips into overdrive and you discover that you’re one of the most intelligent and articulate people in the world. Thoughts have never been so clear, nor have ideas flowed so freely. No matter how difficult the problem, by the end of the session you will have either dreamed up a solution or decided that it’s not worth bothering about.
I passed the hours listening to the gentle lubalub of the hookah and whispered conversations about dead poets and fine deeds. In Sana’a, khat governs. Each day at three, climbing the steps to a smoky room with a bundle under the arm; then closing the door to the outside world, choosing the leaves, gently crushing them with the teeth and waiting for the drug to take effect. No rush, just a silky transition, scarcely noticed, and then the room casts loose its moorings.
In rural areas the chewing of khat starts soon after breakfast, and continues throughout the day, with the children also participating. The stimulant effect is said to lighten the daily tasks. In these poorer regions food may be lacking and the khat decreases the need for meals; on the other hand such is the appeal of the plant that people will sometimes forgo buying food for khat.
Yemem’s people can spend about one-quarter to one-third of their cash income on the plant. This report has a teacher spending 44% of his salary on khat. As discussed in the Yemen Times the cultivation of khat is extremely widespread, and there is concern due to 80% of Yemen’s water being used for khat growing. One reason for khat’s popularity with farmers is the high income it provides, which can be five times that of that from growing coffee or fruit. A wikipedia source states that increasing demand has lead to the area on which khat is cultivated growing from 8,000 hectares to 103,000 hectares from 1970 to 2000.
Chronic khat chewing can cause hypertension in young adults, with a spontaneous regression once consumption ceases. Khat’s tannins may lead to gastritis, stomatitis, oesophagitis, and peridontal disease. The tannic acids produced are also thought to be hepatotoxic. There are also concerns about the pesticides used in khat cultivation.
There is debate as to whether khat is able to produce dependence with some researchers saying that the dependence effects are psychological. There is also debate as to whether a withdrawal syndrome exists. Physical withdrawal symptoms have been documented and may consist of lethargy, mild depression, slight trembling and recurrent bad dreams. Discontinuation results in improvement of sleep and appetite, and fewer constipation problems.
According to the WHO expert committee on drug dependence khat chewing can induce two kinds of psychotic reactions. First, a manic illness with grandiose delusions and second, a schizophreniform psychosis with persecutory delusions associated with mainly auditory hallucinations, fear and anxiety, resembling amphetamine psychosis.
Psychotic reactions to chewing khat are rare, probably due to the physical limits of leaf chewing. When seen they are related to chewing large amounts. Symptoms resolve when the khat is withdrawn and anti-psychotics are not usually needed. Khat psychosis may be accompanied by depressive symptoms and sometimes by violent reactions. It has been argued that khat chewing might exacerbate symptoms in patients with pre-existing psychiatric disorder.
The habit of Khat chewing does manifest a number of socio-economic problems. Khat chewing leads to loss of work hours, decreased economic production, malnutrition and diversion of money in order to buy further khat. Family life is harmed because of neglect, dissipation of family income and inappropriate behaviour and khat is quoted as a factor in one in two divorces in Djibouti. Acquisition of funds to pay for khat may lead to criminal behaviour and even prostitution.
On the other hand there are a lot of benefits from the Yemeni’s love of khat and a lot of people clearly enjoy its use. The crop generates wealth for its cultivators and the need for a rural workforce has stabilized the rate of rural to urban migration. It has positive psychological effects too and many people report that it leads them to be more creative. Its energizing effects benefit the elderly especially and it serves as a medium for social discourse.
Attempts have been made to control the use of the drug but with little success. In 1957 the Adeni political party instigated a ban, but such was the political turmoil over this issue that the party collapsed the following year. Many people complain that Yemeni authorities are not committed to combating the use of khat because the crop is such a moneymaker for senior officials and influential tribal leaders.
In contrast to Yemen, in Saudi Arabia use of the plant is completely banned and there are harsh penalties in place. One less severe approach would be to treat khat like tobacco in the West, with information campaigns about its drawbacks and restrictions on its use.
In recent years as a result of air transport, the consumption of fresh khat leaves has expanded considerably and khat is readily and legally available in the UK. It has been estimated that about 7000 kg of khat pass through Heathrow Airport each week from where it is distributed into the UK and into other European countries.
There have been calls for it to be banned and the BBC reported Faisa Mohammed, chair of the Bromley-based Somali Well Women Project, saying that the abuse of khat was damaging many Somali families in Britain.
Back home the men were the breadwinners but they came to Britain without jobs and took up khat, which has become an addiction. They chew all night and during the day they can’t do anything.
As khat is legal in the UK I thought that it might make for a distracting afternoon to try to purchase some. Living near Whitechapel, as I do, I hung outside a semi-reputable Somali shop until I plucked up the courage to go in.
‘Hello, I was wondering if you sold khat’ I said. ‘You know, that plant you can chew’
‘No we don’t and I don’t approve of it’.
I panicked and told the shop keeper that I was a medical student doing a project on khat and I was trying to buy some for ‘research purposes’
Then the shopkeeper’s friend came in and starting to tell me about all the bad things that have happened to the Somali society in the UK thanks to khat, chiefly men ignoring their families and jobs in order to chew the stuff. He thought it should be banned.
Duely chastened I left.
Adverse effects of khat: A review Advances in Psychiatric Treatment (2003), vol. 9, 456–463 – a really great review – full text available for free!
The impact of qat chewing on health: A re-evaluation by Nageeb Hassan, Abdullah Gunaid and Iain Murray-Lyon British-Yemini Society
Pages about the Middle East run by the Guardian’s Middle East Editor Brian Whitaker
The Curse of Yemen Ian Black Guardian August 12 2008
Here’s Kevin Rushby’s book again:
Lonely Plant Yemen page
High in hell An Esquire article by Kevin Fedarko September 1 2006
That darned khat Village Voice article 14 November 2006
The Curse of Yemen Guardian 12 August 2008