We studied and compared the feasibility and effects of family-based acute treatment and two models of community-based relapse-preventive outpatient care for patients with chronic psychotic disorders who abuse khat in Somalia. Patients with chronic psychotic disorders and their carers accepted the project and appreciated the assistance, as limited it was. In most cases, families worked reliably and closely with the project. Initial exaggerated hopes and expectations towards economic assistance could be dealt with in the course of the project. Our outcome variables showed a disassociation between psychotic symptoms versus levels of functioning and depression - the latter improved while the former did not. We also found that khat use can be reduced even among users with an addictive use pattern. In spite of the methodological shortcomings, our findings demonstrate that community-based psychiatric care in a country with almost no psychiatric resources can improve functioning and depressive symptoms in patients with long-term disorders living in inhumane conditions and is therefore ethically justified. Additionally, they also demonstrate that more stringent research is needed to scientifically prove evidence and that concepts of community-based mental health care need to be further developed.
The low dose treatment with Chlorpromazine seemed to produce a measurable improvement of the symptom levels, especially in the acute treatment phase, and clearly positive effects on every-day functioning and it proved to be relatively safe in respect to medical complications and side effects.
We found that acute treatment of productive psychotic patients in their homes where many of them were chained is effective, i.e. acute symptom levels can be reduced to a level comparable to patients in remission. Similar results are known from Soteria treatment approaches using low-dose medication and home-based treatments in western countries.
Concerning relapse prevention in the community, our results go along the lines of other treatment studies showing that relapse cannot be fully prevented but its risk can be reduced even by low-dose neuroleptic treatment and that first-generation anti-psychotics can be equally effective than newer drugs. Of course, due to the lack of an untreated control group (i.e. treatment as usual), the effect of our interventions cannot be fully evaluated. Furthermore, it is a challenge to define relapse and remission in the setting in which we operated, because we lacked a continuous presence of resources and highly trained staff who would have been able to rate symptoms with clinical instruments. For example, in the dearth of in-patient services, the simple readmission criteria do not appropriately apply. We reduced this question to the measurement of symptom severity on a group basis at pre-, post and follow-up assessments. We found that both positive and negative symptoms improved during acute treatment and deteriorated again in the course of the follow-up period. Changes of positive symptoms from post to follow-up probably were influenced by khat use and medication compliance. Changes of negative symptoms probably reflect the long-term course of illness as they can hardly be influenced by the medication we used.
The data on symptom levels are opposed to the findings on functioning: While both groups differed in their psychopathological outcomes, functioning improvements occurred on an equal base. This reflects the outcome of other research that symptom severity and functioning in every-day roles are non-congruent. Only about 10% of patients restored their functioning completely, which is still substantial face to the chronic manifestation of the disorders. About 60% of patients improved in basic dimensions of human existence like communication, living together and self-care. This is encouraging, as we had recruited chronic cases with protracted course of illness.
We know that a comparison between our groups needs to be treated with caution. But it is still necessary to discuss several important implications resulting from the distinction of the two treatment packages and reasons why outpatients had less favorable symptom course but better khat-related outcomes than remitted patients. Our results demonstrate that medication compliance could have been better maintained among outpatients who had received the acute treatment phase and a much more intensive monitoring and psycho-education of medication use during the preventive treatment phase. This is an important selective finding because non-compliance is one of the most important risk factors for relapse. Also khat use among outpatients was kept at a lower level. Only this group of patients and their families received the intensive acute treatment phase, which included psycho-education and assistance to reduce khat use. According to our observations, also the focus on psycho-education for medication during home visits in the preventive phase also led to a more intense psycho-education on khat effects. We also believe that the better adherence to prescribed medication among outpatients can add to the explanation of the less severe khat use in this group. Based on the well-established pharmacological actions of neuroleptic drugs, we can indeed assume that immediate khat effects such as euphoria are dampened under neuroleptic treatment. This might have reduced compulsive use. Based on these results, we hypothesize that medication compliance and khat abstinence can be positively influenced by higher investments in psycho-education, motivational interventions and monitoring.
Over the full project period, low symptom levels could not be maintained with the exception of depressive symptoms. But this symptomatic increase was more pronounced in the outpatient group. This was not expected especially because medication compliance and khat use reductions seemed to be more successful in this group. One potential reason for this symptomatic relapse might be the fact that remitted patients actively maintained contact to service providers (mostly hospital) and outpatients did not. But just the simple fact that a person had been inpatient before, might make it more likely that he/she will search for specialist care in case of a relapse compared to patients who had never had any contact with inpatient treatment facilities before. Another reason might be that our recruitment has produced two groups with a-priori differences. Remitted patients and their families might have lived in better economic situation, had a better formal education, had more knowledge on schizophrenia and its treatment, might have a more western concept of the disorder or even a higher family support or sense of responsibility compared to outpatients. It is difficult to detect potential a-priori differences based on our data. On the one hand, we found no difference concerning the indicators of economic situation and education, but we did find more in-patient treatments, less chaining and restraining and less malnourishment among the patients of the remitted group. These differences possibly reflect poorer care, more stress and inhumane practices, a more chronic and severe course of illness, a higher sensitivity to khat effects and a later start of treatment after illness onset in the outpatient group. These potential differences and their significance need to be addressed in future studies. And as relapse has high costs to patients and families and its prevention is the most important goal in the post-acute treatment phase, future research will need to study the question explicitly which relapse prevention treatment model is the more favorable in a given situation.
Our findings also demonstrate the complex effects of khat use on psychotic outcomes. According to our data and observation, khat use in the acute phase of treatment had a high positive association to the severity of florid symptoms of psychosis. This result replicates the findings reported in the literature that khat use can induce psychotic symptoms or cause exacerbation of pre-existing psychotic disorders. According to our observations, we had managed to motivate outpatients in the first six weeks of the study to stop consuming khat almost completely; this is comparable to the in-patient treatment where patients are not given access to khat. Abstinence is likely to have supported initial treatment effects. However, in the post-acute relapse prevention treatment, this association between khat and symptoms unfolded in more complex interactions. Abstinence motivation of patients and carers eroded in the course of the follow-up period and most patients had returned to khat chewing in the course of the 10 months. But khat use correlated at this point of time inversely with positive psychotic symptoms, i.e. when patients felt well and functioned satisfactory they chewed more khat. These at first sight contradictory correlations may be explained, by the fact that the amount of khat use by a single patient varies greatly over time in a very dynamic system. Factors in this system that increase khat use are addiction and the fact that khat is a common and integral part of social life in the Somali culture. These two factors probably explain why patients restart khat use after remission, i.e. when patients are less psychotic they chew more khat. Factors that decrease khat chewing are external restrictions of access to khat through measures like hog-tying and the desire of the patient to stop khat use. Indeed, we found anecdotal evidence that khat use after remission is noxious and might constitute a risk factor for relapse, because families re-chained patients to restrict khat use when they observed that their psychosis symptoms worsened. This is supported by other studies. Thus, from an ethical perspective, a clinician needs to assume that continuous khat use is a risk factor for a psychotic relapse and has to recommend that khat use is discontinued because even small amounts might be noxious. In this context khat needs to be seen as part of the repeated cycle of relapse and remission, chaining and unchaining of patients. This also demonstrates that the interpretation of an isolated correlation between khat use and psychosis based on data from one single point in time is not meaningful to describe the underlying complex relationship. Antipsychotic medication may help patients to maintain social and occupational functioning and may assist to tolerate consumption within an acceptable range, e.g. by taking the medication in the evening to promote sleep at night. The influence on khat on repeated relapses needs to be explicitly better understood in order to design targeted interventions. Our results also show that short-term intervention strategies to address khat abuse are of limited effect. Our data show that khat addiction is very frequent among psychotic patients and that community-based health services will probably only be effective when its therapy is integral part of the treatment package. Therefore, culturally adequate interventions to address khat addiction urgently need to be developed.
But among users without pre-existing mental disorder khat consumption might actually range from severe abuse with potentially disastrous health effects to more controlled and moderate use patterns that are not or less harmful and that go hand in hand with social integration. The current study was not designed to empirically determine the dynamic boundary between noxious and harmless khat use; future studies are needed to clarify this important question. The difference between noxious and non-noxious khat use probably depends on the amount and hours of use per day, maintaining night sleep, regular food intake etc., all points that need to be explicitly addressed in future studies. According to our anecdotal observations, harmful consequences of khat use among healthy individuals often occur when consuming for several weeks beyond normal amounts (one to two bundles) per day, chewing continuously for more than the culturally sanctioned period of 3 to 5 afternoon hours a day. The consequent inversion of sleeping patterns can be a warning sign of noxious effects on health.
In our work with psychotic patients and their carers in Somalia we observed the common experience of a very severe stigmatization due to mental illness. Patients and carers were excluded and stigmatized in their families and communities and were often abandoned, isolated and impoverished. We, thus, tried to make them feel accepted as valuable members of their communities. The psycho-social assistance turned out to be a vital component of the project intervention. Carers carry a heavy emotional, social and financial burden caring for their mentally ill. Often they reported that the home visits and conversations with project staff were helpful because they found someone to talk to about their stress and thus felt relief. These conversations could then be extended to inform patients and their carers so that they accepted medical recommendations concerning treatment and especially the advice to reduce khat intake.
Our pilot study has a number of limitations. First, our design did not include a control group who received treatment as usual which would have enabled to evaluate the effect of our intervention. Furthermore, both groups of patients entered the study at different points in time; it would have been a great opportunity to recruit one group at hospital intake instead of discharge; this would have made it possible to know whether groups of patients were different before inclusion into the project. In the current project, we probably have compared groups of patients with different a-priori characteristics and courses of symptoms. In future studies, it would be also desirable to include groups of patients without khat abuse and to dismantle effects of different components of the delivered treatment package (i.e. one group without psycho-social interventions). Second, our treatment delivery was also determined by attempts to test feasibility and sustainability rather than current standards of treatment, e.g. using Chlorpromazine and Haloperidol instead of second-generation antipsychotics and using low-dose treatment in all cases - also for those who would have been profited more from higher dosages. However, we followed the WHO guidelines that had been applied in different settings at that time and that were recently published. Third, our treatment packages did not contain important components that are standard in High-Income Countries such as occupational therapy or self-help groups. Self-help groups in LMICs can assist patients and carers to improve social and economic hardships and reduce exclusion and stigmatization in the community. Another challenge that was not addressed in our pilot project is the reintegration of patients into productive life. This might be especially problematic for poorly trained and economically disadvantaged families who constituted the large majority in the present project. Thus, occupational therapy, vocational training and the build-up of income-generating activities on the family level might have helped with the patient’s symptomatic and functional recovery, reduce stigmatization and improve the family’s economic situation. Finally, based on our design and assessment in this sample of patients with chronic psychotic disorder we were not able to determine the exact diagnosis of patients, i.e. whether it was schizophrenia, other long-term psychotic disorders or long-term substance-induced psychotic disorder. In stead, we have focused on selected DSM IV criteria for schizophrenia (characteristic symptoms, social/occupational dysfunctions, duration) to ensure the existence of a long-term psychotic disorder. We believe that the exact diagnosis is not necessary in the context of this study.
Despite limitations this study demonstrates components of effective family-based and outpatient treatment for patients with chronic psychotic disorders in Somalia, where khat abuse among patients is rather the rule than the exception. From a pragmatic point of view, future projects should consider the combination of home visits with psycho-social support and delivery of medication as well as establishing and maintaining contact of the families to the existing in-patient services for referral in case of severe relapses. An inclusion of a self-help as well as an income-generating component for the patients and their families need to be considered because the families live in extreme poverty without much hope to improve their situation and be able to sustain a necessary treatment by own means. Such components might be included during the post-acute treatment phase and should be directed towards patients and their carers. Also patients’ khat addiction must be addressed and consumption be regulated to prevent relapses. Currently there are no evaluated treatment concepts for khat addiction.