Serious mental illness (SMI) are among the top twenty conditions that result in the greatest burden of disability worldwide (1) and also in Ethiopia (2). Acute state of schizophrenia is the most disabling disease state of all Global Burden of Disease (GBD) causes (3). SMI are among the top ten burden of disease in Ethiopia(2). In Ethiopia, the life-time prevalence of schizophrenia, depression and bipolar disorder is reported to be 0.5%(4), 9.1%(5) and 0.5%(6) respectively. Schizophrenia was also the number one diagnosis for admission to mental hospital in the country (7). Also there is a high mortality rate (8)(9) and risk for suicide(9)(10) among people with SMI. Mental disorders are costly to individuals, families, communities and societies(11).
Khat (Catha edulis F) is an evergreen shrub that is believed to have originated from Ethiopia. It grows in many Eastern and Southern African countries and the Arabian Peninsula. Its fresh leaves are chewed and the juice is swallowed to exert its stimulating effect (12). Cathinone is the major active constituent in khat. Cathinone induces release of dopamine and serotonin thus increase the activity in their pathways(13). This are neurotrasmitters thought to be affected and causing SMI.
After khat chewing session ceases, unpleasant after-effects tend to dominate the experience like: insomnia, numbness, lack of concentration and low mood(14) (15). Some chewers also experience unpleasant effects during the chewing process, describing anxiety, tension, restlessness and hypnagogic hallucinations(15). Khat chewers display a range of experiences, from minor reactions to the development of a psychotic illness(15).
There is an ongoing international debate about a causal relationship between khat use and mental illness (16). Although there are many studies on khat in the general population, there are only few studies in mental illness patient. Moreover, there are very few studies on association of khat chewing with reemergence of the disease symptoms in serious mental illness.
Relapse is broadly recognized as the reemergence or the worsening of symptoms. More specifically, certain criteria are used to define relapse; they include aggravation of symptoms, hospital admission in the past 6 months, and need for more intensive case management and/or a change in medication(17)(18).
Relapse in SMI causes worsening of symptoms, progressive cognitive deterioration, impaired functioning and reduced quality of life and families are affected by the emotional stress and financial burden of living with and caring for the patient(19). Relapse may result in hospitalization, treatment resistance, personal distress, incarceration, and interference with rehabilitation efforts (18). Relapse increases the economic burden on health care systems because of its associated morbidity and re-admissions to hospital (18). Costs for relapse cases are much higher than those for non-relapse cases (17). Extended relapse duration and treatment intensity associated with relapse intensify the decrease in both general and regional brain measures (19). Repeated relapse episodes are also risk factors for development of treatment resistance (20).
The main drivers of relapse SMI are non-adherence to medication (18)(21)(22)(23)(24)(25)(19), substance abuse(26) (25)(19), stressful life event (27) (28)(29) (19). Other factors include: treatment discontinuation(30) (31)(32) (23)(33)(34) (35)(36), delayed treatment initiation(28)(23), existence of depression symptoms (22), poor insight into the illness, younger age (19), hospitalization or relapse history (25)(28), poor social support(18)(34) (27)(37), residual symptoms (38)(39), carers' criticism, and poorer premorbid adjustment (30).
Different studies indicate that SMI patients using illicit drug exhibit poorer outcomes in a variety of domains: symptom severity, psychiatric relapse, hospitalization, suicide (40)(41), incarceration, violence and victimization, physical health problems, homelessness (42), extended hospitalization (43), increased healthcare costs, reduced compliance with medications, increase treatment resistance(44), increased depression symptoms(45) and suicide ideation, as well as mania and bipolar disorder(46). The substances mostly studied are cannabis, alcohol and amphetamine but there is no large study on khat effect in people with SMI, but case reports(47) and qualitative study(48) noted that patients with serious mental illness who used khat had their illness exacerbated by the use of it. El-Sayed and Amin’s small size comparative study of khat chewing patients with schizophrenia indicate that khat chewing attenuates all used treatment medications, aggravates the disease symptoms and also deteriorates all biochemical markers (49). Khat chewing is associated with disturbance of mood and behavior, aggravation of delusional symptoms, diminished response to antipsychotic therapy (50).
Even though the above few studies indicate that khat could complicate the course of the illness, until now there are very few studies on association of khat chewing with relapse in serious mental illness. In Ethiopia, where mental health service is poor compared to other African countries (51), and only few number of patients attend mental health service(9) (52)(5)(53), khat chewing could have additional enormous negative impact on treatment and outcome in psychiatric patients. Relapse prevention is one of the key therapeutic goal in the treatment of serious mental illness. But until now the effect of khat chewing on this key outcome domain is not explored.
The main aim of this study is to assess relapse in khat chewer and non chewer people with SMI, specifically; to compare the prevalence of relapse in khat chewers and non chewers and to assess the factors associated with relapse in both khat chewer and non chewer peoples with SMI