Long-term effects of chronic khat use: impaired inhibitory control

So far no studies have systematically looked into cognitive impairments in khat users. This study compared the ability to inhibit and execute behavioral responses in adult khat users and in khat-free-matched sample controlled for age, race, gender distribution, level of intelligence, and alcohol and cannabis consumption. Response inhibition and response execution were measured by a stop-signal paradigm. Results show that users and non-users are comparable in terms of response execution but users need significantly more time to inhibit responses to stop-signals than non-users. The inability to stop on time may have repercussions for daily life activities as driving a car.


Introduction
Leaves from the flowering evergreen khat tree have been chewed in East-Africa since ancient times to alleviate fatigue, stay alert, reduce hunger and induce euphoria. Khat consumption has increased during the last decades in Eastern Africa and has become a global phenomenon spreading to ethnic communities in the rest of the world, such as in The Netherlands, United Kingdom, Canada or United States (United Nations Office on Drugs and Crime, 2010). The airport of Amsterdam and London, where arrived weekly a big amount of khat, have become the European distribution points (Beckerleg, 2008;Pennings, Opperhuizen, & van Amsterdam, 2008). In particular, in The Netherlands, it is legal to buy and sell khat bundles compared to other countries as Canada, U.S.A., France, Norway, Poland where the use, sell and possess of khat is considered illegal.
The acute consumption of khat is associated with optimism, mild euphoria, excitation, talkativeness, increased energy and enhanced self-esteem (Brenneisen, Fisch, Koelbing, Geisshusler, & Kalix, 1990;Kalix, 1996). The half-life is about 4 hours, depending on the amount of chewed khat. When the acute effects vanish, users experience feeling of depletion, insomnia, numbness, depression, lack of energy and mental fatigue. At a long term, chronic (i.e. daily) use of khat is associated with increased blood pressure, development of gastrointestinal tract problems, cytotoxic effects on liver and kidneys and keratotic lesions at the side of chewing).

Cathine
(Norpseudoephedrine) and cathinone (Benzoylethanamine), the active ingredients of khat, are similar in structure and pharmacological activity to amphetamines (Wagner et al., 1982). The two alkaloids act by increasing dopamine (DA), serotonin and noradrenalin (Kalix & Braenden, 1985). For this reason khat is also called "natural amphetamines". Cathinone increases levels of DA in the brain by acting on the cathecholaminergic synapses, retarding DA reuptake inactivation and/or enhancing DA release (Patel, 2000;Wagner et al., 1982), in particular in the striatum (Zelger & Carlini, 1981).
Studies addressing the neurobiological mechanism underlying the use of khat are still lacking as well as studies that have systematically looked into the long-term cognitive effects of chronic khat use. Nevertheless, given the similarity of khat and amphetamine in structure and pharmacological activity, it makes sense to assume that the long-term use of khat affects the same neurotransmitter and brain structures as the chronic use of amphetamine (see Berman et al., 2008). At a structural level, one may thus expect white matter abnormalities, lower cortical gray matter volume, and higher striatal volume. In particular, higher striatal volumes might reflect a compensation for toxicity in the dopamine-rich basal ganglia. At a functional level, in turn, chronic khat use is likely to be associated with reduced functioning of dopamine D2 (DAD2) receptors in the striatum and dysfunctions in prefrontal cortex (PFC) and orbitofrontal cortex (OFC) -areas that have been shown to play major roles in the control of goaldirected action (Miller, 2000).
Interestingly, DA has a key role in inhibitory action control (Colzato et al., 2010;. Behavioral inhibitory efficiency is commonly assessed by means of the stop-signal task (Logan & Cowan, 1984). In this task, participants are first presented with a stimulus (i.e., a go signal) prompting them to execute a particular manual response, and this stimulus may or may not be followed by a stop signal calling for the immediate abortion of that response. Based on the mathematical considerations formulated by Logan and Cowan (1984), the stop-signal paradigm provides a direct behavioral assessment of the individual ability to stop a planned or ongoing motor response in a voluntary fashion and a quantitative estimate of the duration of the covert responseinhibition process (i.e., stop-signal reaction time or SSRT; see Figure 1). Parkinson's patients, who suffer from loss of dopaminergic neurons in the basal ganglia, showed longer SSRTs (Gauggel, Rieger, & Feghoff, 2004) and impaired suppression of conflicting responses (Wylie et al., 2009;Wylie, Ridderinkhof, Bashore, & van den Wildenberg, 2010) compared to matched controls. Consistent with this picture, spontaneous eyeblink rate (EBR), a marker of dopaminergic functioning, reliably predicts the efficiency in inhibiting unwanted action tendencies in a stop-signal task see Logan, 1994, for a review). Along the same lines Colzato and colleagues observed that recreational users of cocaine, who are likely to suffer from reduced dopamine D2 receptors in the striatum (Volkow, Fowler, & Wang, 1999), need significantly more time to inhibit responses to stop-signals than non-users. Very recently, Colzato et al. (2010) found that DA D2 receptor (DRD2) C957T T/T homozygotes were also less efficient in inhibiting prepotent responses.
So far, surprisingly, no studies have systematically looked into cognitive impairments in khat users. In the present study we tested, by means of the stop-signal task (Logan & Cowan, 1984), whether khat use produces deficiencies of inhibitory control. Given the above mentioned links between DA and inhibitory action control on the one hand and between DA and khat on the other hand, we expected impairments of inhibitory control among khat users.

Material and Method Participants
Forty young healthy adults (36 men and 4 women) were compensated for their collaboration. They constituted the two groups of khat users and khat-free controls. The sample was drawn from 50 adults in the Leiden and The Hague metropolitan area, who volunteered to participate in studies of behavioral pharmacology. Participants were recruited via ads posted on community bulletin boards and by word of mouth. We made sure that the users met the following criteria: (1) last month consumption by chewing route for a minimum 1 year; (2) no clinically significant medical disease and (3) no use of medication criteria. All khat users met more than four of the seven criteria that according to the American psychiatric Association DSM-IV and the World Health Organization (ICD-10) define addiction: tolerance, withdrawal, difficulty controlling the use, negative consequences for job, family and health, significant time or emotional energy spent in searching/consuming the drug, put off or neglected activities because of the use, and desire to cut down the use. Khat-free controls met the same criteria except that no one reported any history of past or current khat use.
Participants were asked to refrain from taking all psychoactive drugs for at least 24 hours before the test, not to consume alcohol on the night before the experimental session, and to have a normal night rest. Participant's compliance with the instruction was encouraged by taking a (no further analyzed) saliva sample test at the beginning of the session. In psychopharmacological research this deceptive method is often used and considered effective in studies addressing acute effects (Colzato, Erasmus, & Hommel, 2004;Ridderinkhof et al., 2002) and long-term effects of drugs (Alting von Geusau, Stalenhoef, Huizinga, Snel, & Ridderinkhof, 2004;. Participants in two groups were matched for ethnicity (100% African), age, sex, IQ, (measured by Raven's Standard progressive matrices (SPM); Raven, 1988) and alcohol and cannabis consumption. Even if khat was the preferred drug of use for the participants, some of them drunk alcohol (7) on a weekly base and used cannabis (3) monthly base. All khat users (and non-users) reported to have never used LSD, MDMA, cocaine, amphetamine, barbiturates, ketamine, GHB or speed. Demographic and drug use statistics are provided in Table 1. Written informed consent was obtained from all participants after the nature of the study was explained to them. The protocol and the remuneration arrangements of 25 Euro were approved by institutional review board (Leiden University, Institute for Psychological Research).

Apparatus and stimuli
The experiment was controlled by a ACPI uniprocessor PC running on an Intel Celeron 2.8 gHz processor, attached to a Philips 109B6 17 inch monitor (LightFrame 3, 96 dpi with a refresh rate of 120 Hz). Responses were made by pressing the "Z" or "?" of the QWERTY computer keyboard with the left and right index finger, respectively. Participants were required to react quickly and accurately by pressing the left and right key in response to the direction of a left-or right-pointing green arrow (go trials) of about 3.5 X 2.0 cm with the corresponding index finger.

Procedure
All participants were tested individually. Participants completed the SPM (Raven et al., 1988) and performed the stopsignal task for about 30-min. Participants were allowed to take a short break (up to 5 minutes) between task blocks.

IQ
Individual IQs were determined by means of a 30-min reasoning-based intelligence test (Raven Standard Progressive Matrices: SPM). The SPM assesses the individual's ability to create perceptual relations and to reason by analogy independent of language and formal schooling; it is a standard, widely-used test to measure Spearman's g factor as well as fluid intelligence (Raven et al., 1988). Participants completed the SPM and subsequently performed on the behavioral task measuring inhibitory control.

Stop-Signal Task
The experimental session consisted of a 30-min session in which participants completed a version of the stop-signal task adopted from Colzato et al., (2007); see also Colzato et al., 2010). Each trial began with the presentation of an arrow (pseudo-randomly) pointing to the left of right (with a probability of 50% each). Arrows were presented pseudo-randomly for maximal 1500 ms, with the constraint that they signaled left-and right-hand responses equally often. Arrow presentation was responseterminated. Intervals between subsequent go signals varied randomly but equiprobably, from 1250 to 1750 ms in steps of 125 ms. During these interstimulus intervals, a white fixation point (3 mm in diameter) was presented. The green arrow changed to red on 30 % of the trials, upon which the choice response had to be aborted (stop trials). A staircasetracking procedure dynamically adjusted the delay between the onset of the go signal and the onset of the stop signal to control inhibition probability (Levitt, 1971). After a successfully inhibited stop trial, stop-signal delay in the next stop trial increased by 50 ms, whereas the stop-signal delay decreased by 50 ms in the next stop trial when the participant was unable to stop. This algorithm ensured that motor actions were successfully inhibited in about half of the stop trials, which yielded accurate estimates of SSRT and compensates for differences in choice RT between participants (Band, van der Molen, & Logan, 2003; see Figure 1). The stop task consisted of five blocks of 104 trials each, the first of which served as a practice block to obtain stable performance.

Figure 1.
Calculation of stop-signal RT (SSRT) according to a race model. The curve depicts the distribution of RTs on go trials (trials without a stop signal) representing the finishing times of the response processes. Assuming independence of go and stop processes, the finishing time of the stop process bisects the go RT distribution. Given that the button-press response could be withheld in 50% of all stop trials, stop-signal RT (200 ms) is calculated by subtracting the mean stopsignal delay (100 ms) from the median go RT (300 ms).

Statistical analysis
First, independent samples t-tests were performed for analyses of age, sex, IQ differences between genotype groups. Second, individual SSRTs for stop-signal trials were calculated to index response inhibition for all participants. SSRTs were analyzed separately by means of univariate ANOVAs with Group (Khat users vs. Khat-free controls) as between-subject factor. Third, to test whether the magnitude of inhibitory efficiency is proportional to the degree of exposure to khat, we computed Pearson correlation coefficients between the amount of cocaine consumed and SSRT. A significance level of p<.05 was adopted for all statistical tests.

Stop-Signal Task
Analyses of mean RT to go-signals showed that khat users (530 ms) did not react significantly faster than khat-free controls (480 ms). SSRTs were computed for each participant and for each group separately. All participants were able to stop their responses on stop-signal trials successfully in about half of the time a stop signal instructed them to do so (51.9 % in Khat users and 49.7 % in Khat-free controls), indicating that the dynamic tracking algorithm worked well in both groups. The percentage of choice errors to gosignals was low and did not discriminate between Khat users (1.8 %) and Khat-free users (1.0%). Most importantly, SSRTs were significantly longer for users (236 ms) than for non-users (192 ms), F(1,38) = 33.21, p< 0.001, MSE = 584.624, η 2 p = 0.47, see Figure  1. To test whether the magnitude of cognitive impairments is proportional to the amount of Khat consumed, we computed Pearson correlation coefficients between the individual lifetime khat exposure, hours chewing and number of bundles used in a khat session and SSRT. No significant correlations were obtained, probably due to the limited distribution of the data.

Figure 2.
Calculation of stop-signal RT (SSRT) according to a race model. The curve depicts the distribution of RTs on go trials (trials without a stop signal) representing the finishing times of the response processes. Assuming independence of go and stop processes, the finishing time of the stop process bisects the go RT distribution. Given that the button-press response could be withheld in 50% of all stop trials, stop-signal RT (200 ms) is calculated by subtracting the mean stopsignal delay (100 ms) from the median go RT (300 ms).

Discussion
This study tested, for the first time, whether the use of khat is associated with a detectable selective impairment in the ability to inhibit responses. As expected, we found that khat users were roughly comparable to khat free controls in Go RT but khat users showed significantly elevated SSRTs. In other words, chronic khat use is associated with impaired inhibitory control. We attribute this deficit to the possibility that, at long-term use, cathinone, the active ingredient of khat, is associated to dysfunctions in PFC and a reduced DA level in the striatum -the neurotransmitter that plays a crucial role in response inhibition (Colzato et al., 2010;Colzato et al., 2007;Gauggel et al., 2004).
It may be important to note that the group difference in response execution was unreliable but approached the statistical significance level, suggesting that a larger sample might have rendered this effect reliable. On the one hand, this means that it would be premature to exclude a general performance deficit in chronic khat users until converging evidence is available. On the other hand, however, the staircase method that we used allowed separating SSRT from the general RT level, which ensures that the former cannot be explained on the basis of the latter. That is, the SSRT effect does indicate a specific impairment in inhibitory processes in khat users over and beyond a possible general performance deficit.
Even though the empirical connection between inhibitory control functions and khat use is considerable, the causal relation between the two may not be straightforward. Indeed, we cannot exclude that preexisting neuro-developmental factors may play a mediating role and that khat users may suffer preexisting problems in inhibitory control and impulsivity, as it is already the case for cocaine users (Bechara, 2005;Verdejo-García, Lawrence, & Clark, 2008). Notwithstanding this caveat, the connection between inhibitory efficiency and khat use seems rather strong -the more so as a number of possible confounds were controlled for in this study: the khat users that participated in the current study were barely exposed to other drugs and the two groups were well matched in terms of age, IQ, sex, race, and alcohol and cannabis consumption. Especially the matching of age was essential: while inhibitory control seems not to be related to general intelligence, there is evidence that cognitive inhibitory processes decline in efficacy throughout the life span (Williams, Ponesse, Schachar, Logan, & Tannock, 1999).
The present findings raise the question whether recreational khat users also show impairments in other cognitive control functions, such as the shifting between tasks and mental sets, and the updating and monitoring of working memory (Miyake et al., 2000). The direct effects of khat use on the brain need to be explored as well. It remains to be demonstrated, for instance, that the use of khat produces changes at neuromodulatory level (DA), cortical functioning (decreased neural activity in the striatum and prefrontal cortex), genetic vulnerability and changes in expression of genes. For instance, it would be informative to investigate whether, among khat users, there is also a genetic association with the Taq A1 of the DRD2 polymorphism as in the case of alcohol dependence (Blum et al., 1990) and cocaine addiction (Noble et al., 1993). This association would be useful as marker for a genetic vulnerability.
Of particular interest would be to look into the acute effects of khat. Previous research addressing the acute effect of other psychostimulant drugs -as cocaine -has shown a druginduced facilitation of inhibitory control (Fillmore, Rush, & Hays, 2006). Interestingly, in this study, stop-signal performance revealed a quadratic dose-response function suggesting that the improvement of inhibitory control is limited to a range of intermediate doses, while with lower and higher doses performance deficits are more likely. It also remains to be seen whether the longterm use of khat has similar effects and after-effects (after periods of abstinence) on receptor characteristics, DA sensitivity, etc., as have been observed with the long-term use of other psychostimulant drugs like cocaine (Kreek, Nielsen, Butelman, & LaForge, 2005).
The findings of this study are rather worrying because, first, many real-life situations require the active inhibition of prepotent actions, as in the case of traffic lights turning red or of criminal actions. Consistent with this idea, the increasing number of traffic accidents in the Eastern Africa countries has been related to the chewing khat habit (Toennes & Kauert, 2004). Chronic khat use may indeed lead to a marked deterioration of psychophysical functions (as inhibitory control) implicated in driving behaviour.
Second, this impairment of inhibitory control has serious implications for personal or societal functioning. This reduced level of inhibitory control may even be involved in the emergence of addiction: the more a drug is used, the less able users are to prevent themselves from using it. In fact, socioeconomic and familiar problems are common among khat consumers. Many men secure their daily portion of khat at the expense of vital needs, indicating dependence. Family life is harmed because of neglect, dissipation of family income and inappropriate behaviour and in countries like Ethiopia or Kenya, khat addicts are the main group among persons treated for drug problems (UNODC: World Drug Report, 2010).