Mental illness is an international health crisis that puts the lives of over three hundred million people (Four percent of the world’s population) at risk. The study was conducted at the Erigavo Mental Hospital in Somaliland and its main focus was the bond between substance abuse and mental illness. The research was to check the influence of the different drugs, screen mental health problems, and draw a link between drugs and mental illness. The sources of the quantitative data were a total of 27 employees and managers. This study is cross-sectional. We employed the measure of the magnitude and direction of a linear relationship between two variables with the Pearson correlation coefficient. The outcomes that were acquired show that there was use and particularly abuse of khat, substance smoking, and alcohol consumption, the score means of which were quite high. The investigation results, however, imply that through drug use and other forms of alcohol drug abuse, one of them counter various mental health problems. Furthermore, the addicted people demonstrated the tendency to use force in their attempt to solve the conflicts and to experience the highest degree of tension, with the mean score of the former giving 4.11 while the standard deviation of the latter giving 1.086, thus this shows the mental impact of drug use on the inhabitants of Erigavo. The main result of the study was the strong, positive relationship between drug addiction and mental illness, which became evident through an r - value of 0.509 and a p - value of 0.559. It means that those people who are involved in drug misuse are the ones who are likely to have mental health disorders. Based on the findings of the study, we suggest a combination of measures to recover drug addiction and mental illness. This consists in strengthening prevention. The study that lays the groundwork for suggestions, involves an approach that is holistic in nature. The main ideas of preventing drug usage, psychological health care, enhancing mental health services, and working towards certified professionals are key integrated activities of the whole concept. The hospital, thus, will be in a better position to eliminate the two major disease components namely; drug abuse and mental ailment. Thus, in this way, with the help of the new treatment approaches, a hospital provides and their patients who are quite likely to recover and lead healthy.

Mental illness is a widespread issue. Four percent of the world’s population, or more than three hundred million individuals, suffer from sadness [1]. These concerning numbers are indicative of the widespread occurrence of mental illness in general. An astounding one in four persons is said to have had mental health issues at some point in their lives [2].

There are a lot of differences, both within and across nations. It is shocking that between thirty-five and fifty percent of individuals in the Global North who suffer from serious mental health illnesses do not obtain treatment; for those residing in the South, that number almost quadruples to seventy-six and eighty-five percent [3]. The level of civil society mobilisation, which is critical for a successful response, shows a comparable discrepancy. Only forty-nine percent of low-income nations have institutions that support people with mental health issues and psychological and social impairments, compared to Eighty-three percent of nations with elevated incomes [4]. Particular communities are disproportionately affected worldwide, particularly women and the impoverished. Because they are five times more likely than the average population to experience mental health issues, refugees and asylum seekers are particularly susceptible [5]. A breakdown or crisis in their mental health affects over sixty-one percent of migrants. This draws attention to a characteristic shared by mental illnesses: much like physical health, mental health is influenced by a wide range of social, political, and economic circumstances. These include discrimination, exposure to violence, unemployment or precarious employment, education gaps, and social and economic hardships [3].

Drug abuse is a part of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association and the International Statistical Classification of Diseases (ICD) published by the World Health Organisation no longer includes the diagnosis of “drug abuse.” [6].

The prevalence of khat usage in East Africa was determined to be 37.8%. Males (73.5%) made up the majority of khat users, followed by those in the 18–24 age range (41.1%), Muslims (46.6%), Oromo ethnic group (47.2%), single (51.4%), high school students (46.8%), and working adults (80%). By applying the Self Reporting Questionnaire-20’s cut-off point of 7 out of 20, it was determined that 25.8% of the research participants experienced mental discomfort. Higher rates of mental discomfort were seen among males (26.6%), those over 55 (36.4%), Orthodox Christians (28.4%), Kefficho ethnic groups (36.4%), widower (44.8%), uneducated (43.8%), and farmers (40.0%) [7].

Many people in Somaliland regularly ingest a drug known as khat. This chemical belongs to the amphetamine family of drugs and has stimulant properties [8]. The majority of Somali males chew this, which is made of fresh leaves. It is imported from Ethiopia and is cultivated in small quantities by farmers in Somaliland [9]. Khat affects a person’s mental and psychological well-being aside from its impact on the community as a whole. It also has social, economic, and health implications [10]. Khat was identified in the 2004 GAVO mental health situational analysis report as one of the primary problems impacting mental health. When asked if they thought Khat causes mental illness at this baseline exam, 37% of respondents said they did. On the other side, a 2002 VIVO survey found that 80% of individuals with psychosis had used Khat excessively before becoming unwell [11].

The Ministry of Health does not have a written policy on environmental issues health and safety, which enables psychiatric health care providers to enhance the quality of care provided to patients. Moreover, the Erigavo Mental Hospital does not appear to be making the necessary efforts to support the integration of screening, inspections, interventions, medication use, and care coordination between general health systems and specialty substance use disorder treatment programs or services [11].

The Erigavo community in Somaliland faces a serious problem with mental disease. Extended hospital admissions due to mental health problems are a common sign of a significant health crisis in the area. Frequent indications of mental illness are depressive or hopeless feelings, disoriented thought patterns, excessive anxieties or fears, sharp mood swings, and social disengagement. Although there is a wide range of possible causes of mental disease, including trauma, events in life, genetics, and the environment, the main emphasis of this study is the connection between drug usage and mental illness. It is believed that drug usage is the primary source of mental health issues in the Erigavo population. Understanding the precise consequences of drug misuse on many aspects of mental disease in the Erigavo community is the knowledge gap that this research attempts to address. Previous studies on this subject have used a variety of target demographics, research methodologies, and techniques for data processing. The purpose of this research is to give a thorough evaluation of the connection between drug usage and mental illness in the Erigavo community so that more potent preventative and treatment approaches may be developed.

General objectives This study aims to assess the correlation between drug abuse and mantel illness at Erigavo Mental Hospital in Erigavo, Somaliland. Specific objectives 1. To examine the impact of different types of drug abuse at Erigavo Mental Hospital in Erigavo, Somaliland 2. To find out the level of mantel illness at Erigavo Mental Hospital in Erigavo, Somaliland 3. To establish the relationship between drugs and mantel illness at Erigavo Mental Hospital in Erigavo, Somaliland.

Research approach and design

This cross-sectional research, which employed quantitative methods, was carried out in the Erigavo district. Through methodical data collecting that addressed the research study, it outlined the study’s objectives. The psychiatric hospital in Erigavo, Somaliland employed a standardized questionnaire to gather quantitative data on drug usage and mental disease. The methods and approaches utilized for the research paper’s entire activity, comprising the many actions conducted during the study, served as the main foundation for this work.

Research population

The entire population with the same necessary features made up the research population for the study. Twenty-nine people were the study’s target population. To get the necessary data for the study, the researcher spoke with hospital workers at several of Erigavo’s mental health facilities.

Inclusion criteria: The participants were picked according to their direct engagement in the provision of mental health care within the health facilities of Erigavo. This comprised of the physicians, nurses, and auxiliary personnel who worked in the psychiatric wards or mental health units. The inclusion criteria demanded that the participants must be in mental health care for more than a year and also have activeness which necessitated them to be employed at the time of the research to achieve the most accurate and relevant findings.

Exclusion criteria: The study’s researchers rejected individuals who were not directly involved in mental health care or lacked relevant professional experience. Hospital staff who solely work in non-psychiatric departments, temporary employees, and those with less than a year of mental health care experience were the ones not considered. Apart from that, retired or former staff members were excluded to maintain current perspectives.

Sample size

The procedure of choosing certain components from the study’s target population determined the sample size. Therefore, the study’s sample size consisted of 27 participants, including managers and staff, from the Erigavo mental institution. These chosen respondents provided the required data for this investigation and made up the study’s sample size. The Slovene formula of selection served as the researcher’s direction for determining the study’s sample size.

$n=\frac{N}{1+N(e^2)}$

N: Population size

n: sample size

E: level of significance = e=0.05

$n=\frac{29}{1+29({0.05}^2)}=27 respondents$

Sampling procedure

Purposive sampling was the methodology behind this work, guaranteeing the desired amount and quality of the respondents’ answers. To ensure the group they desired to participants was chosen, we carefully hand-picked the participants.

Research instruments

The questionnaire was an essential data collection instrument. The questionnaire was the primary weapon used. A self-administered questionnaire was made to collect the data for this study. The survey consisted of both closed- and open-ended questions. Questionnaire: The data collection tool used in the research was a survey that incorporated the aforementioned questionnaire. The majority of the main data was gathered by the researchers, who used this approach to acquire data. The respondents were given the questionnaires to complete. The survey instrument was elaborated and given to participants in Somali which was the first language of the study subjects. This not only allowed for clear understanding but also accurate responses as all the respondents were Somali speakers. The reasoning for the use of the native language was to banish the nullification of the language barriers that had caused unclearness in the questions and the poor quality of the answers.

Validity and reliability

These are the tools that the researcher utilised to test the consistency of the instrument and provide clarification. In order to ensure that there are no errors, it is also used to test validity and dependability. Next, the researcher applies the following formula to ensure validity and reliability.

$V=\frac{RQ}{TQ}$

V: Validity

R: Reliability

RQ: Relevant Question

TQ: Total number of Questions

$V=\frac{13}{18}=72\%$

Data gathering procedure

Once the questionnaire was ready, the researchers used it to gather pertinent data for the study, both main and secondary, and sent the respondents a transmittal letter to let them know what was going on. As researchers, they went through the following three steps to gather and classify the data: Prior to gathering data: The research study’s instruments were ready at this point so that it could be carried out successfully and quickly. While gathering data: In order to minimise the amount of time, the researchers took use of this opportunity to set appointments and timetables for their responders. Following data collection: In order to determine whether any data was missing, the researchers sorted and verified the data at this point in order to prepare it for analysis and presentation.

Data analysis

In this study, the correlations were investigated through the performance of correlation tests, which aimed to show the fashion in which drug abuse and mental health outcomes are related to one another. The Pearson correlation coefficient, being the measure of the strength and direction of the linear relationship of variables, helped to achieve the goal by employing the Pearson correlation analysis. The p - values, which in this case were empirical, were the mechanism through which the statistical significance of the connection between the variables detected was estimated. Namely, p - values less than 0.05 were considered indicators of strongest correlations. Along with this, the mean and standard deviation were calculated to evaluate the availability of resources. The Statistical Package for the Social Sciences (SPSS), version 25, was the tool that was useful for the analysis: it gave a wholesome search and understanding presentation of the data that is included. The statistical report allowed the possibility for us to find the defining patterns and relations.

Demographic characteristics of the respondents

Based on the data presented in Table 1, the gender distribution of the respondents at the Erigavo Mental Hospital in Erigavo, Somaliland shows a predominance of male participants. Out of the total 27 respondents, 17 were male, accounting for 65% of the sample. The remaining 10 respondents were female, making up 35% of the total. This gender distribution suggests that a larger proportion of the patients receiving treatment at the Erigavo Mental Hospital are male. While the reasons for this gender imbalance are not explicitly stated, it could potentially be influenced by various socio-cultural factors, access to healthcare, or the prevalence of drug abuse and mental illness patterns within the local community.

The age distribution of the respondents at the Erigavo Mental Hospital, as shown in Table 2, reveals that the majority of the participants fall within the 21-34 years age group. Out of the 27 total respondents, 15 individuals, or 56%, are in this age range. The next largest age group is the 44-54 years category, which accounts for 19% of the sample, with 5 respondents. The next group: range of 34-44 years, accounts for four diagonal lines respectively which is equivalent to about 15% of the sample. The “Under 21 years” group only has a single, respondent (4%) while the remaining age groups are both made up of two respondents each; in the final age group –”Above 54 years”. The observed predominance of the 21-34 years age group may suggest that the population visiting or receiving treatment at the Erigavo Mental Hospital is more commonly sought by drugs and mental diseases within adult young populations. This age distribution is an essential aspect of the study since it can alter the type and degree of the associations between drug abuse and mental illness. The researcher must give attention to these age-related trends and their possible effects on the understanding of the dynamics of the issue in Erigavo.

The data in Table 3 sheds light on the educational backgrounds of the respondents at the Erigavo Mental Hospital. The results point to a broad spectrum of education acquired by the people involved. The biggest part 41%, that is, of the respondents, has a degree-level qualification. The next group of people is the Master’s degree group, which forms 37% of the sample. In total, the two higher education categories make up the educational background of most of the participants. Among the remaining respondents, there are those with a diploma (15%), a primary education (4%), and a secondary education (4%). The results show that a small proportion of the sample has a lower level of formal education. The majority of respondents have degree and master’s-level qualifications. This indicates the Erigavo Mental Hospital serves a high educational background population. This may be due to factors such as the availability of healthcare resources, socioeconomic status, or the type of mental health and addiction services that the facility provides.

The data in Table 4 gives us information about the marital status of the respondents at Erigavo Mental Hospital. The findings indicate that most of the people, 56% or 15 of them, are single. The second largest group refers to married respondents who account for 35% or 9 individuals. The rest of the 3 respondents, which is the same as 9% of the total, are widowed. The prevalence of single individuals among the study participants implies that unmarried people might be at a higher risk of seeking or receiving treatment at the Erigavo Mental Hospital. This may be connected to a variety of elements, including social support networks, financial resources, or the risk factors for drug abuse and mental illness among single individuals in the local community. Respondents who were single or married and a small group of widowed individuals show that the study sample is diverse concerning marital status. This diversity is likely to be a contributing factor to the deeper insight into the multidimensional relationships among drug abuse, mental illness, and marital status in the Erigavo.

To examine the nature of drugs

To detect and enlighten the participants about the properties of different drugs, Table 5 is used. A mean range of 4.01-4.76 indicates “Strongly Agree,” being a “Very High” level of text agreement with drug theses. It is agreed by people that the mean scores are between 3.26-4.00 which is considered “High”, on the “Volume” scale, while 2.52-3.25 are cited in the very “Neutral” or the “Moderate” area. On the other hand, a score of 1.76-2.50 means “Disagree” on the “Low” end, and 1.00-1.75 is “Strongly Disagree,” where to answer this way will be “Very Low”.

As shown in Table 6 that exhibits the types of drugs, mainly the adverse effects that drugs have on mental health, as perceived by the respondents at Erigavo Mental Hospital.

The means for all table parameters are higher than 3.5, which implies that the participants are in nearly perfect agreement with each other. This implies that the citizens are well aware and can identify the different means by which drugs together with alcohol and khat can cause or worsen mental health problems.

In short, the respondents are of the opinion that drugs are chemical substances that cause a change in physical, emotional, or behavioral states in the drug user. They equally support the fact that alcohol can change the chemistry of the brain, thus, having unfavorable effects on mental health (mean = 4.07) and that psychiatrists declare most people mentally sick when they chew khat (mean = 4.07).

Besides that, the respondents strongly support the idea that taking chewed Khat can lower the immune system, thereby possibly causing mental illness (mean = 4.11), and also that Khat can cause the user to behave strangely (mean = 4.11). They also strongly believe that when a person becomes addicted to khat, they can experience stress, which may lead to mental illness (mean = 3.67). The respondents also strongly agree that alcohol consumption can change the normal intellectual way of thinking, causing mental disorders (mean = 3.93) and that the coexistence of alcohol problems and mental ill health is very common (mean = 3.93). They also agree that smoking is associated with a range of mental disorders, including schizophrenia (mean = 3.56).

The high level of agreement across these various aspects of drug use and mental illness suggests that the respondents have a comprehensive understanding of the complex relationships between substance abuse and mental health. This understanding may have been shaped by their experiences and observations within the Erigavo Mental Hospital, as well as their broader knowledge and awareness of these issues in the local context.

To find the level of mental illness

The data presented in Table 7 explores the respondents’ perceptions of the level of mental illness and its various manifestations. The mean scores for all the variables in the table are above 3.4, indicating a very high level of agreement among the participants. The respondents strongly agree (mean = 4.11) that individuals with mental health disorders often feel depressed, down, or hopeless. They also strongly believe that mental disorders can significantly impact the person’s relationships (mean = 4.04) and their daily life due to physical health issues (mean = 4.00). The respondents strongly agree that a history of mental illness in a person’s family may be a contributing factor to their own mental disorder (mean = 3.96). They also strongly believe that mental disorders can lead to worries that something is seriously wrong with the person’s body (mean = 3.89) and that mental illness can sometimes cause a family breakdown or occur when the parents are deceased (mean = 3.74). The respondents strongly agree that the treatment of mental illness often involves a combination of psychotherapy and medication (mean = 3.48) and that individuals with mental illness may experience suicidal thoughts or have plans to harm themselves (mean = 3.67). Furthermore, the respondents strongly believe that mental disorders can affect the quality of sleep, with individuals experiencing either less or too much sleep (mean = 4.11). They also expressed agreement regarding the difficulty of a person ill with a mental disorder to come to the point of doing things (mean = 3.63). The consistent level of agreement in these different dimensions of mental illness shows that the respondents have a full knowledge of the multifaceted nature of mental health disorders. This understanding might have been influenced by their experiences and observations in the Erigavo Mental Hospital, as well as their broader knowledge and awareness of mental health issues in the local context. The respondents’ ideas expressed in Table 7 reveal the complexity of mental illness and its profound effects, which include not only the physical and psychological health of the individuals but also their family relationships and everyday performance. This knowledge can be used to create more comprehensive and efficient methods of mental health treatment and care for the people in Erigavo.

The relationship between drug abuse and mental illness

According to Table 8, the study established to make an analytical analysis on the objective which is stated that there is a relationship between drug abuse and mental illness in Erigavo Mental health. The study findings revealed drug abuse and mental illness in Erigavo Mental Health Hospital had an r - value of 0.509 and a p - value of 0.559 This means that there is a relationship between drug abuse and mental illness in Erigavo mental health hospital. It is accepted that there is a strongly positive relationship.

Narrative analysis

The narrative analysis presented in Table 9 provides valuable insights into the perspectives and experiences of the respondents regarding mental health practices, treatment options, and strategies to address drug addiction in the Erigavo community. From the analysis made, it was found that most of the respondents agreed there are no proper in-and-out patient care practices for psychiatric patients by the Ministry of Health. If this is the case it highlights how poor mental health support from government departments means that people with severe and enduring, complex needs are getting neglected. In terms of strategies on how mental illness could be treated, the participants suggested that treating a patient with both medication and psychological intervention coupled with access to whole healthcare services is possibly efficacious. It further suggests a preference for a comprehensive, multidisciplinary model in mental health care. In order to fight against drug addiction, the respondents proposed two main ways of acting: introducing activities whose aim is an increase social awareness about the negative consequences of taking narcotic substances and regulating the sale of potentially intoxicating goods. It serves to underline the importance of an integrated strategy that targets education, prevention, and enforcement against the root causes of drug taking. They also warned how changes in the behavior of people can be a red flag for drug use, and that help is nationwide from psychologists to social workers. This highlights the need for early intervention and substance abuse assistance programs. Mental health and substance abuse intervention verifications as well as the Erigavo community can be more comprehensive and more effective if they are built from conclusions made. By addressing the gaps and challenges identified by the respondents, the Ministry of Health can work towards creating a more supportive and inclusive environment for individuals with mental health and substance abuse concerns.

According to the study’s findings, drug addiction and the treatment of mental illness are closely related among the respondents who work at the Erigavo Mental Hospital. Specifically, using correlation analysis, the results showed a positive association (r = 0.509, p = 0.559) indicating that a higher proportion of individuals with substance misuse problems also had mental health difficulties. This is consistent with earlier research in the field that highlights the strong correlation between substance abuse disorders and mental health issues. Schuckit [12] also found that drug abusers must have been exposed to psychiatric conditions such as depression, anxiety, and psychosis. Morisano, Babor, & Robaina [13] provide support for the ongoing importance of the co-occurrence of drug abuse and mental illness in public health, reporting comparable rates of these co-occurring conditions. The results of prior studies are supported by the equal distribution of the sexes, the male group’s higher exposure (65%), and the study’s further evidence of the younger age group’s preponderance (56%) of participants aged 21 to 34. According to a study by Tuchman [14], men are more prone than women to engage in risky behaviours, such as substance misuse, which may be the direct cause of mental health problems. Women who suffer from depression or anxiety frequently exhibit internal symptoms, such as fear and hypochondria. However, owing of the social and cultural stigma, they are also disregarded and marginalised in communities that are seeking therapy. This uneven representation of genders can be attributed to a variety of factors, including cultural norms, disparities in the delivery of healthcare services, or stigma associated with seeking mental health treatment, particularly in traditional communities such as Somaliland. The intriguing finding that lower education levels and drug misuse have a common link is that the percentage of high respondent education level (41% parts for degrees and 37% for master’s degrees) contradicts this finding. Sogunro [15] has a contrasting view, suggesting that in addition to schooling, increased stressors like pressure from the workplace may also be to blame for these people’s feelings of needing to turn to drugs or other alternative forms of stress relief. Furthermore, research findings indicate that respondents believed that khat addiction contributed to mental health issues. The first reports on the topic came from Hansen [9], who conducted a study demonstrating how the common practice of chewing khat in Somaliland and other parts of the Horn of Africa can lead to mental health issues like anxiety, depression, and psychosis. Participants’ overall perception of the detrimental effects of alcohol and khat on mental health is in line with findings from studies on substance misuse conducted around the world, which indicate that both substances are linked to mental health issues [16]. Therefore, the findings of this study support the widely accepted notion that substance addiction and mental illness are related, as well as the typical demographic trends that support this theory. The perspectives expressed by the participants are highly informative and have the potential to inform the implementation of public health interventions in Erigavo. Consequently, they underscore the importance of employing integrated strategies that tackle mental health and drug misuse.

The study established the effect of drug addiction and mental health, in this section the researcher gives the conclusion to the study findings related to the study objectives. The results indicated that there were females more than males among the individuals working in the Erigavo mental hospital and the majority of the respondents were junior staff. Second, the study established the level of mental illness and the effect of drug addiction. There is also a significant and positive relationship between mental illness and drug addiction. Better mental health and reduced drug use help people to promote their health. In addition to that, the hypothesis of the researcher was accepted and the theory on which the study is based is proven because the majority of the respondents agreed that drug addiction causes mental illness as well as that reducing substance abuse promotes people’s health. The Erigavo Mental Hospital should give more consideration to the needs and concerns of the Department of Mental Health also the Ministry of Health should have a written health and safety policy that includes programs and producers for environmental health and safety which helps the psychiatric healthcare workers to improve the quality of care and efforts are needed to support integrating screening, assessments, interventions, use of medications, and care coordination between general health systems and specialty substance use disorder treatment programs or services.

Limitations of the study

There are several limitations to the study. The first issue is that the small sample size of 27 responders might not accurately represent the larger Erigavo Mental Hospital population, which could affect how broadly applicable the results are. Furthermore, the study relied solely on self-reported data, which is subject to error or social desirability bias. Furthermore, the study’s cross-sectional design makes it more difficult to determine the connection between drug consumption and mental illness. In order to overcome these constraints, future research should enlist a broader and more varied sample of participants, incorporate objective measurements in addition to self-reports, and investigate the causal linkages using longitudinal designs.

Suggestions for further research

To strengthen the conclusion’s external validity, we should think about using a larger sample size and a wider spectrum of racial and gender identities in future studies. It is anticipated to lead to a better understanding of the connection between drug usage and mental disease by including more objective measurements, such as biological markers and clinical assessments. Longitudinal assessments are recommended in order to track the participants’ changes over time and determine causality. Furthermore, by looking at qualitative research approaches and speaking with individuals from various backgrounds, we can gain a deeper understanding of the complicated subject of substance abuse and mental health.

Ethical considerations

The Sanaag University Institutional Review Board granted ethical permission for the study. Every participant gave their proper consent, ensuring that they were not coerced into publishing the study against their will. Standards of ethics were adhered to throughout the entire study process.

1. Smith K. Mental health: a world of depression. Nature. 2014;515(7526):180-181. Available from: https://doi.org/10.1038/515180a
2. Librach SL, Emanuel LL. Palliative care: core skills and clinical competencies. Elsevier Health Sciences; 2011. Available from: Available from: https://www.sciencedirect.com/book/9781437716191/palliative-care.
3. Roberts S. Mental illness is a global problem: we need a global response. Available from: Available from: https://www.healthpovertyaction.org/news-events/mental-health-world-health-day-2017/#:~:text=Mental%20illness%20is%20a%20global%20problem.,mental%20ill%2Dhealth%20more%20generally.
4. World Health Organization. Comprehensive mental health action plan 2013–2030. 2021. Available from: https://www.who.int/publications/i/item/9789240031029.
5. World Health Organization. Mental health. 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response.
6. Regier DA, Kuhl EA, Kupfer DJ. The DSM‐5: Classification and criteria changes. World Psychiatry. 2013;12(2):92-98. Available from: https://doi.org/10.1002/wps.20050
7. Damena T, Mossie A, Tesfaye M. Khat chewing and mental distress: a community based study, in Jimma city, southwestern Ethiopia. Ethiop J Health Sci. 2011;21(1):37-46. Available from: https://doi.org/10.4314/ejhs.v21i1.69042
8. Mahamoud HD, Muse SM, Roberts LR, Fischer PR, Torbenson MS, Fader T. Khat chewing and cirrhosis in Somaliland: case series. Afr J Prim Health Care Fam Med. 2021;8(1). Available from: https://doi.org/10.4102/phcfm.v8i1.1124
9. Hansen P. The ambiguity of khat in Somaliland. J Ethnopharmacol. 2010;132(3):590-599. Available from: https://doi.org/10.1016/j.jep.2010.02.028
10. Hussein YZ, Wondimagegnhu BA, Misganaw GS. The effect of khat cultivation on rural households’ income in Bahir Dar Zuria District, Northwest Ethiopia. GeoJournal. 2023;88(2):1369-1388. Available from: https://doi.org/10.1007/s10708-022-10697-2
11. GAVO. Baseline survey report on mental health situation in Somaliland. Hayaat Women Trust Org. 2004. Available from: https://www.hayaatwomentrust.org/wp-content/uploads/2013/12/gavo_mental_health_somaliland.pdf
12. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101:76-88. Available from: https://doi.org/10.1111/j.1360-0443.2006.01592.x
13. Morisano D, Babor TF, Robaina KA. Co-occurrence of substance use disorders with other psychiatric disorders: implications for treatment services. Nord Stud Alcohol Drugs. 2014;31(1):5-25. Available from: https://doi.org/10.2478/nsad-2014-0002
14. Tuchman E. Women and addiction: the importance of gender issues in substance abuse research. J Addict Dis. 2010;29(2):127-138. Available from: https://doi.org/10.1080/10550881003684582
15. Sogunro OA. Stress in school administration: coping tips for principals. J Sch Leadersh. 2012;22(3):664-700. Available from: https://doi.org/10.1177/105268461202200309
16. Edwards B, Atkins N. Exploring the association between khat use and psychiatric symptoms: a systematic review. BMJ Open. 2022;12(7):e061865. Available from: https://doi.org/10.1136/bmjopen-2022-061865