The khat plant contains psychoactive alkaloids with psychostimulant properties, and has been used for centuries as a recreational and religious drug, mainly in some African and Middle Eastern countries. With changing migration patterns, epidemiological and clinical outcomes may have changed. The aim of this article is to review current knowledge on pharmacological, epidemiological and clinical aspects of khat use. Khat use is still highly prevalent in the countries mentioned, and in African and Yemeni emigrant groups. Preclinical and clinical data confirm its addictive potential as well as possible psychological, psychiatric and medical consequences related to stimulant use; however, existing epidemiological studies do not focus on the prevalence of problematic use or dependence. There are no indications of high prevalence of khat use in other cultural and ethnic groups. Data are lacking on possible increased psychotogenic risks when khat is used outside of the original cultural context. As with alcohol use in many countries, khat use can be considered as a lifestyle in some specific countries, covering the spectrum from nonproblematic use to problematic use and dependence. Khat dependence is associated with high morbidity and societal and economical costs.

Psychiatric advance directives (ADs) allow an individual to state their preferences for future treatment at times when they may be unable to make considered decisions. There are differences in their form and legal value and the process associated with their use and completion. Several studies have now been completed to assess the impact of ADs on service use and coercion. Their results give a mixed picture but directives nevertheless have the potential to support the empowerment process, minimize experienced coercion, and improve coping strategies. These may in turn reduce the frequency of in-patient service use. Further studies on the different processes of facilitation involved and on different populations are necessary to improve our knowledge and use of these potentially powerful interventions.

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Topiramate is one of the currently most promising compounds in the field of addiction medicine. This paper discusses its potential utility related to a phase model of addiction development, focusing on the assumption that addiction is a continuous process involving different neurobiological pathways, depending on the stage of addiction. A specific emphasis will be made on the development of dysfunctional automatic behaviors in late stage of addiction and the central role of glutamate and AMPA receptors. The aim is to propose that if a too broad effect of anti-addiction medication is expected (such as anti-craving, anti-relapse and preventive effects), the results might be disappointing. The speculative specific efficacy of topiramate in addiction is described.