Psychiatric Treatment During Ramadan Calls for Individualized Decision-Making

By Will Boggs MD

May 20, 2019

NEW YORK (Reuters Health) - Muslims with psychiatric disorders need individualized guidance regarding their management during the Islamic month of Ramadan, when fasting can last 10 to 20 hours daily, according to a new report.

"Physician awareness regarding Ramadan fasting and openness to discussion is important in working with Muslim patients," Dr. Juveria Zaheer of the University of Toronto, Canada, told Reuters Health by email. "If a physician feels that a medication is necessary or critical, and the timing cannot be altered, it is important that they share this information with the patient in a respectful way, reviewing risks and benefits, and soliciting the patient's perspectives."

"Every patient is different; some may feel distressed while others may feel relieved and supported," she said. "Physicians can express an openness to discuss with a patient's family members or religious supports and follow their lead."

During Ramadan - from the evening of May 5 to the evening of June 4 in 2019 - Muslims abstain from food, water and sexual activity from dawn to sunset. While people with illnesses that are affected by fasting are exempted from the religious requirement to fast, many people with mental illness choose to participate due to the spiritual significance of Ramadan for Muslim communities.

Dr. Zaheer and colleagues discuss general considerations for physicians, including the timing and dosing of psychiatric medications, during Ramadan in their report, online May 2 in The Lancet Psychiatry.

Sleep patterns often change to accommodate the predawn meal (suhoor), so individuals whose exacerbations can be triggered by sleep disruption and patients with bipolar disorder who might be especially sensitive to circadian-rhythm disturbances might require special attention during this month.

Case series have suggested that eating disorders might worsen during Ramadan, so these patients might also require closer monitoring.

Muslims who consume alcohol could be at risk for alcohol withdrawal symptoms during Ramadan; they should be advised how to recognize and manage such symptoms, the authors say.

Fasting during Ramadan can have positive effects on patients' emotional and spiritual well-being and enhance social connectedness, so many patients choose to fast throughout the month. These patients, in particular, need special attention to their medication regimen and their preferences, the team advises.

For patients at high risk of deterioration if medications are changed or withheld, clinicians should advise them not to fast, although long-acting injectable medication might be an acceptable alternative.

Ultimately, patients should be supported in the decisions they make in collaboration with both a medical professional and a religious scholar.

"In Islam, many people are exempt from fasting but can benefit from the spiritual connections that Ramadan can bring," Dr. Zaheer said. "Stigma or lack of awareness related to mental health issues can be found in many communities, including Muslim ones. It is my hope that through the hard work of Muslim diaspora community members, religious leaders, activists, and mental health organizations, our communities can be safe and supportive spaces for all Muslims."

"The lack of evidence available in this area makes it an important area of research inquiry, particularly research that focuses on the lived experiences and perspectives of Muslim people with mental health conditions regarding Ramadan fasting," she said. "Working with patients, families, and spiritual leaders to destigmatize mental illness, raise awareness, and support inclusion should be a major priority."

Dr. Heba Abolaban, Women's Health Network Care Coordination Consultant with the Massachusetts Department of Public Health, in Boston, who has also reviewed the care of fasting Muslim patients, told Reuters Health by email, "Each patient is unique and should be consulted separately. An informed shared decision between the patients and their health providers is highly valued and can lead to a safe and healthy fasting whether the patient is mentally or physically ill."

When physicians believe medication is necessary, "it will be better to consult an Imam or a Muslim chaplain," she said. "This will make the patient who wishes to fast Ramadan feel more comfortable and confident in taking the decision not to fast. However, many Muslim patients are already aware about the Islamic ruling on taking a specific medication so they won't need to consult an Imam in this regard."

"Islam is the religion of mercy," Dr. Abolaban said. "If a Muslim patient cannot fast during the day for a medical reason, they can still participate in the evening meal 'iftar' if they wish to."


Lancet Psychiatry 2019.