From the Editor

For some patients, it carries deeply religious meaning. For others, it will be a time for reflection. And for us clinicians, it must be thought of in terms of patients’ management.

As our Muslim patients begin Ramadan, there are implications for care. About 80% of Muslims in North America will fast. Should medication times change? Would sleep be disrupted? Are patients on lithium at greater risk of toxicity? In a new paper, Dr. Zainab Furqan – a resident in the University of Toronto’s Department of Psychiatry – joins co-authors from three countries in considering Ramadan and care. They note that several groups are exempt from fasting but “many people who are exempt from fasting due to illness choose to fast during this month due to the spiritual significance of Ramadan for Muslim communities.”

They write: “It is important for clinicians not to undermine the importance of this spiritual practice for their patients.”

newmoon11A small moon and big challenges for care?

In this week’s Reading, we consider their new paper.

And an invitation: the Reading of the Week series invites guest contributions. If this is of interest, please let me know.


Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan”

Zainab Furqan, Rania Awaad, Paul Kurdyak, Muhammad I Husain, Nusrat Husain, Juveria Zaheer

The Lancet Psychiatry, 2 May 2019  Published Online

Ramadan is the ninth month of the Islamic lunar calendar and is a period of spiritual significance for Muslims. Fasting during Ramadan is considered obligatory for those who can do so. Muslims who fast abstain from food, water, and sexual activity from dawn to sunset. As Ramadan is observed according to the lunar calendar, the first day of Ramadan moves forward by 11 days of the Gregorian calendar each year; therefore, depending on the season and location, fasting can last between 10 h and 20 h daily. Generally, each fast is initiated by a meal before dawn (suhoor) and ended with a meal at sunset (iftaar). Qualitative studies indicate that for many Muslims, the act of fasting during Ramadan is deeply valued and cherished.

Several groups are exempted from the religious requirement to fast, including women who are menstruating, pregnant women whose health could be negatively affected, people who are travelling, children, the elderly, and people who are acutely and chronically ill, both with physical or mental illness. Illness severity and the possibility of exacerbating the condition by fasting are to be taken into account, and Muslims with such conditions are advised to consult with both a medical professional and a religious scholar about the safety and advisability of fasting before each Ramadam, where appropriate. Despite being encouraged to seek medical advice from their doctors, many people who are exempt from fasting due to illness choose to fast during this month due to the spiritual significance of Ramadan for Muslim communities.

Clinician awareness of Ramadan fasting and active probing of Ramadan fasting practice among Muslim individuals with mental disorders is particularly important because patients might look to their physicians for professional opinions about whether they can safely fast during Ramadan.

csp-photo-copyDr. Zainab Furqan

So begins a paper by Furqan et al.

They review the literature:

  • Mood Disorders. “Four studies have examined the relationship between fasting during Ramadan and effects on patients with bipolar disorder. Two Moroccan studies found relapses in either depression or mania in previously stable patients during Ramadan. By contrast, two Pakistani studies have shown improvement in mania and depression scores, without a significant difference in adverse events related to lithium.”
  • Suicide. “Several studies from Muslim-majority countries have shown a decrease in suicide incidence during Ramadan compared with the rest of the year, suggesting a potentially protective effect of Ramadan fasting in these countries.”
  • Eating Disorders. “We found no large studies that evaluated the effect of Ramadan fasting for patients with eating disorders. However, two small case series have shown potential worsening of disordered eating during Ramadan.”

The paper includes a panel box discussing “clinical considerations for physicians” (reproduced here without editing):

  • Patients with bipolar disorder might be particularly sensitive to circadian rhythm disturbances and could require increased monitoring of their symptoms during this month.
  • Physicians working with patients with active eating disorders or a history of disordered eating should discuss risks and benefits of fasting and consider close follow-up in this period and in the months following.
  • Alcohol consumption is not permitted in Islam; however, clinicians should not assume that all Muslim patients do not use alcohol. Muslims with alcohol use disorder might be at risk for alcohol withdrawal symptoms during Ramadan.
  • Fasting during Ramadan might confer benefits for patient’s emotional and spiritual wellbeing, as well as social connectedness.
  • Consider including the patient’s spiritual supports in decision making if the patient would find this helpful.

They conclude:

A better understanding of the effect of fasting on health can allow for more nuanced decisions between clinicians and patients, so that informed decisions can be made about balancing faith-based practices and health.

A few thoughts:

  1. This is an important paper.
  1. This is a highly relevant paper. Again, the vast majority of Muslims in North America do fast.
  1. The authors do a solid job of providing suggestions.
  1. What about medication management? The authors pose several questions. “If a medication is dosed twice daily, can it be given safely if the interval between doses is shortened (ie, between sunset and dawn)? If a medication is activating and usually dosed in the morning, when should it be given during Ramadan? If it is given at the pre-dawn meal, will it disrupt subsequent sleep? Is the absorption of a medication affected by food? How might this affect dosing during Ramadan?” They also caution us about lithium (fasting may lead to higher levels) and potential withdrawal from some medications (like benzodiazepines).
  1. It is striking how little research has been done in this area. The authors write delicately: “high-quality evidence in this area is scarce.”
  1. This paper has received much media attention. The Globe and Mailinterview with senior author Dr. Juveria Zaheer is particularly lucid and worth highlighting.The article can be found here:
  1. This week’s paper ties in well with the recent selection on CBT for depression. At a distance, they seem to have little in common: the JAMA Psychiatry study was a network meta-analysis considering effectiveness and acceptability of different forms of CBT; this paper was a commentary on a religious event and its clinical implications. But both are trying to achieve a greater personalization of mental health care. Given the problems around medication compliance and follow-up rates, the goal of personalization is potentially life saving.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.