Tackling Ramadan With A Mental Health Condition

As Sofia partakes in fasting during Ramadan this year, her biggest challenge is far different from that of the majority of Muslims. “Most of my friends will be struggling with keeping their energy levels up, or making sure they pray on time. For most, there’s always a challenge to make sure you don’t overeat. My challenge will be to make sure that I eat anything at all.”

The 26-year-old is one of millions of Muslims around the world currently taking part in the Islamic holy month, in which Muslims are prohibited from eating or drinking during daylight hours. For Sofia, Ramadan is extra difficult. A few years ago, she was diagnosed with anorexia nervosa, after being hospitalised when she fainted in a college class.

Though Sofia has been undergoing treatment with a therapist and learned to manage it, she says that Ramadan can often act as a trigger for the illness to creep back again. And because of the religious connotations of fasting during the holy month, she says that rather than restricting food intake being a problem, it can “sometimes be encouraged” and seen as a sign of devotion to God.

“I’m a devout Muslim, and one of the five pillars of Islam (the obligations upon all Muslims) is Sawm (fasting). So every time Ramadan comes, I believe I have to fast. At the same time, I’m always in fear that it [the eating disorder] will come back. It feels like there’s always this conflict between my body and my soul.”

Though Islamic scholars tend to urge Muslims who are fit and able-bodied to fast, the vast majority agree that fasting should not be obligatory for those who are pregnant, elderly or sick. And though this would normally mean that those suffering with mental illness are prohibited from fasting, both a lack of discussion within some Muslim communities, as well as a larger, societal stigma around mental health generally, means that many Muslims with such conditions may not be aware, or don’t consider themselves to be sick enough not to fast.

“There is still a huge stigma attached to mental illness, along with a lack of understanding of how it manifests and impacts on an individual,” says Akeela Ahmed, the former executive director of the Muslim Youth Helpline and campaigner on youth and gender issues. “So often friends and families can expect someone with poor mental health to fast. Most of the people I've worked with, who are dealing with mental health issues, feel guilty if they do not fast.”

According to Ahmed, the stigmas associated with mental illnesses in Muslim communities also means that those like Sofia are sometimes left in the dark when it comes to reconciling their conditions and their religious belief. “What I found when I was working with people who had eating disorders was that it wasn’t treated like other physical illnesses,” she says. “If you’re physically unwell, then you don’t fast – but those who were dealing with mental illnesses would adjust their schedules to take their medication as part of their suhoor (morning meal) or when they broke their fasts.”

“From my experience, most Muslim people with mental health challenges receive very little support from either within their community or from mainstream agencies,” she adds. “There needs to be more work done to tackle the taboo surrounding mental health issues and raise awareness about how to manage it.”

It’s not just eating disorders. For some Muslims, the month of Ramadan can also be a challenge for managing mental health issues that are not directly related to eating. One study published by the Journal of World Psychiatry found that around 45% of Muslims reported to suffer some form of manic or depressive episode during Ramadan fasting, while other studies, including one published by the British Medical Journal, found that fasting-related changes in circadian rhythms and sleeping patterns are thought to “contribute to the exacerbation of psychiatric symptoms.”

Muhammad Haydari, a 24-year-old, is one of a number of Muslims who find Ramadan daunting in regards to managing episodes of manic depression – a diagnosis he received last year while completing his exams at university.

“At the time I was prescribed three different medications that I was taking throughout the day, as a way to manage sporadic episodes,” he says. “But when Ramadan came I wasn’t sure what to do – I grew up in a very religious household, and as the oldest man I felt it was an obligation to fast.” Though Haydari continued to take his medication, he only did so during the hours he was allowed to eat – meaning that he went without medication, despite his doctor’s warnings, for up to 18 hours.

“It was a stupid thing to do in hindsight,” he says, sighing. “But at the time I didn’t really understand what was going on and I didn’t take the illness seriously. I had also asked the Imam at the local mosque I attended – he didn’t really understand that much about mental health, so he just told me that I should fast as much as I can, and use the holy month to pray as a way of getting better.”

Haydari followed what his Imam had said, but as a result experienced some of the darkest moments of his life. “There were times when I was completely out of control – I had points where I felt I wasn’t a good Muslim and that my condition was a way of Allah punishing me. And there were other times when I had no energy and lay on the floor for hours crying and wishing I was dead... All the time I just felt I was out of control, which is kind of the antithesis of Ramadan... it’s supposed to be the time when we exercise full control of our bodies in order to worship.”

Haydari isn’t fasting this Ramadan due to taking medication, but, like Ahmed, he agrees more needs to be done to raise awareness of mental health issues in Muslim communities.

“The funny thing is, we have lots of doctors who always give talks about things like Parkinson's, or cancer, but they don’t really say much about things like depression or anxiety and other conditions that I know many young people face. It’s a huge issue that needs more attention before people get really hurt.”

It’s a sentiment shared by Dr. Mahmood Mahsid, a clinical psychiatrist who has worked with patients from Muslim backgrounds. He told me that while there was “an increasing acknowledgement about mental health” in Muslim communities around the world, illnesses would often be left untreated “until the last minute”.

“I’ll normally be referred Muslim patients once they’ve been diagnosed from the hospital, so their conditions already tend to be quite severe,” he says. “Most people generally know little about the signs and symptoms of mental illnesses. That’s particularly exaggerated in communities where speaking about mental health is already a taboo for cultural reasons,” he says.

From his experience, Mahsid says that peer pressure can also be at play when it comes to Ramadan, and not wanting to duck out of fasting. “With Ramadan it’s not just about individual worship – it’s the idea that a whole community fasts, and they come and eat together. So I imagine that lots of Muslims who take their religion very, very seriously want to be part of this community, and will put it before themselves.”

He adds: “The toughest thing to do – both as a doctor, and, I imagine, within the community, is to convince people they aren’t going to be punished for not fasting. I know of a few patients who say that Ramadan is an opportunity to be forgiven of their sins, so they feel compelled to do it, even at the expense of their health. So I think more needs to be done to emphasise that mental health matters just as much as physical health, and that not fasting because of it doesn’t make you any less religious.”

The latter is a struggle that Sofia is attempting to reconcile this year. Though she is fasting, with the help of a professional dietician, she is only doing so for six hours, rather than undertaking the full fast, and she is eating meals specifically designed for her. Yet she admits there are times that she feels her fasts are insufficient. “Rationally, my head tells me I'm doing the right thing for my body. But when I see the rest of my family and my friends doing full fasts while I get to eat, I do get a sense that theirs count for so much more, and that does have an impact on how I worship.”

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