A systematic review on the effect of Ramadan on mental health: minor effects and no harm in general, but increased risk of relapse in schizophrenia and bipolar disorder
| 11 feb 2018
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Publicado en línea: 11 feb 2018
Páginas: 7 - 16
Recibido: 26 oct 2017
Aceptado: 26 dic 2017
DOI: https://doi.org/10.2478/gp-2018-0002
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© 2018 Reinhard Heun, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
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| Authors (year) | Country | study focus | study type | Subjects | gender | age (mean) | assessment | outcome | study result | conclusion | limitations | possible bias |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Turkey | new eating disorders in adolescents | case series | 6 patients admitted to hospital | 5 females | U-17 years | case history | hospital admission | increase in admission to hospital for eating disorder during or shortly after Ramadan | Ramadan may trigger eating disorders in those with a predisposition | small sample | selection and awareness bias | |
| Kuwait | wellbeing of subjects with sleeve gastrectomy during Ramadan | within-subject design, telephone survey on fasting and non-fasting day | 207 participants who had had sleeve gastrectomy | 166 females | 35.2 years | Patient Health Questionnaire (PHQ-9) depression scores | slightly higher depression scores during versus after fasting. | fasting did not cause clinically significant depression | Fasting was well tolerated in subjects with sleeve gastrectom | selected sample, difficult to generalise | recall and response bias | |
| Oman | Ramadan as trigger of alcohol withdrawal | case report | one alcoholic | male | 48 years | patient history | symptom description | koro-like symptoms (delusion that penis was amputated] | Ramadan my trigger alcohol withdrawal | extraordinary case | awareness bias | |
| Tunisia | effects of music on sports performance during Ramadan | with-in subject design in 4 sports sessions | nine physical education students | male | 21 y | self-rated enjoyment and anxiety | enjoyment and anxiety during sports performance | reduced enjoyment during versus before Ramadan in the music condition, less anxiety in the music condition | listening to music may be beneficial during sports warming up during Ramadan | low number of subjects | selection bias, non blinding | |
| Turkey | quality of life during fasting in subjects with a cancer-related stoma | cross sectional case control with followup in fasting subjetcs | 14 fasting, 42 non-fasting subjects | 23 females.7 fasting, 16 non-fasting | 53.9 years in fasting, 56.5 years in non fasting subjects | disease specific quality of life scales | no effect on emotional, role, cognitve and social functioning | Ramadan fasting had almost no influence on quality of life. | Stoma patients should be alllowed to decide on fasting. | minor sample differences, no randomisation, very special sample | selection and recall bias | |
| France | effects of Ramadan fasting on sports performance and mood | pre-post within-subject assessments | 8 middle distance athletes | male | 25 years | Profile of Mood State Questionnaire | depression subscore | No change of depression scores between days 0, 21, 31 | The subjective mood is unchanged by Ramadan fasting | lack of control group | selection bias, limited generalisability | |
| Tunisia | effects of Ramadan on mood states | pre-post intervention | 20 soccer players | male | 17.6 years | Profile of Mood State Questionnaire | depression subscores | No change of depression scores between week before, week one and week four of Ramadan | The subjective mood is unchanged by Ramadan fasting | lack of control group | selection bias, limited generalisability | |
| Jordan | effects of Ramadan on parasuicide | naturalistic time-series analysis 1986-1991 | population of Jordan | both | not provided | reports of parasuicide who seeked medical aid | numbers of events in months before, during, after Ramadan | less parasuicides reported during Ramadan | Ramadan has a short term effect on reported parasuicides during but not after Ramadan | reporting bias, difficult to generalise to other countries | possible awareness bias, low number of reported versus expected parasuicides | |
| Morocco | relapse rates in bipolar disorders during Ramadan | prospective cohort study | 170 patients with stabilized bipolar disorder | 87 females | 36.2 years | Hamilton Depression Rating Scale, Bech-Rafaelsen Scale, for anxietyamilton Anxiety Rating Scale | 37 out of 111 fasters, 9/59 non-fasters relapsed | Fasting during the Ramadan month increased the risk of relapse among bipolar patients by 2.77 fold in comparison to nonfasters | Fasting during Ramadan may have negative impacts on bipolar disorder. | selected hospital sample in psychiatric care | selection bias | |
| Erol, Baylan, Yazici 2012 | Turkey | effect of Ramadan on eating behaviour | pre-post follow up | 79 young volunteers who consistently fasted during Ramadan | 63 females | 16.3 years in both gender groups | Eating Attitude Test and Bulimic Investigatory Test, Edinburgh | no change in score before to after Ramadan | no change in self-reported eating behaviour | Ramadan does not affect eating behaviour | low sample of males | selection bias |
| Iran | effects of Ramadan on quality of life in Multiple Sclerosis | pre post follow up | 218 Multiple sclerosis patients selected via MS society | 150 females | 33.6 years | Multiple Sclerosis Quality of Life-54 (MSQOL-54] guestionnaires | hogher MSQOL-54 after fasting | The mean mental health composites of quality of life increased significantly after fasting | increased mental health relate d quality of life of MS patients after versus before Ramadan | selected sample, difficult to generalise, short study duration | selection bias | |
| Pakistan | Effect of fasting during Ramadan on mental state in bipolar affective disorder | pre-post follow up | 62 bipolar patients | 9 females | 31.5 years | Hamilton Depression Rating Scale (HDRS] and Young Mania Rating Scale (YMRS] | significantly reduced HDRS and YMRS scores during and after Ramadan | Ramadan Lead to reduced psychopathology in bipolar patients during and after | Ramadan fasting has no adverse effects on mental state of bipolar patients | selection into tertiary treatment centre | selection and attrition bias | |
| Egypt | effects of fasting on biological parameters and mental health in schizophrenia | pre-post follow up | 100 randomly selected outpatients with schizophrenia (31 with, 69 without metabolic syndrome) | all male | 39.6 years in subjects with, 37.9 years in those without metabolic syndrome | Positive and Negative Syndrome Scale (PANSS) | 31 patients with metabolic syndrome showed increased PANSS scores | Ramadan fasting increased psychopathology in patients with high body mass index | more nutrition education may be needed for schizophrenic patients during Ramadan | selected patient group, males only | selection bias, poor generalisability | |
| Denmark | effect of Ramadan-type of intermittend fasting on cognitive function and mood | intra-individual comparisons under different conditions | 10 healthy lean volunteers | male | 25.2 years | Likert-type scale of specific mood-related feelings | reduced postive feelings in the afternoons during fasting | no effect of Ramadan-type-fasting on cognition | Ramadan-type fasting does not affect cognition in healthy volunteer, but reduces mood | selection of 10 healthy volunteers | selection bias | |
| Morocco | relapse in bipolar disorder during Ramadan | intraindividual comparisons during follow-up | 20 clinically stable bipolar patients | 11 females | 32.1 year | Hamilton Depression and Bech-Rafaelsen scales | relapse | 45% of the patients relapsed during Ramadan | Ramadan impacts on the stability of bipolar patients | low number of subjects | selection and attrition bias | |
| Marocco | irritability and anxiety before, during and after Ramadan | intra-individual pre-post follow up | 100 volunteers | male | 32 years | severity of irritability with visual analogue scale | continuous increase in irritability during the month | anxiety and irritability were increased during Ramadan | the effect is stronger in smokers | self-selection of volunteers | selection bias | |
| Iran | Effect of Ramadan on emotional reactions of nurses | pre-post follow up | 313 nurses | 137 females | 37.8 years | Depression, Anxiety and Strees Scales (DASS) | reduction of DASS scores in nurses | depression and stress levels were significantly reduced after in comparison with before the holy month | Fasting has been effective in diminishing stress and depression levels among nurses. | pre-post comparison, no data during Ramadan | selected sample | |
| Malaysia | effect of Ramadan fasting on spatial attention through emotional stimuli | pre post follow up. Imtraindividual comparisosns | 40 volunteers | 20 females | 26,3 years | guestionnaire | happiness and pleasantness added up to mood levels | fasting improved the mood of participants, i.e happiness and pleasantness | Ramadan changes the processing of emotional stimuli | poor assessment of mood | selection bias | |
| Germany | effects on mood and quality of life | propective case-control follow up | 50 young healthy subjects | male | 26.2 years | Hospital Depression and Anxiety Score, and Beck’s Depression index-ll | scores in depression and anxiety slightly improved during Ramadan | Ramadan fasting had a postitive effect on anxiety and depression | Ramadan fasting has no negative effects on mood and quality of life | depression results varied by scale used | selection bias, poor generalisability | |
| Morocco | daytime sleepiness, EEG and mood | intraindividual follow-up | eight volunteerss | male | 20-28 years | mood includng happiness, sadness, calmness and tension assessed by visual analogue scale | global mood scores decreased during Ramadan intermittent fasting, especially in the afternoon | mood and subjective alertness were reduced during the day, more pronounced in the afternoon. | Ramadan reduces daytime mood | only male volunteers, poor generalisability | selection bias | |
| Morocco | diurnal variation of mood during Ramadan | time series analyses, intraindividual | 10 healthy subjects | male | 20-28 years | mood includng happiness, sadness, calmness and tension assessed by visual analogue scale | global mood scores decreased during Ramadan intermittent fasting | Ramadan reduces morning and afternoon mood | Ramadan fasting reduced the mood during the day | selected sample of male volunteers, not representable for females | selection bias | |
| Turkey | Effects of Ramadan fasting restrictionson eating behaviours in obese women | pre-post comparison | 34 obese women | female | 40.7 years | Eating Attitude Test (EAT) and Bulimic Investigatory Test, Edinburgh [BITE] | no changes in EAT, BITE scores and Body Mass index | No changes in eating behaviour before to after Ramadan in obese women | Ramadan does not affect attitudes towards eating in obese women. | selected sample | selection bias |