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

Ramadan is the ninth month of the Islamic lunar calendar, referred to as the Holy Month. Fasting during Ramadan is one of the five religious duties of adult Moslems. Moslems who participate will abstain from eating, drinking and smoking during the day from sunrise to sundown. During Ramadan, all wrongdoings including self-destructive behaviour and anger towards others are prohibited. Moslems with severe diseases can refrain from fasting during Ramadan. However, it may not be clear to doctors who is fit or unfit for fasting in different diseases.

After sundown and during the night, Moslems can eat and drink as much as they need, thus compensating for the lack of fluid and calorie intake during abstinence. Late eating and drinking either alone or in social gatherings will reduce the time available for night time sleep. Thus, the body metabolism and the diurnal sleep cycle are likely to be affected by Ramadan (Brahammam 2006).

There are 1.6 billion Moslems in the world living in many different countries and environments. Ramadan thus affects a large proportion of the global population. The social, religious and mental activities and effects of Ramadan may vary by country (Waterhouse et al. 2008).

Ramadan may affect sexual function in men (Talib et al. 2015). Ramadan can affect the chronobiology of the body temperature and energy expenditure (Bahammam et al. 2010). The effect of Ramadan fasting on sleep and daytime fatigue may depend on the season of the year, the latitude of the place, and thus the length of day and night. It may also depend on social factors such as working hours, shop opening times, meal and prayer times (Bahammam 2006).

Sleep has been shown to be affected in many psychiatric disorders: Patients with depression often suffer interrupted sleep and sleep-onset rapid eye movement periods. Poor sleep may be an early sign or a trigger of depression and manic episodes in bipolar disorder. Sleep deprivation has been used as a therapy for severe depressive disorders. During manic episodes, the need for sleep is known to be reduced. Temporary sleep changes have been observed during Ramadan (Leiper et al 2008). Most of the effects of Ramadan fasting on sleep can be reproduced by experimental fasting outside Ramadan (BaHammam et al. 2014).

Change of appetite is a main feature of different eating disorders and depression. Excessive fasting is the characteristic of anorexia nervosa. Fasting has been assumed to improve the mood, in general, but has only rarely been used to improve the mood in depression. Such interventions have not become general practice for practical reasons, but the long-term effects of fasting on mood are also not yet clear (Fond et al. 2012).

The present systematic review will focus on mental health and assess how much it is affected by Ramadan. It investigates if Ramadan and the induced fasting have positive or negative effects on mental health in the general population, in special subgroups of the populations and in different patient groups.

We performed a literature search on Pubmed and Medline in September 2017 using the following search terms: Ramadan and mental health or depression or anxiety or schizophrenia or bipolar disorder.

The search identified a total of 294 papers. We then reviewed their titles and abstracts.

One paper in French was excluded.

Ninety-nine papers were falsely identified because one of the authors had the name Ramadan, but were then excluded as these papers did not relate to the holy month of Ramadan, or mental health and Ramadan.

Of the remaining 194 papers of which the abstracts were screened, 162 papers did not focus on mental health issues according to the abstracts.

Thirty-two full papers were reviewed and assessed, and one additional paper was identified via the reference list.

Two review papers and one editorial did not contain any data. Eight other papers did not focus on mental health or provide any data on mental health in Ramadan.

The data from 22 studies were extracted and summarised in a table.

The data extraction focused on study question, study design, subject characteristics, assessment instruments, outcome, study results, conclusions and possible bias. The foci of individual studies and their designs showed considerable variety. However, we did not apply any further selection of papers concerning study type, quality and outcome, as this would reduce the number of papers considerably and would, therefore, have restricted the current already limited overview on the effects of Ramadan on mental health.

The studies on the effects of Ramadan on mood and mental health in the general population and healthy volunteers provide contradicting evidence. Three studies reported positive effects: Depression and stress levels, were significantly reduced in Iranian nurses after in comparison with before the holy month of Ramadan; the effects on anxiety levels were lower and statistically non-significant (Koushali et al. 2013). Mood and the processing of emotional stimuli in volunteers was improved during Ramadan (Molawi et al. 2016). Officially reported para-suicides in Jordan were reduced during, but not after Ramadan (Daradkeh 1992).

In contrast, five studies reported negative effects: Ramadan fasting increased fatigue in nurses (Ovuyolu et al. 2016). Irritability and anxiety were increased in healthy male volunteers during Ramadan, with the effects being more pronounced in smokers (Kadri, Tilane et al. 2000). Roky et al. (2000, 2003) reported reduced subjective alertness and mood scores in 10 and 8 volunteers during the day throughout Ramadan. Harder-Lauridsen et al. (2016) also reported reduced mood levels in volunteers in the afternoon during Ramadan.

The contradiction in the outcomes of the studies cannot be neglected or easily explained by study type. These differences will make it necessary to properly assess under which circumstances positive or negative effects of Ramadan on mental health can be observed.

The effects of Ramadan on mental well-being in sports and physical activity were mostly positive, at least not negative: Sports performance and fatigue, but not mood, were reduced during compared to before Ramadan (Chennaoui et al. 2009, Chtourou et al. 2011). Aloui et al. (2015) saw increased sports performance in physical education students with music during Ramadan, but the different effects on enjoyment and anxiety were inconsistent with a motivational enhancement by music.

These positive outcomes may be related to the fact that the observed samples consist of young physically active subjects. In general, Aloui at al. (2016) recommend that judokas only try to lose weight before or after Ramadan.

The effects of fasting on the mental health in people with some severe physical disorders were quite positive: Ramadan-related religious fasting did not cause depression or low mood in subjects with cancer-related stoma (Altuntas et al. 2013) and gastric sleeve surgery (Al-Ozairi et al. 2015). Mental health-related quality of life was even better after versus before Ramadan in patients with multiple sclerosis (Etemafidar et al. 2017).

In summary, there is some, even though limited, evidence that fasting can be performed well by subjects with some severe physical disorders.

The publications on eating and eating disorders are positive in the way that eating disorders only seem to be triggered in a small subgroup of subjects with enhanced vulnerability to eating disorders: Akgul et al. (2014) observed an increase in hospital admissions during and shortly after Ramadan in a case series that may be caused by fasting induced triggering of eating problems in vulnerable adolescents. But Ramadan fasting did not affect attitudes towards eating in young volunteers (Erol et al. 2012) and obese women (Savas et al. 2014).

Thus, Ramadan fasting does not seem to change eating behaviour in general, but it may affect eating behaviour in few subjects vulnerable to eating disorders

There is limited evidence that the effects of Ramadan fasting on mental disorders is more harmful than beneficial: Ramadan-induced alcohol restriction may lead to acute alcohol withdrawal and finally acute paranoid symptoms (Al-Sinawi et al. 2008). There was no effect of Ramadan on mental health in patients with schizophrenia without metabolic syndrome; however, positive and negative symptoms of schizophrenia deteriorated in those with a metabolic syndrome (Fawzi et al. 2015). Disease-related psychopathology, that is, depression and manic symptoms, improved in patients with bipolar disorder during and after Ramadan (Farooq et al. 2010). However, Kadri, Mouchtaq et al. (2000) observed an increase of relapses during Ramadan. According to Eddahby et al. (2014), fasting during the Ramadan month increased the risk of relapse amongst patients with bipolar disorder by 2.77 fold in comparison to non-fasters.

Consequently, even though the psychopathology may reduce in bipolar disorder, there is a considerable excess risk of relapse during Ramadan. It may thus be advisable to recommend Ramadan fasting in subjects at risk of alcohol withdrawal, in patients with schizophrenia and metabolic syndrome and in patients with known bipolar disorder.