April 12, 2021

What all physicians need to know about Ramadan and its clinical implications

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David Gratzer: Welcome to Quick Takes. My name is Dr. David Gratzer and I'm a psychiatrist here at the Center for Addiction and Mental Health (CAMH) in Toronto. As you know, tonight begins Ramadan, a period of spiritual significance for Muslims around the world. As clinicians, what should we know about Ramadan as we're taking care of our patients? What is the clinical significance and implications of this, the beginning of the ninth month of the Islamic lunar calendar?

Joining us today, we have two guests, Dr. Juveria Zaheer, who is a psychiatrist at CAMH, as well as a clinician scientist with the Institute for Mental Health Policy Research. She's also a returning guest. Welcome.

Juveria Zaheer: Thanks so much for having us.

David Gratzer: And we're also joined by Dr. Zainab Furqan, who is a very senior resident of psychiatry, graduating in just a couple of months and will soon be on staff at the University Health Network, at least for now. Welcome.

Zainab Furqan: Thank you so much. I’m so excited to be here.

David Gratzer: First things first, thank you for joining us. Let's start by asking: what is culturally safe care? Dr. Furqan?

Zainab Furqan: Yeah, I think that's a really important question, especially given that we're so lucky to live in such a diverse environment in the greater Toronto area where the three of us practice. In my mind, culturally safe care acknowledges the reality that people that we're seeing, patients that we're seeing, often come from very different backgrounds, whether they're cultural backgrounds, spiritual backgrounds, socioeconomic backgrounds, and recognizing that we as clinicians are coming from our own backgrounds and we have our own biases and assumptions. And culturally safe care means creating a space between you as a clinician and the patient where the patient can come as a whole person with all their diverse backgrounds and identities and have their needs met in a mental health setting or health care setting in general.

David Gratzer: Good. And now let's focus on the period of spiritual significance. Dr. Zaheer, what is Ramadan for our listeners who may not be so aware?

Juveria Zaheer: So, as you mentioned, Ramadan is the ninth month of the Islamic lunar calendar and is a period of really important spiritual significance for Muslims.

Over 80 percent of Muslims in North America fast and for Muslims during Ramadan, fasting means abstaining from food, water and sexual activity from dawn till sunset. And I think the most important thing about Ramadan is it's something that is very meaningful and very cherished. It brings people together. And at the end of Ramadan, there's a big religious celebration called Eid al-Fitr, which is one of the most holy days in the Islamic calendar.

David Gratzer: What are then some of the possible clinical considerations? Dr. Furqan?

Zainab Furqan: Sure, fasting in different cultures is practiced in various ways, and for Muslims, the act of fasting, as Dr. Zaheer was mentioning, means abstaining from food, water, sexual activity and medications as well during the daylight hours. So that means for people who have medical and psychiatric illnesses who may be taking medications during the day, the timing of that is going to be affected. Furthermore, the act of refraining from eating and drinking can have implications on certain disorders, including, for example, diabetes being the most obvious one. But disruptions in sleep and eating patterns can also have implications for mental illnesses. And so that's why this becomes relevant in psychiatric practice.

David Gratzer: So what are some mental health conditions that we should think about the implications of Ramadan? Doctor Furqan, do you want to elaborate for a moment?

Zainab Furqan: Sure. For me, the most important one that came up in our review of the literature is bipolar disorder. As we know, bipolar disorder is one of the psychiatric illnesses that can be most sensitive to changes in sleep and circadian rhythm patterns. And we know that these changes occur during Ramadan. So just to walk you through what a typical day in Ramadan can look like for Muslims: people wake up often at around 4:00, 4:30 am before the sun rises, they have a meal and then they often go back to sleep for a few hours before getting up and starting their day. And then during that day, they're not eating, drinking. And then at night when the sun sets, they have a meal that we call Iftar (breaking of the fast) where they can eat again. And so often sleep is very much, sleeping patterns are very much, changed. And so for illness like bipolar disorder, where sleep disturbances can trigger manic depressive episodes, this becomes particularly relevant.

Another group of disorders that becomes relevant are eating disorders. Unfortunately, we have very limited literature in terms of research studies on this topic. However, Muslims who have this lived experience have written and spoken about it, and the ones who have spoken about it publicly talk about how they can experience exacerbations in their eating disorder because this month almost offers a culturally sanctioned way to uphold some of their disordered eating patterns. So these are health implications that might not be as obvious to us as some of the physical health implications are, but are certainly there.

David Gratzer: Doctor Zaheer, I know a couple of years ago you did a Lancet psychiatry paper in which you were the senior author. You guys did a literature review, frankly there wasn't incredible literature on this important topic, but you did have some things you found.

Juveria Zaheer: I think the process of the literature review is so interesting for Dr. Furqan and I, both of us are Muslim women, both of us are acute care psychiatrists. And I remember Zainab coming to my office and saying we should write about this because there's literature on diabetes and other health conditions. But I haven't really come across anything about Ramadan and mental health. And I remember thinking, oh, my goodness, I'm a psychiatrist. I know that Muslims fast and in my role in the emergency department this is something that I don't tend to ask about. And I think the other piece that was really important is in Islam you can get a medical exemption from fasting. So Imams, family spiritual providers, will say “go talk to your doctor”. And I think for a lot of us, we want to do no harm. So we'll say, oh, you don't have to fast. But we need to remember that in Islam Ramadan is a period of social connectedness, of reflection, of great meaning. And so we were hoping that we could review the literature to see what kind of recommendations we could make, hard and fast ones, because the evidence really isn't there. But what are some general guidelines? What is a general approach for family physicians or psychiatrists? What are some questions we can ask? And with the literature that is available, how do we know, you know, how lithium levels are affected? for example. Other things that we really thought about is, you know, in Islam, alcohol use is forbidden. But many Muslims do engage in alcohol use. And so if you stop alcohol use suddenly during Ramadan, you may be at risk for withdrawal. You know, if you're using a stimulant medication, for example, as Zainab said, you might take it at Suhur in the morning and then it's really hard to fall back asleep afterwards. And so there was a lot of information on things like lithium and lithium levels, which is relevant to practice. Lots of information about circadian rhythms. But that was, I would say, pretty much it.

David Gratzer: I think that's a good point, so there isn't amazing literature to tap, despite the fact that there are, what, some one point seven billion Muslims and any, or perhaps most, will be fasting! So then it becomes a matter of approach. Walk me through how I might speak to one of my Muslim patients about Ramadan and I might speak to him or her about the possibility perhaps of not fasting. Dr. Zaheer?

Juveria Zaheer: So I think in our experience working with Muslim patients and thinking about our families and friends and social networks, for a physician even to broach this topic, I think, is almost revolutionary. And I'm thinking about, you know, my parents and my grandparents. If their family doctor said to them, “I know Ramadan is coming up. What are your thoughts on the medications you're taking?” I think just that opening of a conversation goes so far. And I think that it's really important to consider it to be a conversation. So I think one of the really important places to start is to ask someone, “Do you generally fast? Were you planning to fast this year? What does fasting mean for you?” And I think there could be some really interesting exploration there about meaning and fasting, about things like stigma, because if you're not fasting and you know your family or community notices, people can feel an internal sense of distress around that. And to try to understand someone's cultural context before you go jumping into medications or jumping into diagnosis, I think can be a very reasonable first step. And then maybe Zainab if you wanted to expand on the next steps.

Zainab Furqan: Of course, when you have asked the patient if they generally tend to practice fasting, you can also ask their permission about whether they want to discuss medications and the option of not fasting. I think it can be really validating for some patients to recognize, to have a physician recognize, that mental illness is illness and if severe if it’s going to be damaged by fasting that it is a very valid and reasonable reason not to fast. And that's recognized by Islamic scholars and leaders as well. And so for physicians to just have this knowledge and be able to share that with patients can be very validating.

So I think about a case where a Muslim woman came to me. She had a well-established history of bipolar disorder but during the first week of Ramadan she started to notice significant hypomanic symptoms emerging. And we were quite concerned about her condition deteriorating into a full blown manic episode. We looked at her history together and we did observe that many of her manic episodes had been triggered due to lack of sleep.

And so, you know, I shared this with her. Looking at your pattern of illness, this is this seems to be a big trigger for you. Then I asked her, what would it mean for you not to fast? And so that opened the door for her to be able to voice that this is such a spiritually and culturally significant time for her that it's so enjoyable to be able to sit down with your family, break fast together, gather with friends, gather with your social networks. And so it was really helpful, actually, for me to hear that, for me to recognize that there are aspects of this that she would be really missing and for us to then brainstorm strategies of being able to engage in the cultural and spiritual practices of this month. At the end of the appointment ¬- it's very vivid for me - she commented that it is so validating to hear from a physician that damaging my health in this case is not the right thing to do for me. And so that was actually one of the big motivations for this paper.

David Gratzer: That was a very helpful case in terms of somebody with bipolar affective disorder. Doctor Zaheer what cases, what problems, have you come across in terms of patients over the years?

Juveria Zaheer: I think when we think about people who present to emergency departments, or people who present to inpatient units, we can make the assumption, like in Doctor Furqan's case that they are, you know, too ill to fast. But we do know that sometimes even when people are admitted to hospital, there can be a desire to fast. So I'm thinking about one case with a longer stay patient in hospital where there was really a tremendous desire to fast. And as far as the physician was concerned, they could probably make it work. And so what they did is they brought in the Muslim chaplain. They had these discussions, had discussion with family and talked to dietary around, making sure that the meals were delivered at the right time, which is sometimes a bit of a challenge. But these are all challenges that are absolutely surmountable. In another area here if someone is taking oral antipsychotic medications, in this case, there can be a role of switching to an injectable, a long acting injectable. So that way you don't have to worry about taking meds orally or changing the timing of the medication. So that was another consideration in that particular case.

David Gratzer: So we're meeting with our patients, we're acknowledging Ramadan, we're talking about how they view Ramadan, we're talking about it in terms of their illness experience, particularly mindful for those with bipolar, eating disorders, based on literature. But of course, this is a major event for anyone. And so it would be worthwhile broadly discussing it, certainly thinking about alcohol and substance use. These are all reasonable tips. Any other suggestions for clinician colleagues before we talk about meds?

Juveria Zaheer: I think we have a lot of patients who have anxiety disorders or depressive disorders, especially now thinking about the COVID-19 pandemic and the stress people are under. I think it's really reasonable, as in the case of that Zainab described. If someone does have depression or anxiety to talk to them about, you know, problem solving: What would it be like to fast? What would it be like not to fast? What would be more protective for their mental health? And to have that open conversation. Because for 10 people, you may get 10 different answers, but if you get ten different answers to work with them within the guidelines that we have to provide the best care possible.

David Gratzer: Let's talk about medications, we've touched on this already. Obviously, as psychiatrists and as health care professionals, we prescribe much. Lithium we've touched on. The fluid status, possible dehydration, possible implications for lithium levels. What are your thoughts, Dr. Furqan?

Zainab Furqan: Yes, so before I get into the details of lithium, I'll just comment on one study that we found in our literature review, which was a study from Kuwait, a Muslim majority environment where 60 percent of patients that they surveyed were making changes to their medications without consulting their physicians. So that's an important thing to remember. That people might be making these changes and so active probing by physicians might actually go a long way in this situation.

So with regards to lithium, again, it will be really important for clinicians to advise people that there is a risk of lithium toxicity with prolonged periods of dehydration or fluid restriction. And so especially when fasts are very long, a lot of caution needs to be exercised. So if there is a situation where the patient is really well informed about the risks and benefits and they're aware about what to look for in terms of lithium toxicity, they might be able to fast. However, if there's been any concern about lithium toxicity in the past, especially when the fasts are very long, it's important to consider not fasting and consider fasting when the days are shorter.

David Gratzer: Now, there are other medications beyond lithium. Let's think very concretely. Doctor Zaheer, we tell a patient to take a med twice a day. What are the implications if they're fasting and the day is very long because the number of sunlight hours is very long?

Juveria Zaheer: That's a great question. And I think, in general, we should always try to see if we can make medications a little bit easier to take. But specifically during Ramadan, if a medication is dosed twice daily, we can ask ourselves, can it be given safely during the interval when the interval between doses is shortened? So can we give it then in the evening or at dawn and then at sunset again? Or can we give it as one dose? We need to think about the side effects of the medication. So if you're giving something kind of predawn, is that going to interfere with being able to go back to bed? And if we're giving something really sedating at that time, is it going to make it really tough to get up at four, four thirty in the morning when the days are long to get up for the predawn meal? So those are some questions that we can consider. Another really important question to think about is medication absorption. So we have medications in psychiatry like Ziprasidone, for example, that need to be taken with food. And we often suggest that people take them with dinner or take them with lunch, take them with a certain amount of calories. And so if a patient is on medication that is going to be affected, that the absorption is going to be affected and might be worthwhile changing the timing of that dose as well.

David Gratzer: And just to pivot and think about med's: we've talked about lithium sedating medications, meds that work better with food like Lurasidone or other meds. What about general antidepressants, general antipsychotics? Any special considerations? Dr. Furqan?

Zainab Furqan: Again, I think back to a clinical case that's helpful to illustrate this point.

I had a man with major depressive disorder who usually took his Bupropion in the morning. As we know, bupropion is an antidepressant that's activating. When he found that when he was taking it at the predawn meal at around 4:00 a.m., he found that it was really tough to go back to sleep and he was feeling very tired during the day. So one of the strategies that we tried was that right after he broke his fast or at around 8:00 p.m., he would take his Wellbutrin. It wouldn't be until 11:00 p.m. or 12 that he would go to bed and he found it a bit easier to be able to go to bed, get some sleep, wake up for the predawn meal, go back to sleep and start his mornings a bit later at nine or 10. So that worked really well for him. So with medications like bupropion or aripiprazole or lurasidone, things that can be activating, you might have to experiment with the timing a little bit.

David Gratzer: It's a Quick Takes tradition that we end with a rapid fire minute where we ask a series of questions in quick succession. Are you guys ready? We'll put a minute on the clock. Who's going to go first and then we'll rotate who who's going to start?

Zainab Furqan: I'm happy to start.

David Gratzer: Dr. Furqan, we're going to put a minute on the clock and the first question goes to you. What is one thing that you'd like clinicians to know about Ramadhan in mental health?

Zainab Furqan: I would love to know that for some people this month offers a lot of potential for mental well-being to be enhanced and for people to be really connected spiritually and socially. And for some people, there is risk as well. And so to hold that really balanced view and to have that open discussion with your patients.

David Gratzer: Dr. Zaheer, over to you. One surprise over your years of clinical practice and caring for somebody during Ramadan?

Juveria Zaheer: I think I, like many physicians, assume that people want to be told that they're not allowed to fast, but it is kind of like the get out of jail free card. And what I found both professionally and personally, that this isn't the case, that talking about Ramadan isn't about getting a get out of jail free card for your doctor. Sometimes it's about validation that it's actually safer for you not to fast. And that's OK. And you're still a good person and still a good Muslim. And sometimes it's about figuring out how we can let you do this in a way that is safe and well supported

David Gratzer: Now at the buzzer. One last question and both of you can answer. Both of you have lives informed by faith. And in fact, will be celebrating Ramadan. What's one memory you have that makes this this month extra special for you?

Juveria Zaheer: I think for me, when I think of my family and my extended family. I grew up in Newfoundland with a very kind of vibrant but small Muslim community. I think of my grandparents. I think of at the end of Ramadan when they see all of their grandkids and there's a big Muslim-style barbecue in Hamilton and everybody gets together. I think about my little brother and how he, you know, does a bird show in public and doesn't drink all day, even though it's super-hot because it's so important to him and how he eats everything in my house when fast is broken. So it's family for me. I think

David Gratzer: Dr. Furqan?

Zainab Furqan: For me, I remember my first. So many Muslim families will have a little bit of a celebration for kids or teens who are fasting for the very first time in their lives. So I remember back to when I was about nine years old, all my family friends gathered. There were presents. It was a celebratory meal at the end of the day, and it’s really a special memory.

David Gratzer: Wonderful. And that is the end of this episode of Quick Takes. Thank you for joining us.

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Until next time.

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