Ramadan: Advising clinicians on safe fasting practices

Photo by mohamed_hassan

If you are a basketball fan who recently watched Portland Trail Blazers’ Enes Kanter play against the Warriors in the western NBA semi-finals, you may have heard about Ramadan fasting. But most Americans haven’t — and that includes clinicians.

“Even those clinicians who are aware of Ramadan often do not fully understand the nuances of fasting,” explains Rania Awaad, MD, a clinical assistant professor of psychiatry and behavioral sciences and the director of the Muslims and Mental Health Lab at Stanford. “For example, there is no oral intake from sunup to sundown of food, liquids and also medications. For clinicians who may be alarmed by this, it’s important to remember that fasting is globally practiced safely by adjusting the timing and dosing of medications and by following best practices like consuming enough fluids to rehydrate after the fast.”

Ramadan is the ninth month of the Islamic calendar, which is 11 days shorter than the solar year. This year in the U.S., it began on May 5 and ends on June 4. During Ramadan, many of the nearly two billion Muslims around the world fast during the sunlight hours as a means of expressing self-control, gratitude and compassion for those in need.

Several groups are exempted from this religious requirement — including pregnant women, children, the elderly and people who are acutely or chronically ill — but some fast anyway because of the spiritual significance, Awaad says.

“Ramadan is a very spiritual and communal month. So when clinicians immediately advise their patients not to fast, they may not realize they’re inadvertently isolating their patients from the broader community and support system,” Awaad says. She notes this is particularly important for patients with mental health disorders.

Awaad says she strongly advises clinicians to encourage their patients to seek a dual consultation with both a faith leader and medical professional at places like the Khalil Center, a professional counseling center specializing in Muslim mental health. Alternatively, patients observing Ramadan can consult both their faith leader and physician individually and help facilitate a consultation between both entities.

“Without a holistic treatment plan, patients are either fasting when they shouldn’t be — not taking their medications without telling their health care provider — or they are potentially not partaking in Ramadan when they can be,” Awaad says.

In a recent editorial in The Lancet Psychiatry, Awaad and her colleagues outline more clinical suggestions on the safety and advisability of Ramadan fasting that she hopes physicians will consider. For example, the editorial suggests that physicians working with patients with eating disorders should discuss the risks and benefits of fasting and consider close follow-up in this period and in the months following.

But the first step is knowing whether patients are Muslim. By co-teaching the “Culture and Religion in Psychiatry” class, Awaad says she helps Stanford psychiatry residents become comfortable asking about their patients’ religion, in the same way they are trained to ask other sensitive questions like sexual orientation.

“If we miss that our patient draws strength and support from their religion, then we miss the opportunity to support them holistically by incorporating their faith leader or faith community into their treatment plans,” Awaad explains. “The last Gallop poll revealed 87 percent of Americans believe in God, so it’s important to incorporate this into our patient care.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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Stanford psychiatrist focuses on mental health needs of Muslims

Photo, of Rania Awaad giving a recent talk, by Anum Ahmad

Prior to studying medicine, Stanford psychiatrist Rania Awaad, MD, studied Islamic law. As a local religious leader, she said that many people in her community are actually surprised to learn that she’s also a physician.

However, this dual training is at the heart of Awaad’s research and clinical work, which focuses on the mental health needs of Muslims. I recently spoke with her to learn more.

What are the mental health challenges faced by Muslims?

“In our recent sociopolitical climate, there’s been quite a bit of negative focus on Muslims and other groups. And we have the highest level of hate crimes against Muslims ever in American history — about six times higher than post 9/11.

In the Bay Area, we have a consortium of mental health and general medical providers who are trying to figure out how Islamophobia — the fear of the Islam religion or Muslims — affects the general health of Muslims. So far, we’ve seen a lot of anxiety, depression and post-traumatic stress disorder.

There’s already quite a bit of PTSD within the community, because many Muslims that immigrate to America come from areas of conflict. Current policies can trigger immigrants’ underlying PTSD, anxiety and depression, as I recently described in the American Journal of Psychiatry.”

Are there barriers to mental health care for your patients?

“There’s a lot of paranoia about medical providers documenting their issues in an electronic medical record. They’re afraid this medical information will be combined with a Muslim registry. Initially we told patients not to worry, because unconstitutional things like that don’t happen here. But then the travel ban helped substantiated their fears.

There are also barriers directly tied to faith beliefs — concepts like the evil eye or spirits. If someone is having psychosis, for example, people may say he is possessed and should be taken to his religious leader instead of a mental health professional.”

What can you do to overcome these challenges?

“Mental health professionals can approach a patient’s faith leader for a religious consultation. I help train chaplains and imams and I’m also teaching doctors to engage with faith leaders. For many people, their faith is a source of strength and support. So leaving that out completely means that you’re not really providing adequate, holistic care.

There are a limited number of mental health professionals proficient in understanding the Muslim faith and culture. Through the Khalil Center, I’m working with other dual-trained practitioners to develop a manual, book and training seminar on Islamic psychology from a practical clinical perspective. We’re trying to provide guidance for practitioners without Islamic training to work with this unique minority group.”

How did you end up specializing in the mental health needs of Muslims?

“I thought I was going to be an ob/gyn. But during medical school, I married my husband who is an imam and a director of a nonprofit. At one point he told me what our community really needs is someone who can work in mental health, based on what he saw as a community leader. He inspired me to become a psychiatrist.

I also feel my dual training was meant to be. In high school I embarked on a lifelong journey of formal Islamic studies training. I’m currently a professor of Islamic Law at Zaytuna College, a Muslim liberal arts college in Berkeley. My dual training kickstarted the Stanford Muslim Mental Health Lab and Wellness Program that I founded and direct, and it has allowed me to lay the groundwork to train others.”

What are some other things you’re working on?

“The SMMH Lab is part of a consortium that is studying the effectiveness of integrating faith concepts with therapy for different faith communities — Muslim, Jewish and Christian groups. We’re using evidence-based, objective metrics like the depression inventory scale.

I also oversee the Bay Area Muslim Mental Health Professionals group, which has led to many other initiatives like a Bay Area Muslim mental health community advisory board and a crisis response team.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.