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Depressive thoughts from Islamic perspective:

Depressive thoughts from Islamic perspective Dr. Walid Sarhan F. R. C. Psych Consultant psychiatrist AMMAN-JORDAN

Declaration of interest :

Declaration of interest None

Muslim world population:

Muslim world population Muslim population has been ever increasing through birth rate as well as  high rate of conversions. Islam is fastest growing religion and consequently this religion has become now the largest followers on this planet .  At this moment Muslim population stands at  2.08  billion which is far greater than currently estimated 1.6 to 1.7 The percentage of Muslim population in North America is  1.71


Muslims A notable proportion of Arab peoples are Muslim, and Islam is the world's second most practiced religion,   with one of the highest increases in the number of practitioners . Today there are an estimated 6   million Muslims in the United States, and nearly 15 percent are people of Arab ethnic origin Despite Arab peoples' presence in the West and East, there has been little published in the psychiatric literature.

Countries With The Largest Muslim Populations (2009):

Countries With The Largest Muslim Populations (2009) Country Number of Muslims Indonesia 203 million Pakistan 174 million India 161 million Bangladesh 145 million Egypt 79 million Nigeria 78 million Iran 74 million Turkey 74 million Algeria 34 million Morocco 32 million Iraq 30 million Sudan 30 million Afghanistan 28 million Ethiopia 28 million Uzbekistan 26 million Saudi Arabia 25 million Yemen 23 million China 22 million Syria 20 million Russia 16 million

Muslim Growth:

Muslim Growth Islam is the fastest growing religion in the United States. The Yearbook of American and Canadian Churches 2000 gives the figure of 3,950,000 Muslims in America today. Islamic Horizons states that there are eight to ten million Muslims in North America. The most common figure cited (the statistic the United States government regularly uses) is about six million. The largest concentrations of Muslims are in California, New York, and Illinois — with an estimated 400,000 in the Chicago area

Mosques in America :

Mosques in America The first official mosque was built in Cedar Rapids, Iowa in 1934. Today, according to the Council on American-Islamic Relations (CAIR) based in Washington DC, there are more than 1,209 known mosques throughout America


Arabs The standard definition of the Arab world comprises the 22 countries and territories of the  Arab League  stretching from the  Atlantic Ocean  in the west to the  Arabian Sea  in the east, and from the  Mediterranean Sea  in the north to the  Horn of Africa  and the  Indian Ocean  in the southeast .  It has a combined population of around 422 million people, with over half under 25 years of age

Arab-American Population Growth:

Arab-American Population Growth In the 2011 American Community Survey, the U.S. Census Bureau reported there were close to 1.8 million Arab Americans living within the United States, an approximately 47% increase in population size from 2000 .   Some believe, moreover, that this dramatically undercounts the population. According to the  Arab American Institute , for instance, the number of Arab-Americans is increasing at an even greater rate, with a total population closer to 3.7 million.

Arab Canadian population:

Arab C anadian population According to the 2006 census, the Arab ethnic population numbered almost 350 000 people of which 71 705 described their ethnic origin as Arab

Muslim Canadian population:

Muslim Canadian population According to  Canada's 2011 National Household Survey , there were 1,053,945  Muslims  in  Canada  or about 3.2%  of the population, making them the second largest religion after Christianity and the fastest growing religion in Canada. [2] In the Greater Toronto Area (GTA), 7.7% of the population is Muslim, making GTA the highest concentration of Muslims in any city in North America


Toronto The  demographics of Toronto  make  Toronto  one of the most  multicultural  cities in the world. Data released by  Statistics Canada  as part of the  2006 census  indicated that 49.9% of Toronto's population is foreign-born .  According to the 2011 National Household Survey (NHS) performed by Statistics Canada, that percentage had dropped - only slightly - to 48.6 %   Islam  is the second most popular religion with 8.2% of the population,

the World Gallup Poll survey:

the World Gallup Poll survey representative populations of 143 countries (140,000 ), finding that 92 percent of people in 32 developing countries indicated religion was an important part of daily life a survey of developed countries by Angus Reid Strategies involving 5,800 found that 48% of respondents said religion is a “very important” component of their daily lives Based on information collected on 238 countries, 13,000 ethno-linguistic peoples, 5,000 cities and 3,000 provinces by the World Christian Database, atheists make up less than 0.01% of the populations of 24 countries. the United States, the most recent Gallup Poll conducted in late 2011 found that 55% of Americans indicated that religion is very important in their lives and 26% said it is fairly important, leaving only 19% who said it was not important

Individual Development in Arab-Muslim Societies:

Individual Development in Arab- M uslim Societies Arab societies tend to be "father dominant" (patriarchal): The father is the head of the family and is considered a powerful and charismatic figure. He commands respect as the legitimate authority for all matters of the family (El-Islam, 1983). The patriarchal structure extends throughout all levels of society. The father of the nuclear family is subordinate to his own father, who in turn defers to the authority of the head of the clan. All clan heads are subordinate to the head of the tribe or  hamula . The tribal or clan leader also serves as the spiritual and practical father of the whole group—he represents the collective to the outside world, oversees the rules for the clan or tribe, and guides their actions . In effect, the patriarchal structure creates a complete and autonomous society within a society, functioning as a single unit .

Decision-Making on Mental Health Issues among Arab-Muslims:

Decision-Making on Mental Health Issues among Arab-Muslims T he value of individual independence is often balanced or outweighed by that interdependence within the family unit. While the structural extended family, in which several generations reside in a single household, is no longer as common in these communities as it was a few decades ago, a functional extended family system has emerged in which frequent contacts and interdependence bind Together several nuclear families from the same clan. In either case, the decision to seek professional medical help is often made by the family as a collective M. Fakhr El-Islam Transcultural Psychiatry 2008 45: 671

Attitudes toward depression among a sample of Muslim adolescents in the Midwestern United States.:

Attitudes toward depression among a sample of Muslim adolescents in the Midwestern United States . Muslim adolescents tend to be more traditional with family, social, and religious values. This value system plays an important role in their likelihood of seeking and accepting professional help for depression Haroun Z et alInt J Adolesc Med Health. 2011;23(3):293-301. Section of General Internal Medicine, The University of Chicago, Chicago, IL 60637, USA

Prevalence and predictors of postpartum depression among Arabic Muslim Jordanian women serving in the military:

Prevalence and predictors of postpartum depression among Arabic Muslim Jordanian women serving in the military The purpose of this cross-sectional correlational study was to investigate the prevalence of symptoms and psychosocial predictors of postpartum depression (PPD) among Arabic Muslim Jordanian women serving in the military. Income, intenseness of pregnancy, mode of birth, family social support, and perception of stress were the strongest predictors of PPD. There was a reciprocal relationship between PPD and psychosocial variables, with women having low levels of perceived stress and satisfaction with social support having fewer symptoms of postpartum . Yehia DB,et al J Perinat Neonatal Nurs . 2013 Jan-Mar;27(1):25-33; quiz 34-5. doi: 10.1097/JPN.0b013e31827ed6db

Mood Disorders:

Mood Disorders Although depression is considered to be the most common disorder in Western cultures. Some scholars regard depression as a disorder of the Western world, which lacks universal applicability . Depression in the Arab population is prevalent with classical or modified clinical presentation. ( Marsella , 1978 ,Fernando, 1988).

Silent Epidemic of Depression in Women in the Middle East and North Africa Region:

Silent Epidemic of Depression in Women in the Middle East and North Africa Region As the world is being gripped by economic depression, international psychological epidemiologists have amassed evidence to suggest that psychological depression and its variants are becoming leading contributors to the global burden of disease with the Middle East and North Africa (MENA) region being no exception. Sultan Qaboos Univ Med J. 2009 April; 9(1): 5–15. Published online 2009 March 16.


Lack of education about depression ,lack of availability of appropriate therapies, competing clinical demands, social issues, and the lack of patient acceptance of the diagnosis were among the most important barriers to the identification, diagnosis, and treatment of patients with depression in this population Nasir LS , Al- Qutob R. J Am Board Fam Pract . 2005 Mar-Apr;18(2): 125-31. PMID : 15798141 [PubMed - indexed for MEDLINE ]   Barriers to the Diagnosis and Treatment of Depression in Jordan. A Nationwide Qualitative Study


The level of awareness of depression was acceptable. However, further efforts are necessary to establish public educational programs related to depression in order to raise awareness regarding the disease . Sayer Al- Azzam et al International Journal of Occupational Medicine and Environmental Health Volume 26, Issue 4 , pp 545-554 -2013 An audit on public awareness of depression symptoms in Jordan

The 'evil eyes':

The 'evil eyes' The 'evil eyes' of others Who notice or hear about one's happiness, success or possessions are believed to be capable of causing him to lose them . Anhedonic depressed patients who have lost their capacity to experience happiness or pleasure, attribute the loss to envy, and they easily talk about their emotional loss to ward off the possibility of further envy by others

Evil eye-Lebanon:

In a study about the effect of the evil eye in Lebanon , 81.3% of the mothers reported that they believed that evil eye had had a harmful effect on their infants ( Harfouche , 1981 ). Arab/Muslims perform several rituals that are intended to protect them from the evil eye, some of which may seem bizarre, such as incantation, and the use of amulets, blue beads, or a horseshoe ( Donaldson, 1981; Harfouche , 1981 ). Evil eye-Lebanon


W omen Cultural factors may condition the development of depression in women who cannot fulfil their culturally-prescribed - monorole of marriage and motherhood. Having no husband or children or living under a threat thereof, may be a 'potent factor in the genesis of depressive symptoms in women . I n the Arabian Gulf area, especially among the illiterate. They ultimately develop' a chronic culture conditioned form of neurosis, where neurasthenic and hypochondriacal symptoms dominate the clinical picture.

Love Failure:

Love Failure Loss of a mate and love failure, which figure prominently among depressed western patients, are uncommon precipitating factors among Arab depressives. Culturally-shared religious beliefs and prescribed ritual practices reduce the pathogenic effect of grief . Responsibility for failure in arranging marriage is shared by the whole family so its impact on the individual' is greatly reduced.

Where to seek help?:

Where to seek help? Many Arab/Muslims believe that way to seek help would be from healers , or Shekhes , to exorcise the Jinn or to undo the influence of the evil eye or black magic through amulets or certain rituals. Depressed patients seek help of medical practitioners late. Psychiatric help will only be reached very late in the majority of cases. Very small percentage will start by psychiatric consultation but this is on the rise .

Self help and psychotherapy:

Self help and psychotherapy The only responsibility the patient has is to avoid sinning, and, after such an illness, to submit herself to religious healers ( Shekhes ) in order to exorcize the Jinn . These beliefs, of course, prevent the patient from playing an active role in psychotherapy based on self-responsibility and on “working on the self.”

Inheyar A’sabi (nervous breakdown):

This disorder is reactive and involves a variety of symptoms such as anxiety, depression, dissociation, psychosis, and also somatic symptoms. Mixed rather than distinct syndromes seem to be a very common clinical picture among Arab/Muslims. It creates a lot of sympathy from the community. Inheyar A’sabi ( nervous breakdown)

Somatic symptoms:

Somatic symptoms Patients develop patterns of symptoms in keeping with what medical practitioners consider illness . A somatic concept of illness that concerns the medical profession is entertained by most Arab- Muslim patients and medical practitioners alike . Therefore, presentation of patients with somatic symptoms is the rule.

Primary health care:

Primary health care Depressed patients complain of pains, aches or symptoms of autonomic dysfunction rather than psychological symptoms that are differentiated from associated bodily symptoms . The majority of medical practitioners in the Arab –Muslim world , who have been trained to think of the human being as an assemblage of parts and particles, resort to a multitude of physical investigations for their patients' bodily symptoms in their search for an organic etiology The patients and the family prefer that. Commonly reassurance and psychotropic prescription at times and rarely referral.

The expression of affect is therefore culture-related:

The expression of affect is therefore culture-related A comparison between depressive patients in Egypt, India, and Britain revealed that the Egyptian Arab/Muslim and Indian patients displayed more anxiety and somatic symptoms than did the British . Anxiety was displayed in 99% and somatic symptoms in 87% of the Egyptian sample ( Abd El- Gawad , 1995)


Suicide Suicide is a major sin, the punishment for which is eternal hell during the afterlife of the person who commits it . Depressed Muslims, including Arabs, may passively wish they were dead or 'pray to God to take their life away. Parasuicidal acts of pathological care-eliciting were found to have no relationship to the degree of adherence to Islamic religious practice. ( Abd El- Gawad , 1995 )


S uicide suicidal thoughts in the Egyptian depressives were relatively high compared with the low rates of suicide and attempted suicide . Guilt feelings among the Egyptian sample were relatively few. ( Abd El- Gawad , 1995 )

Suicidal Thoughts: Suicide Rate Among Southern Calif. Muslims Increases:

Suicidal Thoughts: Suicide Rate Among Southern Calif. Muslims Increases Editor’s Note: InFocus News, one of our ethnic media partners and a winner of two awards in the just-concluded Southern and Central California NAM awards, reports that the rate of Muslims committing suicide in Orange County and Los Angeles alone between 2006 and 2008 was 15.5 times higher than the rate in the previous ten years


A ggression Bazzoui and Al- Issall found that Arab depressives in Iraq, rather than expressing guilt feelings, are more likely to be aggressive to others on whom they project responsibility for the illness .


Guilt T he Islamic religion provides a comprehensive code of conduct and interpersonal relationships , the guilt attached to wrongdoing nearly always has a religious component . Some Muslim depressives combine projection and guilt when they attribute their illness to God's punishment in retribution for their real or imaginary wrongdoing.


Hopelessness According to Islamic culture it is blasphemous to give up hope for relief of suffering because patient endurance is rewarded in the afterlife . Hopelessness was not a prominent symptom experienced by depressed inpatients (both natives and expatriates) surveyed in Kuwait . (El-Islam, Moussa, Malasi , & Mirza , 1988).


Crying The patient may find it impossible to cry. Male depressed patients deliberately prevent themselves from crying because they feel that weeping would undermine their masculinity.


Breathlessness Breathlessness is one of the common somatic complaints in depressed Arab- M uslim patients. The patient has difficulty in taking in air during inspiration , which is sometimes described as if it were air hunger. Breathlessness is often attributed to the experience of tightening up of the chest . Repeated sighing, which assures the patient of his ability to take in enough air by deep inspiration now and again, has a temporary comforting effect.


Dreams The depressed mood is more likely to find expression in dream contents which center around death and the dead

Symbolic love and sex:

Symbolic love and sex Heartache' is a common complaint among female depressed patients. It usually refers to the loss or inability to achieve or maintain a loving relationship to a key figure . Depressed men complaining of back pain usually have sexual problems, for the back is believed to be the origin of their virility and procreativity .

“hwo sammelly badani.”:

Metaphoric descriptions of the experience of an Arab/Muslim patient may add more confusion and misunderstanding to the assessment of the reality testing . As an example, one expression that is commonly used by Arab/Muslims is “ hwo sammelly badani . ” This expression literally means “He poisoned my body,” while the intended meaning is “he made me nervous.” An unaware therapist or translator who hears a woman saying “Yesterday my husband became furious and poisoned my body,” may misinterpret this as delusion or as a homicide attempt. “ hwo sammelly badani . ”

Triangle therapeutic relationship:

Triangle therapeutic relationship Rather than being limited to the patient-doctor dyad, the Arab-Muslim therapeutic relationship is often triangular, with other family members equally involved in the process . Family members act as welfare officers or social workers for most Arab-Muslim patients, paying patients 'clinical expenses and helping them restore their physical, mental and social wellbeing after illness. This is specially if the patient is psychotic or addict and uncooperative.

PowerPoint Presentation:

The Arab doctor-patient relationship Doctor Family Patient


Confidentiality Individual agreement to disclosures to family Family informed by patient Joint interviews Family background as a measure of normality/pathology Family psycho-education Family members as co-therapists

Authoritarian therapist:

Authoritarian therapist Arab- M uslim patients and their families transfer onto therapists culturally shared attitudes, especially those related to age and gender. For instance, when dealing with intergenerational conflict in Kuwait, members of both generations would be surprised if a middle-aged therapist did not reject younger peoples’ anti-traditionalist and modern ideas. Similarly, a good or effective therapist in Egypt and Arabian Gulf countries is expected to be authoritative rather than to offer choices to patients . (El-Islam, 2005).


Hopelessness According to Islamic culture it is blasphemous to give up hope for relief of suffering because patient endurance is rewarded in the afterlife . There is evidence that this belief may shape the symptomatology of affective disorders . For instance, hopelessness was not a prominent symptom experienced by depressed inpatients (both natives and expatriates) surveyed in Kuwait (El-Islam, Moussa, Malasi , & Mirza , 1988).

Relationships between Psychiatrists and Traditional Healers in Arab Cultures:

Relationships between Psychiatrists and Traditional Healers in Arab Cultures The relationship between professional psychiatrists and traditional healers varies in different Arab communities from the extremes of full integration to outright opposition and enmity, with variable degrees of cooperation and intermediate positions in most traditional cultures . Psychiatrists and traditional healers usually deal with each other’s failures. Formal legal governmental permission for or sanctions against traditional healers varies from one country to another (El-Islam , 2006c).

Cultural aspects of therapy:

Cultural aspects of therapy In keeping with culturally-shared explanations of depressive manifestations, therapy practices among traditionally-oriented Arab-Muslims include the prescription of anti-envy amulets, T he appeal to shrines of dead Muslim sheikhs, O ccasionally the performance of pilgrimage and “ O mra ”. Visiting Mecca .

Depression is not condemned in Islam:

Depression is not condemned in Islam Islam doesn’t require us to be superhuman . If one experiences negative feelings, he is encouraged to resist them with positive thoughts and actions if possible , Or and to seek professional help if the case is clinical, exactly like any other form of illness.

Role of Islam in the management of Psychiatric disorders:

Role of Islam in the management of Psychiatric disorders With the significant growth of the Muslim population all over the world, there exists a corresponding increase in the need for mental health services that suit this group of patients. Research demonstrates the effectiveness of the integration of spirituality and religiosity into psychotherapy and how religious beliefs could affect the management plans. This article discusses the impact of various beliefs in the Islamic faith on the bio-psychosocial model for the management of different psychiatric disorders including focusing on the modification of psychotherapeutic techniques as cognitive restructuring. It also shows other types of therapies such as music therapy, meditation therapy, and aromatherapy. The main emphasis remains to ensure that Muslim psychiatric patients get ethical, acceptable, and effective treatment. Walaa M. Sabry  and  Adarsh Vohra Indian J Psychiatry. Jan 2013; 55( Suppl 2): S205–S214

Religious and Spiritual Factors in Depression: Review and Integration of the Research:

Religious and Spiritual Factors in Depression: Review and Integration of the Research A large and growing volume of research suggests that religious or spiritual beliefs and practices may be used to cope with or adapt to stressful life circumstances . Although there are many genetic, developmental, and environmental factors contributing to the onset and maintenance of depression, failure to cope with life stress is often a major underlying factor  The purpose of this review is to summarize quantitative research on the religion-depression relationship, including randomized clinical trials that have examined the effects of religious interventions on depression Bonelli R.M. et al Depression Research and Treatment Volume 2012 (2012), Article ID 962860, 8 pages

Religious and Spiritual Factors in Depression: Review and Integration of the Research:

Religious and Spiritual Factors in Depression: Review and Integration of the Research At least 444 studies have now quantitatively examined these relationships . Of those, over 60% report less depression and faster remission from depression in those more R/S or a reduction in depression severity in response to an R/S intervention . In contrast, only 6% report greater depression.

Conclusions :

Conclusions Arabs are mainly Muslims ,other non Arab Muslims have different cultural beliefs that affect their health and depression. The family is the base of the Arab- Muslim community rather than the individual. Depression is presenting both in the classical and modified pictures. Advising Muslim patients to pry and read Quran gives him trust in the clinician. Guilt ,hopelessness and suicide are less prevelant .

Thank you:

Thank you


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R eferences Raphael Bonelli, Rachel E. Dew, Harold G. Koenig, David H. Rosmarin , and Sasan Vasegh , “Religious and Spiritual Factors in Depression: Review and Integration of the Research,” Depression Research and Treatment, vol. 2012, Article ID 962860, 8 pages, 2012. doi:10.1155/2012/962860

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