Mental Health, Sleep Quality, and Psychological Well-Being during the Holy Month of Ramadan (2024)

1. Introduction

The twenty-first century has witnessed heightened attention on the relationship between spirituality and religious factors affecting mental health and psychological well-being [1,2]. Religious components such as trust in God, reading and listening to the Quran, and participating in rituals like prayer and Ramadan fasting have been linked to decreased levels of depression, anxiety, and stress [2]. Ramadan, a pivotal month in the Islamic calendar, involves the practice of diurnal fasting observed by Muslims worldwide. This fasting period brings about substantial lifestyle adjustments as participants align their daily routines with the fasting regimen. Not only are individuals’ daily activities affected, but changes in their physical and mental performance, as well as their social life, are observed [3].

There is robust support for the positive effect Ramadan has on the mental well-being of the diverse populations who participate [2,4,5,6,7]. One review of 11 studies, which focused on the mental health of Iranian university students who engaged in Ramadan fasting, highlighted its profound influence on improving self-esteem and overall mental health [4]. These findings resonate with a study reporting an impressive reduction in anxiety and depression scores among over 80% of fasting individuals [5]. A similar study revealed an improvement in mental health scores among individuals who fasted the entire month of Ramadan. Conversely, lower scores of mental health were observed post Ramadan for groups who did not participate [6]. Moreover, a study of 182 elderly participants, who observed Ramadan fasting, exhibited significantly decreased levels of insomnia, anxiety, and depression. This shift in mental health is thought to be attributed to the heightened practice of spiritual beliefs and the presence of religious sentiments, giving individuals increased optimism and perceived control, thereby yielding greater life purpose [7].

It is crucial to recognize that the bulk of the existing literature on mental health and well-being during Ramadan originates from countries where Islam is the predominant cultural force. In these nations, Ramadan prompts extensive changes in daily routines and lifestyle practices, such as reduced work hours, increased social interactions, cultural celebrations, and altered meal schedules. The social atmosphere becomes distinctly more religious and spiritual. In contrast, Muslims in the United States face different circ*mstances, as the broader cultural and social adjustments seen in Muslim-majority countries are less pronounced or entirely absent. As a minority, Muslim-Americans may experience more challenges than benefits during Ramadan, as they must adapt to Western norms rather than having societal structures accommodate their fasting practices. Investigating these unique dynamics is essential to identify effective ways to better support fasting Muslims in the United States during Ramadan.

In addition, previous studies investigating mental health, sleep quality, and psychological well-being during Ramadan have been conducted on relatively small sample sizes or focusing on a singular sex (around 50 participants, predominantly male) [8]. In particular, the arrival of Ramadan often amplifies traditional Islamic gender roles, with women typically preparing evening meals while men tend to work. However, because Muslim women in the United States generally possess more autonomy and independence compared to those in some Islamic-majority nations, gender differences in mental health and psychological well-being are expected, giving way to identifying gender-specific accommodations down the line. Furthermore, few studies explore to what extent one’s level of sleep quality, happiness, and life satisfaction can predict one’s level of mental health, during the month of Ramadan. The majority of the literature has been focused on identifying changes in these parameters that come with participation in Ramadan, identifying differences in pre- and post-groups, without considering how these variables may influence each other during the month. To the best of our knowledge, there have been no previous studies conducted on this matter within the United States. Thus, the opportunity to explore the relationship between mental health, sleep quality, and psychological well-being during Ramadan within a context where such profound cultural shifts are absent remains unexplored.

Mental health disorders rank as one of the primary contributors to the worldwide burden of health issues, making research on this topic essential. Specifically, in 2019, depressive and anxiety disorders were among the top 25 causes of the burden worldwide, with no evidence of a reduction in the burden since 1990 [9,10]. The United States (US) stands out as one of the most affected nations concerning mental health issues. It is believed that one in five US adults are living with a form of mental illness. As of 2021, it is estimated that at least 21 million adults have experienced at least one major depressive episode in the last year [11]. Notably, since the onset of the COVID-19 pandemic, the Anxiety and Depression Association of America revealed that 7 out of 10 US adults experience daily stress or anxiety [12]. Furthermore, according to the National Institute of Health (NIH), rates of anxiety, depression, and substance use disorders have increased, and individuals with preexisting mental health conditions who contract the virus face a higher risk of mortality [13].

The World Health Organization refers to mental health as the “state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” [14]. Under the umbrella of mental health, depression, anxiety, and stress are key components. Symptoms of depression involve a mental state characterized by persistent low mood, hopelessness, cognitive impairments, and behavioral issues, while symptoms of anxiety include excessive worry and physical symptoms such as restlessness and feeling on edge. Stress is operationalized as a state of emotional or mental strain, with feelings such as irritability, difficulty relaxing, and feeling overwhelmed [15]. Sleep quality has been defined as a construct consisting of both quantitative–objective and subjective measures of sleep [16]. Psychological well-being consists of two domains, of which the hedonic domain consists of life satisfaction, or the overall way one evaluates and perceives their life, and subjective happiness, largely measuring the ways an individual subjectively interacts with their world [17].

It is widely acknowledged that the components of mental health, such as stress, anxiety, and depression, are influenced by changes in the quality of sleep, life satisfaction, and subjective happiness [18,19,20,21,22]. Previous studies have investigated this relating to differences in gender and age. In a study of 331 male and female university students with an average age of 21.4 years, depressed individuals’ mean happiness and life satisfaction scores differed significantly compared to the scores of those without depression [18]. A study of 1293 college students with a mean age of 21.5 years reported that lower sleep quality significantly predicted an increase in depression and anxiety scores during the COVID-19 pandemic. Furthermore, the study found that females scored higher than males overall in levels of anxiety, depression, and poor sleep quality [19]. Previous studies have supported that components of mental health may be negatively affected by poor sleep [20,21]. Resonating with this, a study of 552 participants found that sleep quality and mental health parameters were related. Specifically, the Pittsburg Sleep Quality Index (PSQI) successfully predicted variances of 10.1%, 12.3%, and 13.1% in depression, anxiety, and stress, respectively [22].

Thus, the aim of this study is to investigate the extent to which levels of stress, anxiety, and depression are associated with levels of sleep quality, happiness, and life satisfaction during the month of Ramadan. This association was examined for the total sample, male sample, and female samples. It was hypothesized that levels of sleep quality, life satisfaction, and subjective happiness will be significantly and inversely associated with levels of stress, anxiety, and depression during the month of Ramadan across all three groups.

2. Methods

3. Results

4. Discussion

First, this study was pivotal in examining the levels of stress, anxiety, and depression as well as components of sleep quality, life satisfaction, and subjective happiness during Ramadan. Partially supporting the first hypothesis, the scores for mental health across the three groups indicate normal levels of depression, anxiety, and stress, which suggest the maintenance of a general level of mental well-being during Ramadan. This finding aligns with the broader narrative that spirituality and religious engagement, particularly during Ramadan, can contribute to the maintenance of mental health [2,4,5,6,7]. However, it is noteworthy that while participants reported satisfactory levels of mental health, life satisfaction, and subjective happiness, their Global PSQI fell within the range indicating poor sleep. This discrepancy between mental well-being and sleep quality could reflect the unique challenges—such as altered sleep schedules, strained work routines, and changing dietary habits—that individuals face during Ramadan, specifically within a nation where they may not be as accommodated. Given that Ramadan involves longer nightly prayers, poor sleep is often anticipated. Participants are advised to maintain a healthy sleep routine by engaging in physical activity in the evening after their daily meals. Furthermore, a review on the effect of Ramadan fasting on sleep duration and daytime sleepiness revealed a moderate reduction in total sleep time (TST) and a slight increase in daytime sleepiness scores during Ramadan [31], which echoes our findings of moderate daytime dysfunction and sleep disturbances across the three groups. These observations suggest that while fasting during this period can lead to decreased sleep duration, the impact on excessive daytime sleepiness is relatively minimal, indicating a nuanced effect of fasting on sleep quality and highlighting the need for further exploration. It is conceivable that participants’ sleep was affected by other factors such as a bodily change stemming from altered diet, altered medication routines, or smoking cessation. One aspect of sleep not considered is chronotype/circadian preferences. Individuals with a marked circadian preference for morning or evening hours might experience different sleep patterns and quality during Ramadan, which could influence the associations between sleep quality and mental health outcomes discussed in this study. Future research should evaluate these chronotype differences to better understand their impact on sleep quality and psychological well-being during Ramadan. Overall, it appears that the impact on sleep quality is counterbalanced by heightened spirituality and commitment to ritual practices, as evidenced by participants maintaining normal levels of mental health.

Furthermore, our study examined the associations between mental health indicators (stress, anxiety, and depression) and factors such as sleep quality, life satisfaction, and subjective happiness during the month of Ramadan. Consistent with our hypotheses, our study revealed significant associations between these variables for the total sample. Specifically, higher levels of life satisfaction and subjective happiness were associated with lower levels of depression, anxiety, and stress across the total sample. These findings corroborate previous research highlighting the protective role of positive affect and life satisfaction against psychological distress and mental health issues [18,32]. Additionally, poor sleep, as measured by the Global PSQI score, was linked to increased stress in the total sample and particularly among females, while in males, it appeared to contribute to heightened anxiety. This aligns with previous findings that suggest symptoms of poor mental health can be exacerbated by poor sleep quality [19,20,21,22]. Interestingly, although stress and anxiety were affected by poor sleep, there were no associations with indicators of depression. This observation prompts further investigation into whether participation in spiritual rituals such as Ramadan might buffer against the effects of poor sleep, a condition frequently reported during this period [3]. These findings underscore the crucial role of sleep quality as both a beneficiary and a detriment to mental health during Ramadan. Overall, our results suggest that Ramadan may serve as a mechanism for enhancing levels of subjective happiness and life satisfaction, which, in turn, contribute to reduced levels of stress, anxiety, and depression, as seen across our sample, while also mitigating the impact of poor sleep experienced during this period.

Although no statistical analysis between genders was performed, observations based on data shed light on gender differences. Females, on average, reported higher anxiety scores compared to males, while males reported higher levels of depression. This aligns with a 4-year longitudinal study that found females generally exhibited higher levels of general anxiety, whereas males experienced higher levels of depression [33]. These differences could result from varying societal expectations or gender roles associated with Islam. Women are often encouraged to express their emotions and assume household roles, which could lead to increased reports of anxiety and stress. Conversely, men may be discouraged from expressing emotions and are expected to act as a provider, potentially exacerbating feelings of isolation and depression. Interestingly, while sleep quality emerged as a significant predictor of mental health outcomes for the total sample, the associations varied between genders. Sleep quality did not appear to affect male stress levels, as their stress was solely influenced by subjective happiness. Conversely, factors of sleep quality, such as sleep latency, sleep duration, and the Global PSQI score, contributed to stress in females. This resonates with a study exploring gender differences in sleep, which analyzed 3778 young adults and indicated a higher prevalence of poor sleep quality in females compared to males (65.1% vs. 49.8%) [34]. For males, anxiety levels were exacerbated by poor subjective sleep quality and life satisfaction levels. On the other hand, females had no individual contributors for anxiety. These gender-specific differences underscore the complex interplay between sleep quality, life satisfaction, subjective happiness, and mental health outcomes, which may be influenced by sociocultural factors and individual coping mechanisms that vary between genders. Women in some cultures may not have as much autonomy or fewer opportunities to participate in social gatherings outside the home, impacting their sense of well-being during this month. Women also face unique health challenges during Ramadan, such as managing the month while menstruating, pregnant, or breastfeeding. These factors can affect their health differently from men. Moreover, it is possible intersectional differences play a role in the observed difference as one study on gender and caste differences in India reveals. Caste identities impact educational, occupational, and income choices for Muslim women. Upper-caste Muslim women face restrictions on their choices, whereas lower-caste women encounter severe marginalization and double discrimination. This dual oppression can significantly impact their mental health and well-being, as lower-caste women are often excluded from higher professions and forced into low-paid jobs, thereby exacerbating their sense of social and economic insecurity [35]. These insights suggest the need for tailored accommodations, such as workplace flexibility for males, or encouraging shared domestic responsibilities in households to alleviate the burden for females who are required to constantly prepare meals. In general, communities housing Muslim populations should strive for religious tolerance to better support those who partake in Ramadan. In environments where religious intolerance is prevalent, Muslim participants may face discrimination, marginalization, and lack of support for their religious practices. This can increase their stress levels and negatively affect their mental health during Ramadan.

This study has several limitations that warrant caution in interpretation and suggest directions for future research. First, its cross-sectional design limits the ability to draw causal conclusions about the relationships between the examined variables. Longitudinal studies are needed to better understand the temporal dynamics of these relationships, particularly how changes in mental health, sleep quality, life satisfaction, and subjective happiness evolve throughout the month of Ramadan and beyond. Instead of regression models, mediation/moderation models are recommended to allow for a better understanding of mechanisms linking these variables, instead of regression models. Second, the reliance on self-reported measures may introduce potential for response bias, where participants might overestimate positive behaviors or underreport negative symptoms. Future studies could benefit from incorporating objective measures of sleep quality, such as use of ActiGraph (Version 6.14.0) activity monitors, to provide a more accurate assessment. Third, the generalizability of findings may be limited by the sample’s cultural and religious composition. Research in more diverse contexts, including different non-Muslim-majority countries and among Muslims with varying levels of religious observance, would be valuable. Finally, the study’s focus on Ramadan within the USA might not fully capture the nuanced ways in which cultural, societal, and individual factors interact in other settings, suggesting the need for comparative cross-cultural research. Despite its limitations, including the cross-sectional design and reliance on self-reported measures, this research opens new avenues for tailored interventions aimed at enhancing well-being among fasting individuals.

5. Conclusions

This study sheds light on the psychological advantages of life satisfaction and subjective happiness in bolstering mental health amidst the distinctive challenges of fasting within a non-Muslim-majority setting. It also underscores the pivotal role of sleep quality as a potential factor influencing mental well-being. The findings imply that nurturing positive emotional states can function as a shield against potential psychological strain arising from altered sleep patterns and lifestyle adjustments during Ramadan. For practitioners and community leaders, these insights offer pathways for crafting tailored interventions aimed at enhancing well-being and mental resilience among fasting individuals in the United States. The observed gender differences underscore the necessity for gender-specific accommodations, advocating for the incorporation of mindfulness practices, community involvement initiatives, and well-being workshops that accentuate the spiritual and communal dimensions of Ramadan. Implementing such interventions could aid individuals in navigating the intricate balance between upholding traditional religious practices and assimilating into the broader societal fabric of a non-Muslim-majority country.

Overall, this study suggests avenues for future research to delve deeper into these dynamics, utilizing longitudinal methodologies or mediation/moderation models, as well as objective metrics to enrich our comprehension across diverse cultural and religious contexts. Such endeavors could contribute significantly to our understanding of the complex interplay between religious observance, psychological well-being, and sociocultural environments.

Author Contributions

D.J.: writing—original draft, writing—review and editing, collection, visualization. A.A.: conceptualization, methodology, formal analysis, interpretation, writing—review and editing. M.W.M.: visualization, conceptualization, methodology. S.R.L.: data curation, resources. A.S.: data curation, resources. M.E.: data curation, resources. W.C.: writing—review and editing, supervision, project administration, formal analysis. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by University Institutional Review Board of Health and Behavioral Sciences, which conducts anonymized reviews of research involving health and behavioral sciences (IRB Protocol #HUM00226755), approved on 3 March 2023.

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

Data Availability Statement

The data presented in the study are available on request from the corresponding author.

Acknowledgments

The authors would like to thank the study participants for their involvement.

Conflicts of Interest

The authors declare no conflicts of interest.

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