## I. INTRODUCTION The fast of Ramadan is one of the five pillars of Islam; it is also one of the greatest of the marks and observances of Islam. There are many purposes and instances of wisdom in the fast of Author C: Park Orman Family Health Center, Diyarbakir, Turkey. Ramadan with aspects to God Almighty's dominicality, man's social and personal life, and the training of his instinctual soul, and his gratitude for divine bounties (1). Healthy and sedentary individuals have been frequently investigated through Ramadan fasting. Although fasting in the holy month of Ramadan is influential on physical and mental health based on religion of Islam (2) and several studies have described the effect of fasting on physical health (3-6), few investigations have addressed to the relationship between fasting and mental health (7-9). Studies examining the association of fasting and mood can be divided into two groups: the first group features experimental studies, while the other group of studies is observational studies on the effects of Ramadan on mood, i.e. a partial fasting for one month per year. Recent clinical observations demonstrated an early (within few days) favourable effect of medically supervised fasting (for 7-20 days) on depressive symptoms, and an improvement in mood, alertness, pain and a sense of tranquility (10,11). However, the results of such experimental fasting cannot be extrapolated to Islamic intermittent fasting during Ramadan because the duration of each fasting episode of experimental fasting is usually more prolonged than the duration of fasting during Ramadan (12).Moreover, Ramadan fasting has unique characteristics. During every day of the month of Ramadan, Muslims abstain from food, drink and smoking between dawn and sunset. The effect of Ramadan on health has been studied extensively, for example, in relation to diabetes mellitus, electrolyte imbalance, sleep-wake cycle, daytime alertness and other physiological parameters. Unfortunately, the effects of fasting during the month of Ramadan have not been studied adequately in relation to psychiatric disorders. On extensive literature search, we could only find a few studies examining the relationship between fasting and mood changes. Therefore, the effect of Ramadan fasting on mood and depressive symptoms remains to be determined in well-designed studies. In this respect, the month of Ramadan represents an opportunity to study the relationship between mood disorder and Ramadan fasting. The overall objective of this study was to explore the psychological effects that occur during the Ramadan month, especially effects on depression, anxiety, and stress. We hypothesized that fasting people would be happier, joyful, peaceful, carefree and more stress-free during this month. In the present study, we aimed to investigate the spiritual status of doctors who study in the primary health care and to compare mood state of faster doctor to non-faster doctors in the holy month of Ramadan. ## II. MATERIALS AND METHODS We know that factors such as environment, education, economy, geography, season, occupation play a significant role in the etiology of mental illnesses such as depression, anxiety and stress. Therefore, we have included doctors who have the same profession and education level, who have similar economic income, live in the same geographical area and are interested in similar patient groups in the study. In addition, the criteria for participant exclusion from the study were as follows: "Have you experienced a major event such as accident-death that could seriously affect your psychology in the last year?", "Do you have any psychiatric treatment in the last 6 months?", "Do you have a chronic illness?" and "Do you have any drug use continuously?" those who answered "Yes" to the questions $(n = 84)$ were excluded from the evaluation. Thus, the confounding factors were intended to be minimized. The remaining 209 healthy subjects with no known health problems and who were not in the risk groups in terms of mental and physical health were included in the statistical evaluation. ### a) Statistical Analysis SPSS (Statistical Package for the Social Sciences) 21.0 statistical package was used in the data analysis. Data were expressed as frequency, percentage and means (SD). The reliability of the questionnaire was tested and the Cronbach's Alpha value was calculated as 0.963. The relations between the dependent and independent variables were examined with the cross tables (Chi-square $= \chi^2$ ). To compare the two groups in respect to the scores of the scales, Mann-Whitney U was used. The statistical analyses were considered significant if $p < 0.05$. ## III. RESULTS Of the 209 people included in the evaluation, 163 said they "fasted this month in Ramadan" and 46 said "they did not fast this month in Ramadan". The mean (SD) age of the participants was $38.0 \pm 7.5$ (range, 24-64 years). The mean (SD) professional experience of the doctors was $12.4 \pm 6.9$ years (range, 1-34 years). Among the participants, $17.7\%$ ( $n = 37$ ) were female and $82.3\%$ ( $n = 172$ ) were male, $18.7\%$ ( $n = 39$ ) were single and $81.3\%$ ( $n = 170$ people) were married. Other socio demographic data of participants were summarized in Table 1. According to doctors who fasted and did not fast, it was determined that the number of patients applied in Ramadan decreased and the patients were to be more aggressive ( $p > 0.05$ ). According to the DASS score, when fasting people were compared to those who did not fast in Ramadan; depression ( $p < 0.05$ ), anxiety ( $p > 0.05$ ) and stress ( $p < 0.05$ ) scores were found to be lower in fasting sample (Table 2). When compared to those who fasted in Ramadan and those who did not fast; depression, anxiety and stress prevalence were found to be lower in fasting sample (Table 3). The prevalence of depression detected in fasting group was $27.0\%$ in non-fasting group was $45.7\%$ $(p < 0,05)$. The prevalence of anxiety detected in fasting group was $25.2\%$ and in non-fasting group was $41.3\%$ $(p < 0,05)$. Finally, the prevalence of stress detected in fasting group was $21.9\%$ while the rate was $37.0\%$ in non-fasting group $(p < 0,05)$. ## IV. DISCUSSION Ramadan fasting is unique because of its intermittent nature and also has many spiritual benefits. It allows deep introspection and an increased awareness of one's relationship with God and others around them, a greater appreciation of blessings, and it encourages compassion, care, and charity. There are several physical benefits too. Fasting reduces low-density lipoprotein and cholesterol levels, and improves weight and glycaemic control (14). Although Ramadan fasting imposed no adverse effects on short-term memory and did not negatively impact the cognitive flexibility function (7,15), results in another study show that the effect of fasting on cognition is heterogeneous and domain-specific (16). Ramadan fasting results in decreased REM sleep with no impact on other sleep stages, the arousal index or daytime sleepiness (12,17). However, eating exclusively at nighttime imposes significant alterations on individuals' life style and sleep-wake cycles; therefore, food and fluid deprivation theory does not appear to be a convincing explanation for all the presumed impacts of Ramadan fasting. The studies described that combination of changes in sleep-wake cycle, food and fluid intakes, and circadian rhythms was likely to affect mental, physical, and social performances (18). Their findings showed that sleep loss might be responsible for excessive fatigue and reduced alertness in the daytime. Ramadan fasting also imposes deep impacts on the natural circadian rhythm through significant shifts in sleep patterns, body clock, and other physiological indices (18,19). Irritability could be increased during Ramadan fasting which was attributed to reduction in sleep time or nicotine withdrawal (20). Similarly, impairments in vigilance, memory, and continuous attention have been suggested in the course of Ramadan (21). To date, there are only a few studies that have examined the effects of Ramadan fasting on psychological state and mental health, especially on anxiety, depression and stress. In these investigations, there were no differences in tension, depression, anger, vigor, and confusion estimated by the Profile of mood states questionnaire. Only fatigue was higher at the end of Ramadan (22). The result of a pilot study indicates that the Ramadan month may disrupt the mood state of bipolar patients. The relapses were not associated with a change of blood level of lithium. Most of the relapses were of a manic type (77.7%) (23). On the contrary, Farooqa et al. did not find evidence of significant deterioration in mood and mental state. None of the patients relapsed requiring admission or change in treatment. They observed a significant reduction in Hamilton Depression Rating Scale scores during Ramadan compared with pre-Ramadan assessment. The scores on Young Mania Rating Scale also showed a significant decrease during Ramadan compared with pre and post-Ramadan assessments (8). Koushali et al. investigated Effect of Ramadan fasting on emotional reactions in nurses. The level of their emotional reactions was assessed by DASS questionnaire in two stages over 1-2 weeks before and after Ramadan. The findings showed that depression and stress levels were significantly reduced after in comparison with the levels before the holy month $(P < 0.05)$. Despite the reduction of anxiety level in fasting after Ramadan, the difference was not significant (24). The results of another study reveal that according to the DASS score, depression anxiety and stress levels were significantly reduced at the end of in comparison with the levels before the holy Ramadan (p $< 0.05$ ). Before the Ramadan; according to DASS score, the persons who were evaluated normally in terms of mood state, when the before Ramadan scores were compared to the end of Ramadan there was no statistically significant in depression, anxiety and stress between pre- and post-Ramadan. Therefore, it can be said that Ramadan fasting has not a negative effect on human psychology in healthy individuals. The persons who were evaluated depressive, anxious and stressful, when the before Ramadan scores were compared to the end of Ramadan depression, anxiety and stress scores were found to be lower at the end of Ramadan. Thus, it can be said that Ramadan has a positive effect on the psychology of individuals who are experiencing depression, anxiety and stress. The results of the present study reveal that according to the DASS score, depression (p $< 0.05$ ) and stress (p $< 0.05$ ) scores were found to be lower in fasting people compared to non-fasting group. Depression, anxiety and stress prevalence were also found to be lower and statistically significant in fasting sample in comparison with those who did not fast in Ramadan (25). Our study had some limitations, including a small sample size especially in women and who did not fast. Were commend that the study in a larger sample size, should be performed in further investigations. ## V. CONCLUSION Millions of Muslims observe fasting in a wide variety of climatic conditions every year. However, epidemiological research is sparse especially in relation to psychiatric disorders. Gaining comfort and confidence and staying away from depression and anxiety are the most fundamental innate human needs, and researchers are striving to underlie the provision of relief in different ways. The current study results demonstrated that fasting in the holy month of Ramadan have been effective in diminishing stress, anxiety, and depression levels, as the decrement has been statistically significant for the stress and depression rates. Therefore, it is concluded that Ramadan fasting have a protective effect on human psychology. However, it needs to be more elaborated and confirmed through further investigations in the future.

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