Important Considerations for Using Psychiatric Medications During Ramadan
In clinical practice, our approach is for patients receiving antidepressant and anxiolytic treatments to adjust their morning medication doses to the time of suhur (pre-dawn meal) and to take their evening medications after iftar (breaking the fast). For medications taken at noon, it is recommended that patients consult their treating physicians based on the nature and progression of their illness.
A crucial point to remember is that some antidepressants and anti-anxiety medications may have side effects such as decreased saliva production and dry mouth, and these side effects may intensify during fasting. In elderly patients, the use of medications with anticholinergic effects can lead to dehydration and increased confusion, so changing medications or adjusting dosages to the evening may be alternatives.
During Ramadan, the adjustment to suhur and iftar timings and the prolonged periods of fasting can lead to symptoms such as insomnia, difficulty concentrating, irritability, and tension, which are normal reactions that can be observed even in individuals not using psychiatric medications. However, in certain psychiatric conditions like bipolar affective disorder and schizophrenia, it is essential to note that insomnia can trigger episodes and flare-ups of the illness. Because insomnia and stressful life events can provoke episodes even in patients who adhere to treatment, individuals with bipolar affective disorder and schizophrenia, especially those with a history of frequent episodes, should consult their physicians regarding fasting.
For patients with bipolar affective disorder who are in a state of remission, decisions about fasting can be made based on recommendations from their treating physicians, taking into account the progression of their illness and the medications they are using. Another important consideration is the use of medications such as Lithium, Valproic acid, and Carbamazepine, which require monitoring of therapeutic doses through blood levels. Therefore, during Ramadan, reducing, skipping, or discontinuing these medication doses can trigger manic or depressive episodes. Lithium is eliminated through the kidneys, and fasting can disrupt the body's water balance, potentially leading to increased Lithium levels in the blood due to dehydration.
Increased blood lithium levels can result in symptoms of Lithium toxicity, such as nausea, vomiting, diarrhea, tremors, fever, altered consciousness, muscle rigidity, seizures, and arrhythmias. For this reason, it is crucial for patients on mood stabilizers like Valproic acid, Lithium, and Carbamazepine to discuss their situation with their treating physicians.
For young adults and adults with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) who are using medication, it would be appropriate to adjust long-acting methylphenidate formulations to the suhur meal. If combination therapy is used, it should be kept in mind that short-acting medications taken after the effect of long-acting medications wears off may prolong wakefulness and delay sleep time.
For patients with alcohol and substance use disorders, the most significant health issues they may encounter are withdrawal and associated symptoms. Particularly for those with a history of regular, high-volume alcohol use for more than two weeks, rapidly reducing or stopping intake can lead to symptoms such as sweating, palpitations, tremors, insomnia, nausea or vomiting, temporary visual, tactile, and auditory hallucinations or illusions, psychomotor agitation, anxiety, and seizures.
Additionally, it is important for patients with comorbid medical conditions such as diabetes, hypertension, and heart or kidney disorders to communicate with their treating physicians.
