Depression is one of the most prevalent mental disorders worldwide (1). According to the World Health Organization (2012), it is estimated that by 2020 depression will be the second leading cause of poor health and mortality (2). Generally, the two common treatments for depression are pharmacotherapy and psychotherapy, but in many cases, the results are not quite satisfying (3). Thus, health professionals should find a cost-effective therapeutic method to help ameliorate this problem.
It seems that lifestyle modifications can considerably improve depression. Results from therapeutic lifestyle change (TLC) programs have indicated that factors related to lifestyle contribute to development, maintenance and also treatment of depression (1, 4, 5). Therapeutic lifestyle changes offer a potentially safe and cost-effective option for depression management (6).
There are many lifestyle elements whose modification can lead to depression improvement. These elements include physical activity or exercise (7), adequate and high-quality sleep (6), social relationships (8), dietary modification (9), and recreational activities (10).
Religious psychological studies show that integrating religious (Islamic) factors into psychological treatments can enhance the efficacy of such treatments (11-13). To the best of our knowledge, this is the first attempt to investigate the lifestyle factors that are important in depression management from Islamic lifestyle perspective. In this regard, research has shown that incorporating religious practices and beliefs into psychological treatments for depression is associated with positive treatment outcomes (11). It seems that religious interventions for Muslim patients can result in earlier remission of depressive symptoms compared with secular interventions (11-14). While Islam is the world's second largest religion with over 1.8 billion adherents, the role of its practices and beliefs in the therapeutic process of depression is ignored (15).
In this paper, we sought to investigate the role of Islamic lifestyle (Shia Muslim perspective) on depression management. There are several definitions for Islamic lifestyle, but there is no consensus regarding its definition among Muslim researchers. According to Shia Muslim perspective about Islamic lifestyle "generally, it can be stated that Islamic lifestyle consists of a set of religious values, beliefs, norms, thoughts, and behavioural patterns formed based on Quranic teachings and Holy Prophet (PBUH) and Imams' lives, traditions, and narrations" (16). Therefore, we will follow this definition of Islamic lifestyle in this paper.
English-language studies published between 2007 and December 2017 were identified using Scopus, PubMed, and PsycINFO databases. The following keywords were used for all databases using the operator AND: "lifestyle", "depression", "depressive symptoms" (e.g., lifestyle AND depression, lifestyle AND depressive symptoms). Abstracts of all the articles identified in the search were screened to determine eligibility. Articles were included in the review if the following criteria were met: (1) The research should have been conducted on adults between 20 and 60 years old (not on adolescents or elderly people), (2) they should have been written in English, (3) they should have been published in full-text, and (4) they should have been published from 2007 to December 2017.
On the other hand, articles were considered ineligible if (1) they did not meet the inclusion criteria described above, (2) they were review articles, (3) they enrolled patients suffering from a psychiatric disease other than depression, and (4) they were conducted on special populations (e.g., hospitalized patients or mentally disabled persons).
Among 334 identified articles, after removing the duplicate records, 10 articles fully met the inclusion criteria. This procedure is shown in Figure 1. In order to sum up the retrieved results, the researchers extracted the data of interest from all the selected studies, and any disagreements were resolved through consensus. The lifestyle factors reported in each article were extracted and then the elements with the most similarities were placed in the same category.
For investigation of Islamic lifestyle (Shia Muslim) perspective, Islamic teachings (verses of Quran and Hadiths) were used. The main resources for this part of the study included the Holy Quran and Mizan al-Hikmah Encyclopedia (Scale of Wisdom) (17). The authors searched these resources to find Islamic recommendations about the extracted lifestyle factors.
Our search of the three selected databases yielded 334 results, 138 from Scopus, 109 from PubMed, and 87 from PsycINFO. After excluding duplicate and irrelevant results, we eventually identified 10 articles available for full-text review (Figure 1).
After investigating the lifestyle factors mentioned in these studies, we classified them into five categories, including physical activity (exercise), sleep (sleep hygiene and adequate sleep), social relationships (socializing), dietary modification (smoking, alcohol consumption, and eating breakfast), and recreational activities (light exposure, outdoor activity, and sunlight exposure). The summary of these findings is presented in Table 1.
|Author (s)||Publication Year||Type of Study||Lifestyle Elements||Conclusion|
|Cabello et al. (18)||2017||Correlational study||Smoking||Smoking on a daily and non-daily basis was longitudinally related to depression; Depressed people with low physical activity and with heavy drinking patterns were more likely to become depressed over time|
|Sánchez-Villegas et al. (19)||2016||Cohort study||Diet||The Mediterranean lifestyle might reduce the risk of depression|
|Goracci et al. (5)||2016||Randomized clinical trial (RCT)||Sleep hygiene||Adherence to a healthy lifestyle can be effective in preventing depression relapse|
|Xu et al. (20)||2016||Cross-sectional study||Adequate and high-quality sleep||Higher quality and longer duration of sleep, more exercises, more outdoor activities or sunlight exposure, and eating breakfast daily were associated with a lower risk of depression|
|Rahe et al. (21)||2016||Correlational study||Smoking||Patients with major depressive disorder represent an important target group for lifestyle interventions|
|Serrano Ripoll et al. (22)||2015||RCT||Diet||Just giving written lifestyle recommendations is not enough for depressed patients to benefit from them|
|Duong and Lee (23)||2015||Correlational study||Exercise||There is a positive correlation between the amount of exercise engaged in per day and the likelihood to have a positive perception of exercise prescription as a tool in depression prevention and treatment|
|Loprinzi and Mahoney (24)||2014||Correlational study||Diet||People who have positive lifestyle factors were 15% less likely to be classified as having moderate or major depressive symptoms|
|Savolainen et al. (25)||2014||Correlational study||Diet||Self-reported depressive symptoms were less frequent among subjects with a healthier lifestyle|
|Garcia-Toro et al. (1)||2012||RCT||Sun exposure||Depressed patients are able to follow prescribed lifestyle recommendations in the short-term|
Although it seems that religious involvement is an important lifestyle factor that can contribute to the development and persistence of depression (26), but studies have yet considered this lifestyle element for depression management. Because religious involvement is an important aspect of Islamic lifestyle, we aimed to investigate it in addition to other lifestyle factors.
We will investigate each of these factors from both psychological and Islamic lifestyle (Shia Muslim) perspectives.
3.1. Physical Activity (Exercise)
Regular exercising has many physical and mental benefits (27); studies have also shown that physical exercise can reduce the risk of depression (28, 29). It can be used as an independent or adjunct treatment for depression (30).
Several studies have provided support for the antidepressant effect of exercise (7, 31-34). Possible mechanisms that contribute to the antidepressant effects of exercise (both in prevention and treatment) include physiological and psychological domains. The proposed physiological factors include improving blood circulation, changing serotonin metabolism, increasing endorphin release, enhancing levels of brain-derived neurotrophic factor (BDNF), promoting mood elevation, and raising pain threshold (7). On the other hand, psychological contributors include increasing self-efficacy and self-esteem and reducing negative thoughts and rumination (35).
Physical health is one of the most important emphasized aspects of Islam. According to Prophet Muhammad's (PBUH) point of view, a physically strong believer is better and more beloved to Allah than a weak believer (36). Islam encourages its followers to do exercises such as swimming, walking, running, wrestling, horseback riding, and camel-racing (37). The Prophet Muhammad (PBUH) considers walking as a natural drug and says: "The best thing you can cure yourself with, is walking" (17). Thus, being physically active in Islam is highly recommended.
Adequate and high-quality nocturnal sleep is of great importance for both mental and physical health (6). There is a robust body of evidence regarding the relationship between sleep disorders and mood disorders in adults and adolescents (38). Sleep disturbances are reported in 90% of people suffering from depression (39). Therapeutic lifestyle change programs can improve sleep by addressing factors associated with poor sleep, such as insufficient physical activity, caffeine use, and poor diet (1, 5).
Health-related religious studies are rich in describing sleep, its practices, and habits. In Holy Quran, sleep is one the greatest signs of Allah's power. One Quranic verse says, "And among His signs is your sleep by night and by day and your seeking of His bounty, verily in that are signs for those who hearken" (30.23). Islamic quotations emphasized the importance of having enough sleep during the night (17). Based on Islamic literature, Muslims should allocate between 6 to 8 hours to night's sleep (40).
Going to bed in the early hours of the night (around 9 - 10 pm) and waking up early, approximately before Fajr (morning) Adhan (call for prayer) are strongly recommended in Islam (41). In Islam, midday nap (Qai'lullah) is also recommended.
Islam also urges Muslims to consider some practices before sleep, which include (1) going to the toilet, (2) brushing the teeth, (3) making Wudu (ablution), (4) reciting some verses of Quran, and (5) sleeping on the right side or on the back (17). It seems that Islamic practices before sleep can reduce daily stress and prepare the person for a good night's sleep.
3.3. Social Relationships
One of the key elements in lifestyle that influences mental health is social relationships. Research has shown that enhancement of social support is a protective factor against depression and low level of social or emotional support is associated with the development and maintenance of depression (42). There are several possible mechanisms that can explain the relationship between social isolation and depression. Social relationship reduces the level of stress; social activities can decrease rumination and provide social support. Enhancement of marital relationships can boost marital satisfaction, and all of these elements can reduce depressive symptoms (43).
Islam is a social religion, and social relationships are one of the most important parts of Islamic teachings. The Prophet Muhammad (PBUH) says, "Allah's Hand [i.e. divine aid] is with the congregation. Whenever a straying person deviates, Satan snatches him up like a wolf snatches a sheep straying from the herd" (17).
Islam provides social support for its followers from several sources; (1) Relationship with parents (17, 30-32). (2) Spouses' relationship with each other; the prophet Muhammad (PBUH) says, "A man's sitting beside his family (wife and children) is more beloved in the sight of Allah than his spending the night in worship in this mosque of mine" (17). (3) Developing and maintaining relationship with relatives is highly recommended in Islam. The prophet Muhammad (PBUH) says, "If you want to be happy the whole year, reconcile with your kinsmen" (17). Maintaining this relationship is so important that the Holy Prophet (PBUH) says, "If a close relative treats you indifferently and ignores your relationship, do not turn your back on him but keep on doing, on your part, the obligations of relationship towards him" (17). (4) Making and maintaining a relationship with good friends. Imam Ali - the first Shia Imam - says, "One's friend is the closest of one's relations." He also says, "He who lacks friends lacks a bare necessity" (17). (5) Some Islamic practices are performed in groups, such as saying daily prayers together in a mosque is very encouraged in Islam. This form of praying helps people to meet and talk with each other and enhances social relationships (44).
3.4. Dietary Modification
There is a growing body of research indicating that dietary modification has a protective and therapeutic effect against mental health disorders (9). Poor diet can be a risk factor for the development of depression, and healthy diet is a clinically important element for depression improvement (6). Several studies have shown a relationship between poor diet and depression and anxiety (45-47).
Several major elements of dietary modification for depressed patients should be considered. (1) Eating multi-coloured fruits and vegetables (48), (2) fish consumption (49), (3) intake of folate (folic acid), zinc, magnesium, and vitamin D supplements (30), (4) non-use of fast-foods (50), (5) breakfast consumption (51, 20), and (6) reduction/cessation of smoking and alcohol consumption (30).
There are lots of verses in Holy Quran about dieting. As a general rule in Islam, Allah says, "O' Believers! Eat the good and pure (lawful) things that we have provided you and be grateful to Allah if you truly worship Him" (2.172). From Quran's perspective, Muslims must eat good things to have good behaviours (23.51).
In Islam, everything that harms a person's physical or mental health (e.g., smoking and alcohol) is forbidden. The Holy Prophet (PBUH) describes the importance of diet and says, "The stomach is the house of pain and abstinence is the most important medicine" (17). Imam Ali (PBUH) expresses a general recommendation about dieting; he said in his will to his son, al-Hasan (PBUH), "O my son, shall I teach you four things which will make you needless of medicine?" He replied, "Yes, O Commander of the Faithful." So, he said, "Do not sit to eat unless you are hungry. Stand up from the table while you still desire food. Chew properly. Go to the lavatory before you go to bed. If you put these into practice, you will not need medicine" (17).
Islam provides useful tips about a balanced diet, a diet which contains meat, fish, fresh milk, grains, fruits, and vegetables (52). There are two important meals in Islam, breakfast and dinner. The Prophet Muhammad (PBUH) says, "He who wishes to remain alive - though there is no remaining forever - should eat breakfast and eat his/her breakfast early…" (17). In a Hadith about the importance of eating dinner, The Holy Prophet (PBUH) expresses, "Don't leave having dinner even with eating some dates…" (17).
There are also several recommendations about eating in Islamic literature. (1) Over-eating is prohibited, (2) washing hands before and after eating is recommended, (3) remembring Allah is encouraged before, during, and after eating, (4) eating at the same table where alcohol is served is forbidden, (5) eating a bit of salt before and after each meal is recommended, (6) food should be chewed properly, (7) while eating, one should not stare at others who are eating, (8) eating very hot food is prohibited, (9) one should not cool the food by blowing with the mouth instead, let the food remain for some time till it cools, and (10) eating in standing position is prohibited, it is advised to sit while eating (17).
3.5. Recreational Activities
Balancing the "work-rest" dynamic is a crucial element in the management of depression. Depressed patients usually have no specific plan for their leisure time and the frequency of recreational activities is significantly decreased in these patients (53). Recreational activities shift depressed persons' attention away from their problems, while also providing opportunities for experiencing positive emotions (54). Research has shown that participating in organized recreational activities leads to better mental health and reduction of depressed mood in participants (55).
It seems that Islam recommendations cover all aspects of human needs. One of these important needs is the need to relax and enjoy. Imam Ali (PBUH) mentions, "A believer must observe three times during the day; one part of his time needs to be spent in worship and being with God, another part needs to go for daily activities and earning a livelihood and making a living, and the third needs to be spent in making use of Halal pleasures and Godly blessings. This third part of the day is a help to the other plans (that one has for one's day)" (17).
Interacting with natural environments (e.g., jungle, sea, and mountains) is among factors that increase happiness in Islam. Imam Kazim - the seventh Shia Imam - says, "three things strengthen the eyesight (make you happy): looking at green scenery, looking at running water (river or sea), and looking at a beautiful face" (17). Generally, in Islam, every legitimate recreation is permitted and Muslims are asked to allocate some time during the day or week for recreational activities.
3.6. Religious Involvement
Religious involvement is one of the key lifestyle factors in coping with depression (26). Results from a growing body of research in this field have shown a strong negative correlation between depression and religious involvement (12). Religious resources provide strategies for coping with symptoms of depression (56). Performing religious practices may also moderate the relationship between physical functioning and depressive symptoms (57).
There are several beliefs and practices in Islam that affect Muslims' mental health. Islam presents clear recommendations about behaviours, ethics, and social values, which help Muslims to tolerate and develop effective coping strategies to deal with stressful life events (36). Muslims believe that there is just one God and relying on God's power can help them resolve their problems. Muslims believe in the life after death and the Day of Judgement. These beliefs help them tolerate stressful life events better and have good behaviours towards others. Muslims believe in destiny, which means, "everything-all events and happenings in life-have a purpose and there are no random occurrences" (44). Belief in destiny helps Muslims to accept bad situations (like diseases and death of loved ones) easier.
There are also some practices in Islam that help Muslims enhance their mental health. These practices include (1) daily prayers, (2) fasting during the month of Ramadan, (3) helping others, and (4) daily reciting of the Holy Quran.
When Muslims are praying, they are talking directly to God. Praying is a relaxing activity. After the prayers, Muslims also talk to Allah about their wishes and problems, they ask Him to help them.
Muslims are required to fast during the month of Ramadan. Fasting helps Muslims to understand feelings of the poor who cannot afford food. Fasting also affects physical and mental health. The Holy Prophet (PBUH) says, "A man whose [consumption of] food is little, has a healthy stomach and a pure heart, and a man whose food is plenty, has a sick stomach and a hard heart" (17).
Helping others in all forms (e.g., financially, physically, or psychologically) is one of the most important religious practices in Islam. Allah says, "Say, indeed my Lord expands the provision for whomever of His servants that He wishes and He tightens it, and He will repay whatever you may spend, and He is the best of providers" (34.39). The Holy Prophet (PBUH) expresses, "The most beloved of Allah's servants to Him are those that are the most useful to His servants …" (17). Research has shown that charity volunteers report fewer depression symptoms (58).
Daily reciting of Holy Quran verses is another highly recommended religious practice in Islam. Muslims are also encouraged to try to understand and behave based on Quranic recommendations. Listening to the Holy Quran is also recommended. It has been shown that reciting Holy Quran and listing to its verses is effective in reducing stress and anxiety and it can be regarded as an anti-rumination strategy for depressed people (59).
There are many factors, including genetics, personality, cognition, and environmental stressors, that can lead to development and maintenance of depression. Modification of lifestyle elements can considerably improve depression. Many changes have occurred in the lifestyle of a significant proportion of the population in the developed and developing countries like Iran during recent decades. The level of their physical activity has reduced, they have a less healthy diet, their exposure to sunlight is decreased, they do not have an adequate and high-quality night's sleep, and the social interactions between people is decreasing (60).
Research has shown that such lifestyle changes have a negative influence on brain physiology that may raise depression vulnerability (61, 62). While it seems that depressed patients are aware that modification of these faulty aspects of their lifestyle can help them improve their mood, they often do not attempt to change their lifestyle spontaneously (63).
In the current review, we discussed the role of six major lifestyle elements including physical activity or exercise, sleep (adequate and high-quality sleep), social relationships, dietary modification, recreational activities, and religious involvement in depression management from psychological and Islamic lifestyle (Shia Muslim) perspectives.
There were some differences between Islamic and psychological recommendations about the above-mentioned elements. For example, while Islam encourages Muslims to go to bed early at night (around 9 - 10 pm) and wake up, preferably before Fajr (morning) Adhan (approximately around 5 a.m.), some psychological lifestyle interventions want depressed people to go to bed when they are sleepy preferably not before 11 o'clock at night and get up early, never later than 9 a.m. (e.g., ), or it seems that importance of relationship with parents and relatives is more highlighted in Islamic lifestyle than psychological recommendations. The quality of eating (how to eat) is not investigated in psychological studies and there is no recommendation about it in therapeutic lifestyle modification interventions. In Islamic lifestyle, the quality of eating is important and as mentioned before, there are many recommended habits of eating in Islam. Considering these habits while eating helps people to have a mindful eating. A recent study that integrated mindfulness and Mediterranean lifestyle program showed that such interventions are useful in depression improvement (5), but further research is needed to clarify the role of eating quality in depression management.
Generally, both Islamic and psychological recommendations about the afore-mentioned lifestyle elements emphasized on the protective and therapeutic role of lifestyle in depression management. Thus, it could be concluded that although some recommended Islamic lifestyle factors appeared to be beneficial in depression management, still much more research is required to clarify such complicated relationships.
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