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Do the benefits of Islam and positive effects on mental health outweigh the potential negative effects? What is the mental health of Muslims compared to members of other religious groups or those with no religious affiliation? Is level of religiosity among Muslims related to their mental health and is that relationship positive or negative? Systematic research can help to answer such questions.
Summarised here is a systematic review of research published prior to 2010 (Koenig et al., 2012), along with examples of studies published since 2010 that provide a sampling of more recent research (Centre for Spirituality, Theology and Health, 2017). We will focus here on religious coping, depression, suicide, anxiety, substance use, chronic mental illness, and psychological well-being more generally.
Use of Religion to Cope
Qualitative studies in the literature indicate that Muslims often use their religious beliefs to cope with stresses of all kinds. In a 2012 systematic review of research conducted around the world on religious coping (Koenig et al., 2012), 2.4% of studies (11 of 454) were conducted in Muslims. Prevalence rates of religious coping (when participants were asked directly) were 80% and 100% depending on the particular sample. Participants ranged from parents of children with cancer in the United Arab Emirates (Eapen and Revesz, 2003), to residents of Afghanistan coping with war (Scholte el al., 2004), to children in Indonesia dealing with a terrifying tsunami (Hestyanti, 2006). One study examined the coping behaviours of patients with paranoid schizophrenia in Jordan and Germany (Conrad et al., 2007), finding that 29% in Jordan spontaneously (without being asked) mentioned religion as a coping factor compared to 0% of German patients.
Since that review in 2010, research examining religious coping in Muslims has dramatically increased. For example, Nurasikin and colleagues (2013) surveyed psychiatric outpatients in Kuala Lumpur, Malaysia, finding that private religious activities used to cope with illness were related to significantly less depression, anxiety and stress. In a study of haemodialysis patients in Tehran, Iran (Saffari et al., 2013), higher levels of religious coping were associated with greater quality of life and better physical health status. Finally, in a survey of 266 women with breast cancer in Iran (Khodaveirdyzadeh et al., 2016), participants were asked to rate religious coping practices on a scale from 0-3. Here are their responses: seeking help through prayer (2.97 average out of maximum 3.00), remembering God (2.81), doing everything possible and then leaving it up to God (2.72-2.85), appealing to the Prophet and Imams (2.75), attending a pilgrimage (2.69), reading certain prayers (2.60), and reading the Qur’an (2.31). These religious coping practices were related to better adjustment to cancer.
Depression
Given that depression is one of the most common mental disorders in the world, one of the most disabling (Whiteford et al., 2013), and causes more decline in health than chronic diseases such as heart problems, arthritis, asthma, or diabetes (Moussavi et al., 2007), this condition deserves special attention. Because there is rationale for expecting that depression might be either less or more prevalent among Muslims, research in this area should be particularly relevant to mental health professionals. Again, the research presented here is based on a systematic review of the literature prior to the year 2010, and a selective review of more recent studies. First, Muslims and non-Muslims will be compared on rates of depression and depressive symptoms; second, the relationship between religiosity and depression in Muslim populations will be examined; and third, the results of randomised clinical trials of religious interventions tested in depressed Muslims will be reviewed.
Muslims vs. Non-Muslims. Of three studies that compared Muslims and non-Muslims on depression, two found less depression among Muslims compared to Christians in Belgium (Friedman & Saroglou, 2010) and non-Muslims in United Arab Emirates (Hamdan & Tamim, 2011), and one study found more depression in Muslims (college students in Kuwait vs. college students in New Jersey) (Abdel-Khalek & Lester, 2010).
Religiosity within Muslims. In the systematic review conducted prior to 2010 and selected studies representing more recent research, 17 studies were identified that quantitatively measured religious involvement and depressive symptoms (Koenig & Al Shohaib, 2014, p 135). Of those, 12 (71%) found less depression among Muslims who were more religious; one study (6%) reported more depression in the more religious (indirectly affecting mood through perceived intolerance and anger in a study of Muslim immigrants in Belgium); and the remaining four studies found no association. These findings are somewhat more favourable than the 61% of studies reporting inverse relationships and 6% reporting positive relationships in Christians.
Randomised Clinical Trials (RCTs). All three RCTs prior to 2010 examining psychotherapy for depression that included a religious component found it was superior to non-religious interventions in Muslim patients (Azhar & Varma, 1995a,b; Razali et al., 1998). A more recent RCT also found that reciting the Qur’an significantly reduced depressive symptoms among Muslim haemodialysis patients compared to controls (Babamohamadi et al., 2016).
Suicide
Suicide is the most feared consequence of depression, and most suicides occur in those who are depressed, particularly when depression is comorbid with substance abuse disorders (Tondo et al., 1999). Anywhere between 2% and 15% of depressed persons end their lives by suicide (Guze & Robins, 1970; Bostwick & Pankratz, 2000). In our systematic review conducted prior to 2010 and selective review conducted since 2010 (Koenig & Al Shohaib, 2014, pp 140-141), seven studies compared suicide rates in Muslims vs. non-Muslims and nine studies examined the relationship between religiosity and suicide attitudes, attempts, and completed suicide in Muslims.
Muslims vs. Non-Muslims. Muslim-majority countries have some of the lowest reported suicide rates in the world. However, given the strong religious and cultural prohibitions against suicide, this may be partly attributed to under-reporting (Pritchard & Amanullah, 2007). Of the seven studies that compared Muslims and non-Muslims, three reported more negative attitudes, fewer attempts or lower suicide (Levav & Aiesenberg, 1989; Shah & Chandia, 2010; Gal et al., 2012), and one study found the opposite (college students in Turkey had more suicidal ideation than college students in America) (Gencoz et al., 2007).
Religiosity within Muslims. Of nine studies examining relationships between religiosity and suicidal ideation, attempts, or completion in Muslims, seven (78%) found an inverse relationship, and two studies reported no association. These findings are similar to those found in Christian populations, where 79% during this same period of review reported inverse relationships between religiosity and suicide.
Anxiety
Many studies have compared Muslims and non-Muslims on level of anxiety (seven studies), or have examined the relationship between religiosity and anxiety in Muslim populations (24 studies) (Koenig & Al Shohaid, 2014, pp 148-150).
Muslims vs. Non-Muslims. Of seven studies comparing anxiety in Muslims and non-Muslims, six (86%) reported more anxiety in Muslims (Yorulmaz et al., 2009; Abdel-Khalek, 2003; Tomas-Sabado & Gomez-Benito, 2004; Abdel-Khalek & Tomas-Sabado, 2005; Ellis et al., 2013; Inozu et al. 2012), supporting the claim that Islamic beliefs might make some adherents more anxious.
Religiosity within Muslims. While most studies suggest that Muslims are more anxious than non-Muslims, this appears to be true only in Muslims who are less religious. Of 24 cross-sectional studies, 15 (63%) reported inverse relationships between religiosity and anxiety in Muslim populations. In other words, the majority of studies show that Muslims who are more religious are less anxious. This percentage of studies showing less anxiety in religious Muslims is in fact higher than that reported in religious Christians (49%).
Randomised Clinical Trials. There have also been at least four RCTs examining the effects of religiously-integrated psychotherapies for anxiety in Muslims, with all four (100%) reporting a reduction in anxiety significantly greater than for secular psychotherapies or standard care (Azhar et al., 1994; Razali et al., 1998; Razali et al., 2002; Hosseini et al., 2013). A fifth more recent clinical trial has also found that reciting the Qur’an dramatically reduces anxiety symptoms in Iranian haemodialysis patients compared to haemodialysis patient control (BabaMuhammadi et al., 2015). This suggests that psychotherapies designed to increase religiosity or utilise religiosity as a resource appear to be effective in reducing anxiety in Muslims, more so than therapies that ignore religious beliefs.
Substance Use/Abuse
Twelve studies compared alcohol use/abuse in Muslims with that in Christians and other religious groups, and six studies did so for drug use/abuse. In addition, our systematic review (prior to 2010) uncovered two studies that examined the relationship between religiosity and alcohol use in Muslim majority countries, two were identified that were missed by the review, and two more recent studies make a total of six (Koenig & Al Shohaib, 2014, p 154). These same six studies also examined drug use/abuse.
Muslims vs. Non-Muslims. With regard to alcohol use, nine of 12 studies (75%) reported significantly less alcohol use in Muslims compared to non-Muslims, and three of six studies found less drug use/abuse in Muslims compared to Christians and other religious groups (the remaining three studies, all comparing Muslims and Christians in Nigeria, found no difference).
Religiosity within Muslims. Of the six studies that examined religiosity and alcohol use/abuse or drug use/abuse, all six (100%) found significantly lower use among Muslims who were more religious. Although these findings are expected, given the strong prohibitions against intoxicants in the Qur’an, objective research confirms this.
Chronic Mental Illness
Chronic psychotic disorders such as schizophrenia, bipolar disorder, and delusional disorder are among the most common and disruptive of mental illnesses that adversely affect quality of life. Unfortunately, there has not been much research examining these disorders in Muslims compared to non-Muslims. Only three such studies were identified in the systematic and selective reviews. The same is true for research examining the relationship between psychosis and religiosity in Muslims, where we could identify only four studies (Koenig & Al Shohaib, p 154).
Muslims vs. Non-Muslims. Azhar and colleagues (1995) found a high prevalence of religious and culture-related delusions in patients with schizophrenia in Malaysia (>60% Muslim), but did not compare rates in Muslims vs. non-Muslims. One study compared ways of coping with hallucinations among patients with schizophrenia in Saudi Arabia and the United Kingdom (UK), find that those in Saudi Arabia were significantly more likely to cope using religious activities (43%) compared to those in the UK (3%) (Wahass & Kent, 1997). In a retrospective study of psychotic inpatients at a psychiatric hospital in Cairo, Egypt, from 1975 to 1996, Muslims were slightly less likely than Christians to have religious symptoms (delusions, hallucinations, preoccupations). Not surprisingly, Muslims were more likely to present with psychotic symptoms involving the Prophet Muhammad, whereas Christians were more likely to have delusions regarding Jesus and Christian saints (Atallah et al., 2001).
In a more recent study of nearly 3000 college students in Kenya, psychotic symptoms were compared between Protestants, Catholics, and Muslims. Muslims were 38% less likely than Protestants to have any psychotic experiences and 22% less likely to have visual hallucinations, although differences were not statistically significant (Ndetei et al., 2012). In summary, there is no evidence that Muslims are more likely to have psychotic symptoms than non-Muslims, but there is evidence that they are more likely to cope with those symptoms using religious practices.
Religiosity within Muslims. Of the four studies examining religiosity and psychosis in Muslims, two found an inverse relationship with psychosis and two found a positive relationship. Both studies finding more psychosis in highly religious Muslims were in psychiatric patients. One study compared hospitalised patients in Cairo who had received “spiritual healing” (which they defined as excessive use of prayers, reading verses from the Qur’an, exorcism, etc.) with those who had not, finding that psychotic relapse was more common in those with spiritual healing experiences (Salib and Youakim, 2001). The other study in Muslim psychiatric inpatients in Pakistan reported more delusions of grandeur of a religious nature in religious patients compared to non-religious patients (Suhail & Ghauri, 2010). Of the other two studies, one involved a community sample of adults from 18 countries; they found that schizotypal traits were less frequent in Muslims who were more religious (Johnstone & Tiliopoulos, 2008). The other study found that Muslim psychiatric outpatients who had more daily spiritual experiences were more likely to adhere to their medication (Amr et al., 2013).
Psychological Well-being
Many studies have examined the relationship between religiosity and well-being in Muslims, although few have compared Muslims and non-Muslims in this regard. The systematic review of research prior to 2010 and the selective review since then identified 20 studies examining religiosity and well-being, but only one study compared Muslims and non-Muslims (Koenig & Al Shohaib, 2014, p 172).
Muslims vs. Non-Muslims. In the only study identified that compared the well-being of Muslims and non-Muslims, Kazarian (2005) surveyed Christian and Muslim students at the American University of Beirut, finding no difference in psychological well-being between the two groups.
To assess this question further, two international datasets were analysed in order to compare Muslims and non-Muslims on happiness (Koenig, 2016, unpublished data). The first dataset, the International Social Survey Program (ISSP 2008), surveyed a random sample of 59,063 citizens ages 15 to 90 from 40 countries: Australia, Austria, Belgium – Flanders, Chile, Croatia, Cyprus, Czech Republic, Denmark, Dominican Republic, Finland, France, Germany, Great Britain, Hungary, Ireland, Israel, Italy, Japan, Latvia, Mexico, Netherlands, New Zealand, Northern Ireland, Norway, Philippines, Poland, Portugal, Russia, Slovakia, Slovenia, Spain, South Korea, South Africa, Sweden, Switzerland, Taiwan, Turkey, Ukraine, Uruguay, the United States of America, Venezuela, Taiwan, Japan, and South Korea. Interviews were conducted face-to-face, by telephone and by self-completed postal questionnaires. This dataset included 2,152 Muslims (66% from Turkey), 43,663 non-Muslims affiliated with other religions, and 12,237 persons not affiliated with any religious group.
The second dataset was the World Values Survey (WVS, 2005-2006), a random sample of 83,879 adults ages 18 to 85 from more than 80 countries (approximately 1000 per country using full probability sampling). Muslims primarily come from Indonesia (12.4%), Iraq (11.2%), Egypt (19.1%), and Mali (9.5%). The mode of data collection for WVS survey was in person face-to-face interviewing. This project was carried out by an international network of social scientists, with local funding for each survey. The sample included 14,447 Muslims, 52,791 non-Muslims, and 14,631 adults with no religious affiliation.
In the ISSP (2008), Muslims were significantly less likely than non-Muslims or those with no religious affiliation to say they were “very happy” (16.8% vs. 26.9% and 22.2%%, respectively, p<0.0001) (Table 3). This was even true for those who indicated they were at least “somewhat religious;” again, Muslims were also less likely to say that they were “very happy” (17.7% vs. 28.8% and 28.4%, respectively, p<0.0001). On the other hand, Muslims were much more likely than non-Muslims or those with no religious affiliation to strongly agree that “religion helps people find inner peace or happiness” and to strongly agree that “religion helps people find comfort during sorrow or trauma.” Similar findings were found in the WVS (2005-2006).
More recently, the 2017 World Happiness Report asked 3000 people in each of 155 countries to evaluate their current lives on a scale from 0 to 10, where 0 (worst possible life) to 10 (best possible life), and then ranked countries on happiness based on those scores (1 being the happiest country, 155 being the least happy country). Of the 16 countries whose populations were over 90% Muslim, 9 (56%) were ranked between 100 and 155, and only two received a rank between 1 and 50 (Table 4).
There are many reasons for lower happiness and well-being among Muslims, and the Islamic religion is not likely one of them. Many factors affect the mental health of Muslims including the cultural environment, historical events, slower scientific progress than in Western countries (despite initially being far ahead of the Western in terms of medicine and science), overly strict understanding of religious teachings, to name just a few. In fact, a recent United Nations report (AHDR, 2016) found increasing inequality (based on the Human Development Index) in Arab countries (Middle East and North Africa). Armed conflict was common in these regions (17% of the world’s wars and 45% of the world’s terrorist attacks, despite making up only 5% of the world’s population) and the unemployment rate was twice that of the global average (30% vs. 14%) (United Nations Development Programme, 2016). Therefore, socioeconomic and environmental problems appear to be much more prevalent among the world’s Muslim population, compared to other religious groups and those with no religious affiliation. These socioeconomic and environmental problems likely explain the differences in well-being found here, not the Islamic religion. One things is for certain, though. Muslims who are more religious are happier and experience greater well-being and less anxiety.
Religiosity and Well-being in Muslims. Of the 20 studies identified in the literature, all 20 (100%) found significant positive relationships between religiosity and well-being in Muslims. These studies were conducted in Pakistan, Kuwait, Malaysia, Algeria, Saudi Arabia, Egypt, Lebanon and Qatar. Greater well-being in highly religious Muslims was present regardless of country or age of participants. Relationships between religiosity and well-being among Muslims in the ISSP and WVS datasets, however, were not as consistent. In the ISSP, happiness was not related to self-rated religiosity (r=0.035) or frequency of religious attendance (r=-0.038). In the WVS, importance of religion was unrelated to happiness (r=0.002) or satisfaction with life (r=-0.01); however, frequency of religious service attendance was positively and significantly related to greater happiness (r=0.093, p<0.0001, n=13,343) in Muslims.
Given that Muslims often turn to religion in order to cope with difficulties in life (i.e., religion becomes more important to them when they are distressed), this dynamic may conceal a positive relationship between religiosity and well-being for measures of religious importance in cross-sectional studies like the ISSP and WVS.
Conclusions
Based on the research reviewed above, Muslims tend to experience less depression, are less likely to have positive attitudes toward or commit suicide, and are less likely to use or abuse alcohol or drugs. They have similar rates of psychosis compared to non-Muslims, although are more likely to experience anxiety (especially if not religious). The comfort derived from reading and reciting the Qur’an, frequent prayer, devout religious beliefs, and a strong and close knit family and community helps to explain improved coping and lower rates of depression and suicide. Islamic teachings “place the bar high” in terms of ethical values and expectations for behaviour, while emphasising dire consequences in the hereafter if these teaching are not followed. These teachings can easily be misunderstood.
This may help to explain the higher rate of anxiety among Muslims compared to non-Muslims. However, there are many other factors (socioeconomic, environmental, cultural, historical, armed conflict, discrimination) may be a better explanation for these cross-sectional associations, since randomised clinical trials that utilise Islamic religious interventions significantly reduce anxiety, not increase it. Furthermore, there is a greater likelihood that religiosity in Muslims is associated with less anxiety than in Christians (63% vs.. 49% of studies). This suggests that higher anxiety found in Muslims is probably concentrated among Muslims who are less religious.
Based on analyses of large datasets here, psychological well-being (happiness and satisfaction in life) also appears to be somewhat lower in Muslims than in non-Muslims (and even lower than in those with no religious affiliation). However, like with anxiety, this is almost certainly due to greater socioeconomic and environmental stressors that Muslims around the world must deal with. Indeed, one might wonder what the well-being of Muslims would be if they did not have their religious faith to help them deal with these stressors. This is supported by the finding that greater religious involvement within Muslim populations is related to less depression, less suicide, less substance use/abuse, and greater well-being in many studies. Finally, nine out of nine randomised clinical trials (100%) report that Islamic interventions in Muslims improve levels of depression and anxiety more so than do secular treatments or control conditions, underscoring the benefits that this religious faith plays in healing.
Table 3. Psychological well-being in Muslims compared with non-Muslims and those with no religious affiliation
(Editor: Detailed contents of this table has been omitted. Please contact the Editor if you require the details.)
Table 4. Countries with 90% or greater Muslim ranked by overall happiness based on World Happiness Report 2017
(Editor: Detailed contents of this table has been omitted. Please contact the Editor if you require the details.)