Chronic depression in a religious Shia Muslim woman in Iran.

Abstract

Ms. M, a 30-year-old Shia Muslim woman living in a city in western Iran near the Iran-Iraq border, presented with moderate to severe depressive symptoms. She reported severe sadness on most days during the past 6months. She also reported irritability, sleep disturbance, fatigue, excessive thoughts of death, and feelings of worthlessness and guilt. She denied any suicidal ideation, and noted that she thought that “suicide is a great sin.” In her past psychiatric history, she had the same symptoms for at least 10 years, with fluctuations and a few months of complete remissions. She had seen psychiatrists several times and had undergone several courses of various antidepressant medications, including selective serotonin reuptake inhibitors and tricyclic antidepressants, but was not satisfied with any of them. She had not received any psychotherapy. She reported no general medical conditions but complained of several years of diffuse body pains. She reported no substance abuse. Ms. M had been an only child. She later revealed that when she was young, she realized that her mother had an affair. Her father frequently worked night shifts and was not home most evenings. Between ages 4 and 12, she witnessed her mother’s relationship with the other man, which made her feel deeply sad because she could not say anything about it to her father. Ms. M lived as a housekeeping wife with her husband, who worked at a local organization. She seemed to be fairly religious. Several times a month, she attended religious ceremonies in which she led the ceremony and sang sad songs according to her Shia Muslim tradition. At the first interview, she was diagnosed as having major depressive disorder, recurrent, and her psychiatrist recommended treatment with cognitive-behavioral therapy (CBT), which she accepted. In her CBT sessions, a key cognition that emerged as a contributor to her depression was her identification with Fatimah, the daughter of the Prophet Muhammad. According to Shia beliefs, the Prophet Muhammad and his daughter Fatimah were very close; the Prophet sometimes kissed her hand and said to his companions, “Fatimah is a part of me, so anyone who upsets her upsets me.” After the Prophet died, Fatimah, now a young woman, became very sad, and the unpleasant conflicts over the Prophet’s succession increased her sadness and dissatisfaction. She remained sad until her death, which followed soon after her father’s. Ms. M loved her father very much too, but did not see him often because he had moved to another city. Thus, although she suffered from depression and its consequences, she thought to some extent that her sadness was good because she was sad being away fromher father, “just like Fatimah felt sad being away from her father.” In theCBT sessions, her therapist challenged this thought. He reviewed with Ms. M several events in Fatimah’s life in which she demonstrated notable bravery and patience. As Ms. M gradually realized and accepted that her sacred religious figure, Fatimah, was not depressed most of her life and was in fact an active, brave, and patient woman, she could cooperate more with her therapist to treat her depression. Ms. M felt embarrassed and guilty because of her mother’s behavior when she was a child. She felt guilty because she could never oppose her mother or do anything about her mother’s affair. Her therapist used other Islamic religious material to help Ms. M decrease her feelings of guilt. She attended to the fact that according to the Koran, no one is guilty because of another’s acts. She could accept that given her age and condition at that time, there was nothing she could have done about the problem. Ms. M’s depression gradually disappeared over the course of the CBT sessions, and after her 10th session, her scores on the Beck Depression Inventory were generally under 10. She was later diagnosed by a rheumatologist as having rheumatoid arthritis, and her body pains and fatigue decreased markedly after she started pharmacotherapy for her rheumatism.