Hajj and the Mental Health of Muslim Pilgrims: A review

Abstract

Mass gatherings occur in different situations and settings around the world. A mass gathering can range in size from thousands to millions and in nature from recreation (i.e. concerts) to religious festivals (i.e. the Hajj pilgrimage). Such mass gatherings can result in high rates of morbidity and mortality from communicable and non-communicable diseases, 'accidents' and, over recent years, terror attacks. Disproportionately lower consideration has been given to the mental health and wellbeing of people during mass gatherings compared to that given to physical health during such events. Hajj is a religious pilgrimage to Mecca in Saudi Arabia that all Muslims are Islamically obliged to fulfil at least once in their lifetime. With up to 3 million pilgrims attending Hajj annually, it has been described as, 'The largest and longest-standing mass gathering event on Earth'. Although Hajj is a spiritual experience that is considered enlightening by many pilgrims, it can also be highly stressful which can have adverse effects on both physical and mental health. Few studies have been published hitherto on the impact that Hajj has on the mental health of pilgrims. This review article provides a narrative summary of studies conducted on Hajj and the relationship that this mass gathering has with the mental health of pilgrims.

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HAJJ AND THE MENTAL HEALTH OF MUSLIM PILGRIMS:
A REVIEW
Ahmed Hankir1,2,3, Zavid Chariwala4, Usman Siddique5,
Frederick R. Carrick1,6,7,8 & Rashid Zaman1,9,10
1Centre for Mental Health Research in association with University of Cambridge (CMHR-CU), Cambridge, UK
2South London and Maudsley NHS Foundation Trust, London, UK
3Department of Psychiatry, Carrick Institute for Graduate Studies, Cape Canaveral, FL, USA
4British Hajj Delegation, UK
5South West Yorkshire Partnership NHS Foundation Trust, Halifax, UK
6Department of Neurology, Carrick Institute for Graduate Studies, Cape Canaveral, FL, USA
7Neurology, University of Central Florida College of Medicine, Orlando, FL, USA
8Medical Education, MGH Institute for Health Professions, Boston, MA, USA
9Hertfordshire Partnership University NHS Foundation Trust, UK
10Department of Psychiatry, University of Cambridge, Cambridge, UK
SUMMARY
Mass gatherings occur in different situations and settings around the world. A mass gathering can range in size from thousands
to millions and in nature from recreation (i.e. concerts) to religious festivals (i.e. the Hajj pilgrimage). Such mass gatherings can
result in high rates of morbidity and mortality from communicable and non-communicable diseases, ‘accidents’ and, over recent
years, terror attacks. Disproportionately lower consideration has been given to the mental health and wellbeing of people during
mass gatherings compared to that given to physical health during such events. Hajj is a religious pilgrimage to Mecca in Saudi
Arabia that all Muslims are Islamically obliged to fulfil at least once in their lifetime. With up to 3 million pilgrims attending Hajj
annually, it has been described as, ‘The largest and longest-standing mass gathering event on Earth’. Although Hajj is a spiritual
experience that is considered enlightening by many pilgrims, it can also be highly stressful which can have adverse effects on both
physical and mental health. Few studies have been published hitherto on the impact that Hajj has on the mental health of pilgrims.
This review article provides a narrative summary of studies conducted on Hajj and the relationship that this mass gathering has with
the mental health of pilgrims.
Key words: Hajj – mass gatherings – Muslim mental health – pilgrimage – mental illness
* * * * *
INTRODUCTION
Approximately 1.8 billion or 24.1% of the world po-
pulation are Muslims of which 62% live in Asian-Pacific
countries (e.g., Indonesia, Pakistan, India, Bangladesh,
Iran and Turkey), 20% in the Middle East or North Africa
(e.g., Egypt, Yemen, Sudan, Saudi Arabia, Algeria,
Syria), 15% in Sub-Saharan Africa (e.g., Nigeria, Rwan-
da, Kenya), 3% in Europe (e.g., France, Belgium, Aus-
tria, United Kingdom) and less than 1% in North Ame-
rica (e.g., United States, Canada) (Lipka et al. 2017).
Hajj is an annual Islamic pilgrimage to the holy city
of Mecca in Saudi Arabia involving approximately 3
million Muslim pilgrims for over 30 days including a 5-
day core period of intensive rituals and prayers. Hajj has
been described as, ‘The largest and longest-standing
mass gathering event on Earth’. Hajj is one of the Five
Pillars of Islam; it is a mandatory religious duty for
adherents of the Islamic faith that must be carried out at
least once in their lifetime. Pilgrims can also go to
Mecca to perform the rituals at other times of the year.
This is sometimes called the "lesser pilgrimage", or
Umrah. However, even if pilgrims choose to perform
the Umrah, they are still obliged to perform the Hajj at
some other point in their lifetime.
HISTORY OF THE HAJJ PILGRIMAGE
The present custom of Hajj was established by the
prophet Muhammed (PBUH). However, according to
the Quran, aspects of the present custom of Hajj trace
back to the time of the prophet Abraham (RA). Accor-
ding to Islamic tradition, Abraham (RA) was commanded
by God to leave his wife Hagar and his son Ishmael (RA)
alone in the barren desert of ancient Mecca. It is narra-
ted that Hagar succumbed to despair and ran seven
times between the two hills of Safa and Marwah in
search of water to quench her own thirst and that or her
son but to no avail. Returning in a state of resignation to
her baby son Ishmael, she saw that her child started
rubbing the ground with his leg and a fountain of water
gushed forth beneath his foot. Later, Abraham (RA) was
commanded to build the Kaaba and to invite people to
perform pilgrimage there. The Quran refers to these
events in chapter 2 (‘The Cow’) verses 124–127 and
chapter 22 (‘The Pilgrimage’) verses 27–30.

Ahmed Hankir, Zavid Chariwala, Usman Siddique, Frederick R. Carrick & Rashid Zaman: HAJJ AND THE MENTAL HEALTH
OF MUSLIM PILGRIMS: A REVIEW Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 290-293
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The pilgrimage occurs from the 8th to 12th (or in
some cases 13th) of Dhu al-Hijjah, the last month of the
Islamic calendar. Because the Islamic calendar is lunar
and the Islamic year is about eleven days shorter than
the Gregorian year, the Gregorian date of Hajj changes
from year to year.
HAJJ AND HEALTH
Most pilgrims take the necessary precautions when it
comes to their physical health before they travel to
Mecca. For example, they would make sure they take all
the injections and immunizations that their doctor re-
commends (Visser et al. 2011). It would be equally
important for pilgrims to look after their mental health
in the same way they do their physical health. This may
seem counterintuitive to many Muslims since Hajj is
considered a spiritual journey that is beneficial for a
Muslim’s mental health and ‘soul’.
Muslims consider Hajj and the performing of it to be
a blessing and pilgrims describe it as ‘enlightening’ and
a ‘life-changing experience’. However, there are factors
that contribute to Hajj being a highly stressful expe-
rience such as: unfamiliar environment, overcrowding,
heat, physical exertion, limited dietary intake, exhaus-
tion, sleep deprivation and being on a foreign land that
is far away from home (Masood et al. 2011). These
stressors can adversely affect the mental health and
wellbeing of pilgrims (Masood et al. 2011) as will be
discussed and described in the review below.
COMMON MISCONCEPTIONS ABOUT
MENTAL ILLNESS IN MUSLIMS
Muslims often attribute mental health difficulties to
supernatural causes like Jinn possession and/or the evil
eye (Hankir et al. 2017). Muslims with mental health
difficulties may think that Allah is punishing them for a
sin they committed or that they have week faith (Hankir
et al. 2015). Of course, this isn’t true; although Islam
can be a protective factor against mental illness there
are many Muslims who experience mental health
difficulties despite having strong faith (Hankir et al.
2015). Prayer can provide relief and comfort and is very
important, but since mental health problems are often
caused by a psychiatric disease, it is important to seek
help from a doctor for medical treatment in addition to
prayer. The Prophet (PBUH) said:
"Make use of medical treatment, for Allah has not
made a disease without appointing a remedy for it ..."
(Kitah Al-Tibb of Sunan Abu-Dawud).
THE EFFECTS OF HAJJ
ON MENTAL HEALTH
Previous studies have shown that most pilgrims who
developed mental health problems were not told about
the “actual” difficulties involved or the details of rituals
during Hajj. Muslims may have pre-existing mental
illness or may experience mental illness for the first-
time during Hajj. Pilgrims going to Hajj for the first
time and older people seem to be at increased risk of
experiencing a mental illness. Pilgrims who are from
rural backgrounds and who have low exposure to urban
life also seem to be at increased risk of certain mental
illnesses (Masood et al. 2011).
The first few weeks of arrival in Mecca and the core
Hajj period can be the most stressful and this is when
Muslims can feel most anxious. Fear of getting lost, being
on a foreign land and language barriers are all factors that
can cause stress. Anticipation of a mishap such as a
stampede or a terror attack are other factors that can
contribute to stress and confusion. Heat and dehydration
are some of the preventable causes of sudden confusion,
especially in older people (Masood et al. 2011).
Common mental illnesses seen in Hajj are:
Stress related;
Psychosis (experiencing unusual and frightening
beliefs and often hearing voices);
Insomnia (difficulty sleeping);
Mood disorders.
Cases of psychosis were often due to the discontinua-
tion of anti-psychotic medication without medical ad-
vice. It is therefore crucial that Muslims with pre-exis-
ting mental illness such as psychosis continue adhering
with their psychotropic medication. Simple measures
such as going to an isolated place, physical comforting,
nearness to family members, repeated reassurance,
fluids and repeated verbalization of sequence of events
as well as reorientation and deep breathing all help
(Masood et al. 2011).
Narrative Review of Published Research on
Hajj and the mental health of Muslim Pilgrims
Below is a narrative summary of studies conducted
on Hajj and the relationship that this religious mass
gathering has with the mental health of pilgrims.
Bakhtiari and colleagues at the Sharif University of
Technology investigated the relationship between the
Hajj pilgrimage and mental health among university
students in Iran (n=350). The General Health
Questionnaire (GHQ) and the Meaning in Life
Questionnaire were administered on participants before
and after the Hajj pilgrimage. The authors of the study
report that pilgrimage to Mecca lowered anxiety,
depression, and stress levels in their sample and that
there were improvements in social functioning and
meaning in life (Bakhtiari et al. 2017).
However, Fateh and colleagues conducted a
longitudinal study on the psychological effects of Hajj
using the same instrument as Bakhtiari and colleagues
did (the General Health Questionnaire (GHQ)). The
findings of Fateh’s study revealed that there was no
statistically significant difference in the GHQ scores of
pilgrims before and after the Hajj (Fateh et al. 2019).

Ahmed Hankir, Zavid Chariwala, Usman Siddique, Frederick R. Carrick & Rashid Zaman: HAJJ AND THE MENTAL HEALTH
OF MUSLIM PILGRIMS: A REVIEW Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 290-293
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Clingingsmith and colleagues estimated the impact
of Hajj on 1,605 pilgrims from Pakistan. They reveal
that female pilgrims were more likely to report negative
feelings that suggest distress, and are less likely to
report positive feelings of well-being (higher levels of
distress were detected in female pilgrims, as measured
by a version of the K6 screening scale). This could po-
tentially be due to the impact of the Hajj on physical
health. Indeed, the negative physical health effects were
stronger for women than they were for men suggesting
that part of the negative effect of the Hajj on women’s
feelings of well-being could be explained by poorer
physical health. The findings could also potentially be
due to the changes in pilgrim’s beliefs and frame of
reference discussed below (which the psychology litera-
ture suggests can lead to stress). Increased distress in
female pilgrims might be due to the stark contrast bet-
ween the typical Pakistani woman’s daily life and the
relatively greater equality and integration experienced
during the Hajj. The impact of the Hajj on gender atti-
tudes suggests an increased realization that the con-
straints and restrictions women are accustomed to in
Pakistan may not be part of global Islam. It is important
to note that this study revealed that while the Hajj has a
negative impact on a female pilgrim’s emotional state, it
does not affect overall life satisfaction (Clingingsmith et
al. 2009).
Khan and colleagues conducted a study on 136,000
Indian Hajj pilgrims in 2016 (Indian Medical Mission).
They revealed that 182 patients developed psychologi-
cal problems (1.3%) of which 45.7% were stress related
issues, 9.8% psychosis, 7.3% insomnia and 5.6% mood
disorders. The most common symptoms recorded in this
sample were apprehension (45%), poor sleep (55%), an-
xiety (41%), and fear of being lost (27%). All cases of
psychological problems were on their first Hajj, 60%
were male and a majority were from rural areas. 22
patients (12%) required admission to hospital and only
12 pilgrims (6.8%) reported a past history of a mental
illness (Khan et al. 2016).
Ozen and colleagues carried out a study on 130,000
Turkish Hajj pilgrims in 2008 (Turkish Mecca Hos-
pital). 294 participants (0.2%) in their sample presented
to psychiatric services, of which 38.4% reported an-
xiety, 22.1% mood disorders and 11.2% sleep disorders.
The most common symptoms recorded were discomfort
(70%), poor sleep (55%), anorexia (35%), ‘whining’
(30%) and fatigue (28%). 60% of those who presented
to psychiatric services had a previous psychiatric
history, 40% were male, 77% had low education and
71% had not been abroad before (Ozen et al. 2009).
Psychological impact of mass gatherings
The traditional view (which has now largely been
discredited) is that people in crowds tend to:
Lose their sense of self;
Lose their sense of judgement;
Become capable of the most extreme actions.
However, in social identity theory, people perceive a
common group membership and assume a shared social
identity in a ‘psychological crowd’. This leads to:
A cognitive transformation - People stop behaving in
terms of their idiosyncratic beliefs and start be-
having on the basis of shared norms, values, and
understandings.
A relational transformation - The crowd is part of an
extended group rather than ‘‘others’’. This leads to a
shift towards greater intimacy and trust, respect,
cooperation, mutual influence, helping, and also
expectations of help from others.
An emotional transformation - The crowd can dis-
play intense positive effect, termed ‘effervescence’.
Close and supportive relationships can contribute
positively to feelings of wellbeing.
A study of 1,194 pilgrims attending Mecca in 2012
found that people felt safer and perceived the crowds to
be less dangerous when they strongly identified with
others in the crowd. Social identity theory helps to ex-
plain the perception that others in the crowd were suppor-
tive. The survey of pilgrims attending the 2012 Hajj sho-
wed that, although increasing levels of crowd density
reduced feelings of safety, this effect was moderated by
identification with the crowd and perceptions that others
identified as Muslim. Specifically, those who were high
in identification with the crowd actually felt safer as den-
sity increased. Mediation analysis was consistent with the
idea that this moderation effect was because of the per-
ception that others in the crowd were supportive, which
was higher the more that people identified with the
crowd. This same relationship was found for those pil-
grims from Arab countries and Iran compared with those
from other countries, whose greater reported safety was
explicable in terms of their crowd identification and
perceptions of support (Alnabulsi et al. 2014).
CONCLUSION
Although Hajj is a spiritual experience that has been
described as enlightening, it can also be highly stressful
which can have adverse effects on both physical and men-
tal health. Few studies have been published hitherto on
the impact that Hajj has on the mental health of pilgrims.
Currently the literature in relation to the mental health of
Muslims during Hajj is conflicting and the conclusions
from these studies must be interpreted with caution.
Protective factors against developing mental health
difficulties during the Hajj pilgrimage include:
Preparation for Hajj (i.e. being aware of the chal-
lenge and exertion of performing the Hajj (a detailed
understanding of what is involved)) and physical
fitness and healthy diet in months before Hajj.
Support while on Hajj (i.e. family/close friends com-
petent tour staff, realistic itinerary for visit,
professional health services during Hajj, asking for
help during Hajj from fellow pilgrims, consideration
for less crowded times and areas).

Ahmed Hankir, Zavid Chariwala, Usman Siddique, Frederick R. Carrick & Rashid Zaman: HAJJ AND THE MENTAL HEALTH
OF MUSLIM PILGRIMS: A REVIEW Psychiatria Danubina, 2019; Vol. 31, Suppl. 3, pp 290-293
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Future research investigating the impact of Hajj on
the mental health and wellbeing of pilgrims is urgently
needed.
Acknowledgements:
We would like to thank Dr Ian Walker Consultant in
Global Public Health for his permission to use
information from his presentation on mass gatherings
and mental health. We would also like to thank the
British Hajj Delegation for their support and help in
formulating this manuscript.
Conflict of interest: None to declare.
Contribution of individual authors:
Ahmed Hankir & Zavid Chariwala conceived the idea
for the paper and contributed to the literature review
and revised the manuscript.
Usman Siddique, Frederick R. Carrick, Ian Walker &
Rashid Zaman contributed to the literature review
and revised the manuscript.
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Correspondence:
Ahmed Hankir, MBChB
South London and Maudsley NHS Foundation Trust
London, UK
E-mail: Ahmed.hankir@nhs.net