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DEPRESSION AND STRESS

ASK A MUSLIM DOCTOR

Question.
I have been suffering from stress for some time now and I have been offered some anti-depressants by a non-Muslim doctor who has told me I have clinical depression. I have refused to take the anti-depressants because Muslims shouldn’t be getting depressed and they should rely on Allah (swa). What advice would you give me?

This is a very important and common question. I’m afraid there is no simple answer to this. A lot of people misunderstand the true nature of stress, anxiety, depression and other mental illnesses. As a result of this misunderstanding, most Muslims usually fall into two schools of thought regarding this matter. First school of thought is that Muslims don’t get depressed, and if they do, it is because they have very little imaan and they should not seek help from medical professionals, but rather have reliance on Allah (swa) alone. The second school of thought is that Muslims are humans and they therefore also get depressed and so they should not waste any time and seek medical help from health professionals for ‘happy pills’, just like they would seek medication for any other illness…I believe both schools of thought are correct. Therefore one should take up both pieces of advice simultaneously depending on the circumstance. Let me explain!

Mood disorders can be quite a complicated thing to understand. Their seriousness relates to the symptoms of that disorder. The complicating factor is the amount of overlap that can exist in each mood disorder. Medical professionals have classified these mood disorders. I will roughly explain the common ones:

Anxiety or Stress- Anxiety is a feeling of unease. Everybody experiences it when faced with a stressful situation, for example before an exam or an interview, or during a worrying time such as illness. It is normal to feel anxious when facing something difficult or dangerous, and mild anxiety can be a positive and useful experience also. However, for one in ten people in the UK, anxiety interferes with normal life. Excessive anxiety is often associated with other psychiatric conditions, such as depression. Anxiety is considered abnormal when it is very prolonged or severe, it happens in the absence of a stressful event or it is interfering with everyday activities such as going to work or socialising. Anxiety is the main symptom of several other depressive illnesses. These are called anxiety disorders.

• Acute stress reaction – acute means the symptoms develop quickly, minutes or hours after the stressful event. This type of reaction typically occurs after an unexpected life crisis such as bereavement (somebody close passing away). Sometimes symptoms occur before a forthcoming event, such as an important exam. This is called situational anxiety. Symptoms usually settle fairly quickly and no treatment may be needed.
• Adjustment reaction – This is similar to acute stress reaction, but symptoms develop over days or weeks after a stressful situation, for example as a reaction to a divorce. Symptoms tend to improve over a number of weeks or so.
• Post-traumatic stress disorder (PTSD) – this may follow after experiencing or witnessing a traumatic event such as a major accident or military combat. Anxiety is only one of the symptoms, which may come and go. The person may re-live their traumatic experience in dreams or flashbacks. It is normal to react with anxiety to a frightening experience – the term PTSD is only applied if symptoms persist. It may start years after the triggering event.
• Phobias- A phobia is a fear that is out of proportion to the real danger posed by the thing or event that triggers it. Phobias interfere with a person’s ability to lead a normal life. The most common phobias are fear of heights, spiders, mice, blood, injections or enclosed space (claustrophobia).
• Obsessive-compulsive disorder (OCD)- This consists of recurring obsessions or compulsions. Obsessions are recurring thoughts or images that cause feelings of disgust. Common obsessions include germs, dirt or violence. Compulsions are thoughts or actions that people feel they must do or repeat. A compulsion is usually a response to ease the anxiety of an obsession. Excessive handwashing to deal with an obsession about dirt, for example.
• Panic disorder -This is characterised by panic attacks – a sudden sense of anxiety that occurs without warning and with no apparent trigger. The physical symptoms of anxiety can be very severe. Panic attacks usually last 5-10 minutes.
Adjustment disorder with depression- This category describes depression that occurs in response to a major life stressor or crisis.
Dysthymic Disorder- This refers to a low to moderate level of depression that persists for at least two years, and often longer. While the symptoms are not as severe as a major depression, they are more enduring and resistant to treatment. Some people with dysthymia develop a major depression at some time during the course of their depression.
Unspecified depression- This includes people with serious depression, but not quite severe enough to have a diagnosis of a major depression. It also includes people with chronic, moderate depression, which has not been present long enough for a diagnosis of a Dysthymic disorder.
Major depression- This is the most serious type of depression, in terms of number of symptoms and severity of symptoms, but there are significant individual differences in the symptoms and severity. You do not need to feel suicidal to have a major depression, and you do not need to have a history of hospitalisations either, although both of these factors are present in some people with major depression. There is no official diagnosis of “moderate depression.”
Bipolar Depression- This type includes both high and low mood swings, as well as a variety of other significant symptoms not present in other depressions.
The symptoms of depression may vary from person to person, and also depend on the severity of the depression. Depression causes changes in thinking, feeling, behaviour, and physical well-being.
• Changes in Thinking – You may experience problems with concentration and decision making. Some people report difficulty with short term memory, forgetting things all the time. Negative thoughts and thinking are characteristic of depression. Pessimism, poor self-esteem, excessive guilt, and self-criticism are all common. Some people have self-destructive thoughts during a more serious depression.
• Changes in Feelings – You may feel sad for no reason at all. Some people report that they no longer enjoy activities that they once found pleasurable. You might lack motivation, and become more lazy. You might feel “slowed down” and tired all the time. Sometimes irritability is a problem, and you may have more difficulty controlling your temper. In the extreme, depression is characterised by feelings of helplessness and hopelessness.
• Changes in Behaviour – Changes in behaviour during depression are reflective of the negative emotions being experienced. You might act more lazy and not motivated, because that’s how you feel. Some people do not feel comfortable with other people, so social withdrawal is common. You may experience a dramatic change in appetite, either eating more or less. Because of the chronic sadness, excessive crying is common. Some people complain about everything, and act out their anger with temper outbursts. Sexual desire may disappear, resulting in lack of sexual activity. In the extreme, people may neglect their personal appearance, even neglecting basic hygiene. Needless to say, someone who is this depressed does not do very much, so work productivity and household responsibilities suffer. Some people even have trouble getting out of bed.
• Changes in Physical Well-being – We already talked about the negative emotional feelings experienced during depression, but these are coupled with negative physical emotions as well. Chronic fatigue, despite spending more time sleeping, is common. Some people can’t sleep, or don’t sleep soundly. These individuals lay awake for hours, or awaken many times during the night, and stare at the ceiling. Others sleep many hours, even most of the day, although they still feel tired. Many people lose their appetite, feel slowed down by depression, and complain of many aches and pains. Others are restless, and can’t sit still.

Now imagine these symptoms lasting for weeks or even months. Imagine feeling this way almost all of the time. Depression is present if you experience many of these symptoms for at least several weeks. Of course, it’s not a good idea to diagnose yourself. If you think that you might be depressed, see your G.P. Your G.P. can assess whether you are depressed, or just under a lot of stress and feeling sad.

I shall discuss the remedies to these mood disorders from both a medical and Islamic perspective.

It was narrated by Suhayb (ra) that the Messenger of Allah (saw) said: “How wonderful is the affair of the believer, for all his affairs are good, and this applies to no one except the believer. If something good happens to him, he gives thanks, and that is good for him, and if something bad happens to him, he bears it with patience, and that is good for him.” 1

It is a true fact that that the character, perception and experiences of a person play a significant role in a persons ability to cope with stress. It is usually people who have low self-esteem, who consistently view themselves and the world with pessimism, or who are readily overwhelmed by stress, that are more prone to depression. Psychologists often describe ‘social learning factors’ as being major contributors in leading a stressful situation into a seriously negative affect on that person. People generally learn ways of managing stress and respond accordingly to life problems as they occur. If a child grows up in a pessimistic environment, in which discouragement is common and encouragement is rare, that child will have an increased risk of developing depression. Everyone copes with stress through their own learned mechanisms. Some people try to keep their minds pre-occupied with either unrelated issues or work, so as not to face the stressing factor. Some try to ignore it and hope it just goes away on its own accord. Others openly express their anxiety seeking sympathy from others as a comforting factor.

The first question that arises is why do we get stressed or worried? In this regard, the true philosophy of life should be understood. The truth is that we have been created by the Almighty to be tested and tried.
“Every soul shall have a taste of death: and We test you by evil and by good by way of trial. To Us must you return” 2
This trial is conducted through the difficult situations we are exposed to. If we are put through good and pleasant circumstances, then our trial is about whether we remain thankful to the Almighty. If we are put through bad or stressful circumstances, then our trial is whether we show perseverance and patience in these times or not.

Allah (swt) tests us through hardships for a number of reasons:

1. To teach us a lesson for our own misdoings
“Whatever misfortune happens to you, is because of the things your hands have wrought, and for many (a sin) He grants forgiveness”.3

2. To see whether we are truly grateful to our Lord at all times
Now, as for man, when his Lord tries him, giving him honour and gifts, then says he, (puffed up), “My Lord has honoured me”. But when He tries him, restricting his subsistence for him, then says he (in despair), “My Lord has humiliated me.” 4
3. To clean the evil within us

“Allah will not leave the believers in the state in which you are now, until He separates what is evil from what is good”. 5

4. To give us the opportunity to earn reward by showing patience.

“And because they were patient and constant, He will reward them with a garden and (garments of) silk”. 6

Islam has been teaching us ‘cognitive behavioural therapy’ (The therapeutic science of psychology related to coping skills) since the time of Rasoolullah (saw). It is our loss that we have not used this in our daily lives effectively. Islam teaches us that it is the attitude of the individual, to the stressful situation, that has a large impact on how positively that individual responds. This attitude is a learned experience which one adheres to at all times especially at the time of need. Islam provides the essential ingredients to remedy all daunting situations. The following are a few examples:

1. Work towards increasing your Imaan by increasing the performance of righteous deeds.

“Whoever works righteousness, male or female, and has faith, verily, to him We will give a good life that is good and pure, and We shall pay them certainly a reward in proportion to the best of what they used to do.” 7

Lots of benefits are gained through this. The person becomes resilient, his willpower becomes stronger, He becomes more patient, the hope of reward is further increased and thus his anxiety may even be replaced with an inner joy.

2. Always acknowledge and be aware that any distress and worry in this life earns expiation for your sins, purifies your heart and raises your status.

The Messenger of Allah (saw) said:“No illness, fatigue, sickness or grief befalls the Muslim, not even worries, but it will be expiation for some of his sins.” 8

3. Constantly remind yourself about the reality of this world

This world is a temporary abode for us. We are drowned in its luxuries but yet we fail to gain constant happiness. Life is unjust in this world and to expect perfection and happiness throughout life is a deception. The true abode is the hereafter and this life is just a testing ground for us, yet we live in this life and become so engrossed with the most pettish of things like our whole life depended on it. Life is about ups and downs. A bit of laughter one day, and many tears the next. It is how we persevere through this, which is important. The believer is only detained here, as the Messenger of Allah (saw) said: “This world is the prison of the believer and the paradise of the Non-believer.” 9

4. Always refer to the lives and examples of the Prophets and the Pious.

The Prophets and the Pious undoubtedly suffer more distress in this world than any other people. Each person is tested according to their strength. One thing is for sure that when Allah (swt) takes a liking to a person. He tests him.
“No burden do We place on any soul, but that which it can bear” 10
Sa’d (ra) asked the Prophet (saw): “O Messenger of Allah, which of the people suffers the most distress?” He said: “The Prophets, then those who come after them (in terms of status), then those who come after them. A man will be tested according to the strength of his faith. If his faith is strong, then the distress with which he is tried will be greater; if his faith is weak, he will be tested in accordance with the level of his faith. Distress will keep on befalling the slave until he walks on the face of the earth free from sin.” 11
5. Always focus on the Hereafter and make this utmost priority of your main concern.

It was narrated that Anas (ra) said: The Prophet (saw) said: “Whoever is mainly concerned about the Hereafter, Allah will make him feel independent of others and will make him focused and content, and his worldly affairs will fall into place. But whoever is mainly concerned with this world, Allah will make him feel in constant need of others and will make him distracted and unfocused, and he will get nothing of this world except what is decreed for him.” 12

6. Remember death and that every living thing will meet their maker.

This world is only temporary and the real life is the one hereafter. For a believer the greatest comfort is that the stresses of this world are only limited to this world and appreciating the temporariness of this life easies the burden for him.

The Prophet (saw) said: “Remember frequently the one who will destroy all your pleasures: death, for there is no-one who remembers death when in straitened circumstances, but his situation will become easier, and there is no-one who remembers death during times of ease, but his circumstances will become straitened.” 13

7. Increase your supplication to Allah and seek His help.

Du’aa’ (prayer or supplication) is the essence of worship, and includes both protection and treatment. Allah (swt) has full control of all matters and it is only Him who can change things in this world according to how He wishes. This is why The Prophets (as) turned to Allah and prayed to Him for refuge from distress frequently.

Prophet Yaqoob (as) said, “I only complain of my distraction and anguish to Allah” 14
“When My servants ask thee concerning Me, I am indeed close (to them): I listen to the prayer of every supplicant when he calls on Me: Let them also, with a will, Listen to My call, and believe in Me: That they may walk in the right way” 15
8. Send abundant salutations on our beloved Prophet (saw)

This is one of the greatest ways through which Allah may relieve worries:
Al-Tufayl ibn Ubayy ibn Ka’b (ra) reported that his father said to Rasoolullah (saw), ‘I will devote all my prayer (salutations) to you.’ Rasoolullah (saw) replied, ‘Then your worries will be taken care of and your sin will be forgiven.’”

9. Rely upon Allah and trust Him with all matters

“… And whosoever puts his trust in Allah, then He will suffice him…” 16

10. Think about what matters today in a positive way. Do not worry about what may happen tomorrow or regret what happened yesterday.

Abu Hurayrah (ra) reported: “The Messenger of Allah (saw) said: ‘The strong believer is better and more beloved to Allah than the weak believer, and both are good. Pay attention to that which could benefit you, seek the help of Allah and do not feel incapacitated. If anything befalls you, do not say, “If only I had done such-and-such, such a thing would have happened.” Say instead, “It is the decree of Allah, and what He wills, He does,” for saying “if only…” opens the way for Shaytaan.’” 17

11. Remember Allah frequently

Dhikr (remembrance of Allah) has a wonderful effect in calming the soul and relieving stress and worry. “…Verily, in the remembrance of Allah do hearts find rest.” 18

12. Seek refuge in prayer (salaat)

Allah says “O you who believe! seek help with patient perseverance and prayer (salaat); for God is with those who patiently persevere” 19

13. Always be grateful of what Allah (swt) has given you.

Regularly think about the blessings of Allah bestowed upon you. Ponder over all the good things in your life and reflect upon what good things you have been given that others have not.

The Prophet (saw) explained how we could attain this attitude of gratefulness in a hadeeth reported by Abu Hurayrah (ra): “The Messenger of Allah (saw) said: ‘Look at those who are below you, not at those who are above you, so that you will not think little of the blessings that Allah has bestowed upon you.”

14. Keep your self busy with useful work, the pursuit of beneficial knowledge and strive in the path of Allah.

Keeping one self busy in those activities that bring one closer to Allah (swt) are of great benefit. Reciting the Holy Qur’aan regularly or listening to the Holy Qur’aan being recited is a very beneficial act to overcome ones anguish and anger. Another beneficial act is to read the Seerah of our beloved Rasoolullah (saw). Having appreciated the trials and challenges that our beloved Rasool (saw) and his companions made for their ummah, helps to strengthen and create motivation to overcome the stressors of daily life. Sincerity and devotion in worship is more important than the amount of worship one performs as this will truly relieve anxiety. It is important that the work with which you keep yourself busy in, is something that you like to do and is pleasing to Allah (swt). It will then be more effective in bringing about the desired good results. One’s attendance at gatherings related to Islam and being in the company of the god-conscious are two very praiseworthy and beneficial things to keep one self busy in.

15. Constantly be aware of the mercy of the Most Merciful.

Remember that Allah (swt) is only testing you for a just purpose and only for a limited period and truly believe this.

Allah says: “No burden do We place on any soul, but that which it can bear” 20
“So, verily, with every difficulty, there is relief. Verily, with every difficulty there is relief”. 21

In an ideal world where one would constantly be in the company of righteous and pious people, adhering and implementing the above ingredients in to one’s life wouldn’t be too difficult. But in today’s climate holding on to your faith is a real challenge and as a result people’s faith tends to be weak. Worldly dependence is always with us and because of this dependence we are less receptive and willing to accept the remedies prescribed in Islam. For whatever reason, reliance on alternative therapies has become more common. Remedies prescribed by Islam are undoubtedly effective but we may be too engrossed in our worldly pursuits to employ them in our lives even though they work faster than medical therapies. Reality is that if one is in a situation where having tried their utmost in dealing with stress, feels that their depressive symptoms are worsening and are not receptive to these remedies should persevere in this pursuit and not lose hope. He or she should try harder, yet at the same time seek professional help from a doctor as this may be a sign of debilitating clinical depression. As Muslims we believe that all comes from Allah (swt) and that Allah (swt) also provides the means to treatment and cure in this world and this treatment and cure has many sources.
“…Seek treatment: For Allah has created a cure for every sickness. Some treatments are known, others are not…” 22
When stress and depression are controllable and they don’t cause serious physical symptoms then one should just resort to those remedies prescribed by Islam. It is only when these symptoms begin to affect the nature of that person. His lack of sleep and low mood is causing him to miss his obligatory worship no matter how hard he is trying to increase his Imaan. His irritability and intolerance to those around him is making him sin. He is unable to care for his dependents effectively and is becoming quite unwell. Then he should seek all alternative means to cure himself as long as they are shariah compliant. It is not practical today to advise a women who is at her tether with depression and expect her to remain patient and just work on her Imaan, when it becomes obvious that her weakness has led to her Islaam and Imaan becoming negatively affected. The greatest loss would be if she ended up in divorce and left to care for dependent children alone, only because she felt it was not morally right for her to take antidepressants yet she was missing her prayers and behaving un-Islamically. Here I would strongly recommend that she tries her utmost best in working on her Imaan and at the same time seek medical help, which may mean taking antidepressants.
Allah (s.w.a) says in the Holy Qur’aan:
“…and be not cast by your own hands to ruin…” 23
I have seen and treated many cases of Muslim patients who have reached the pits with their Imaan because of their uncontrollable depression but yet having treated them medically they have become strong enough to work and strengthen their Imaan again and have successfully overcome their depression. Depressive disorders make you feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up, which will have a serious effect on their Imaan. You should realise that these negative views are part of depression, and typically do not accurately reflect their life situation or their negligence of Islam and Allah (swt). Negative thinking fades as treatment begins to take effect.
When I see Muslim patients who are suffering with depression and are truly seeking help then I usually give them the following practical advice:
• Do not set difficult goals for yourself, or take on additional responsibility.
• Break large tasks into small ones, set some priorities, and do what you can as you can.
• Do not expect too much from yourself too soon, as this will only increase your feelings of failure.
• Try to be with other people (especially religious people who are positive in their approach); it is better than being alone or being with sinful people.
• Force yourself to participate in activities that may make you feel better especially those activities that you enjoy doing and are pleasing to Allah (swt).
• Try participating in religiously orientated social activities.
• Don’t overdo it or get upset if your mood is not greatly improved right away. Feeling better takes time. Just because you are not coping too well doesn’t mean that you are less religious than those who cope well. Many environmental factors play a role in how you react to stress not just religious ones. The idea is to strive towards overcoming worldly stressors.
• Do not make major life decisions, such as changing jobs, getting married or divorced, without consulting others who know you well and who have a more objective view of your situation. In any case, it is advisable to postpone important decisions until your depression has lifted.
• Do not expect to snap out of your depression. People rarely do. Help yourself as much as you can, and do not blame yourself for not being up to par. Have trust in Allah (swt) for he will respond to your prayers.
• Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.
• Get help from a professional if your symptoms seem to get progressively worse. No matter how much you want to beat it yourself. You may find that your low mood is better having talked to a doctor or other health professional. After all clinical depression is classified as a medical illness in these circumstances because it now has physical manifestations.
So what does professional medical help have to offer? Even severe depression can be highly responsive to medical treatment. Believing that one’s condition is “incurable” is often part of the hopelessness that accompanies serious depression. One has to remember that treatment will not eliminate life’s inevitable stresses and ups and downs. But it can greatly enhance your ability to manage and cope with such challenges so that you begin to think positively and begin to enhance your Imaan again.
The most commonly used treatments for depression are psychotherapy and antidepressant medication, or a combination of the two. Which of these is the right treatment for you depends on the nature and severity of the depression and, to some extent, on individual preference. In moderate clinical depression, psychotherapy is most likely the most appropriate treatment. But, in severe or incapacitating depression, medication is generally recommended, in addition to psychotherapy. In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows you to learn more effective ways of handling your problems.
1. Psychotherapy is used to treat depression in several ways. First, supportive counselling can help to ease the pain of depression, and can address the hopelessness of depression. Second, cognitive therapy. This is a form of psychotherapy carried out by a specially trained therapist. Cognitive therapy involves assessing the reasoning behind people’s thinking, on the basis that incorrect thinking results in abnormal reactions. Behavioural therapy aims to change behaviour. Usually the person is gradually exposed to the situation causing anxiety. CBT combines these two types of therapies, and is proven to be effective for anxiety disorders including phobias and panic disorder. But generally it works to change the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that create the depression and sustain it. Cognitive therapy can help the depressed person recognise which life problems are critical, and which are minor. It also helps them to develop positive life goals, and a more positive self-assessment. Third, problem solving therapy is usually needed to change the areas of the person’s life that are creating significant stress, and contributing to the depression. This may require behavioural therapy to develop better coping skills, or Interpersonal therapy, to assist in resolving relationship problems. Research has shown that these psychotherapies are particularly helpful for treating depression. It is quite unfortunate that there is no current professional Islamic psychotherapy for Muslim patients, as I am sure this would have quite a significant effect on Muslims suffering from depressive symptoms.
2. Medication- Except in the more severe depressions, and bipolar depression, medication is usually an option, rather than a necessity. Antidepressant medication does not cure depression, it helps you to feel better by controlling certain symptoms. If you are depressed because of life problems, such as relationship conflicts, divorce, loss of a loved one, job pressures, financial crises, serious medical problems in yourself or a family member, legal problems, or problems with your children, taking a pill will not make those problems go away but rather it will help you cope with the problems and help reduce the depressive symptoms. .
The medications used to treat depression include many. Each acts on different chemical pathways of the human brain related to moods. It is very important to note that Antidepressant medications are not habit-forming or addictive. This is a seriously misunderstood belief. One can come off them when they wish without them causing any adverse effects. To be effective, medications must be taken for about 4-6 months (in a first episode), carefully following the doctor’s instructions. Always remember that all prescription drugs have potential side effects including paracetamol, but the chance of having those side effects is not common. A wide variety of complementary therapies is available for the treatment of anxiety. However, there is no conclusive evidence that these are of benefit or free from side-effects. Anyone who chooses to take complementary medicines should tell their pharmacist, as interactions with other medicines are possible.
Depression is a very common condition today. Unfortunately because of the social problems that Muslims are faced in todays society, some depressive patients may have uncontrollable symptoms. These patients should seek medical help but should always have trust in Allah (swt). To have complete (Tawakul) trust in Allah (swt) means to rely on him completely and to recognise that ones life and destiny is totally owned and controlled by Him. If Allah (swt) wishes he may use medical help as a means of controlling your depression and this should not be considered a wrong thing but a positive thing as the person is trying to get back to sanity so that they can cope with life and overcome those hindrances that are holding back their Imaan. It is important to understand that seeking help in times of despair is something that Allah expects from us for we are His mere creations.
“Truly no one despairs of God’s Soothing Mercy, except those who have no faith” 24
References:
1. Sahih Muslim
2. Surah Al-Anbiya 21:35
3. Surah Ash-Shura 42:30
4. Surah Al-Fajar 89:15,16
5. Surah Al-Imraan 3:179
6. Surah Al-Insaan 76:12
7. Surah Al-Nahl 16:97
8. Sahih Muslim
9. Sahih Muslim
10. Surah Al-Anaam 6:152
11. Sahih Bukhari
12. Tirmidhi
13. Sahih Muslim
14. Surah Yusuf 12:86
15. Surah Al-Baqarah 2:186
16. Surah At-Talaaq 65:3
17. Sahih Muslim
18. Surah Ar-Ra’d 13:28
19. Surah Al-Baqarah 2:153
20. Surah Al-Anaam 6:152
21. Surah Al-Inshirah 94:5,6
22. Sahih Bukhari
23. Surah Al-Baqarah 2:195
24. Surah Yusuf 12:87

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