"This is a timely review from the Lancet, summarising the potential psychological impact of quarantine. The review defines quarantine as ‘the separation and restriction of movement of people who have potentially been exposed to a contagious disease to ascertain if they become unwell, so reducing the risk of infecting others’. The aim of the article is to provide a rapid synthesis of the evidence to inform policy makers dealing with the corona virus and, despite the absence of widespread routine testing and contact tracing, this review is clearly relevant and provides a platform for future research.
The researchers identified 24 papers, from over 3000, that specifically considered the psychological impact of quarantine. These papers came from 10 countries and included studies of previous recent epidemics, with 16 papers referring to Severe Acute Respiratory Syndrome (SARS) or Ebola. Only five studies compared psychological outcomes for people quarantined and those not quarantined. Furthermore, the studies varied in the methods used with a mix of specific rating scales to assess general mental health, symptoms such as depression or post-traumatic stress and behaviours including alcohol abuse; study-specific surveys; observations and interviews or focus groups. The length of quarantine reported in the studies also differed from 9 days to 30 days, although in 8 studies the length was not specified because it was dependent on the exposure to the specific virus. The study participants included residents living in villages or cities that were quarantined or target populations, including students, parents, employees, horse-owners in the case of equine flu, and approximately a third of studies considered outcomes for hospital employees and health care workers.
The findings paint a picture of poor psychological wellbeing outcomes, with a wide range of psychological distress reported over the studies both during and following the period of quarantine. This included depression, low mood, irritability, insomnia, confusion, fear, anger and anxiety. Several studies identified that quarantine was a predictor of post-traumatic stress, including for hospital staff, parents and children. Only one study reported a reduction in anxiety symptoms and anger 4-6 months after the quarantine period had ended. Another study identified a positive association between alcohol abuse or dependency symptoms three years after being quarantined for health care workers, who had and worked in a high-risk location. For health care workers, quarantine was also positively associated with avoidance behaviours, such as minimising direct patient contact or not going to work. A study of Toronto residents found that for some people the return to their usual lives was delayed and they described longer-term behavioural changes such a vigilant hand washing and the avoidance of crowds.
The analysis also considered whether there were any participant characteristics and demographics that increased the likelihood of poor psychological outcomes. The findings are mixed but, in general, the review suggests that people with a history of psychiatric illness and health care workers were at greater risk of poorer psychological health following quarantine. The factors during quarantine that were identified as having an influence on outcomes included:
- the length of quarantine, with three studies indicating that a longer duration of quarantine (in one study this was defined as more than 10 days) was associated with post-traumatic stress symptoms, avoidance behaviours and anger;
- fears of infection related to personal health or that of family members and particularly if people experienced any physical symptoms, potentially related to the infection;
- frustration and boredom arising from the loss of usual routine and physical contact;
- inadequate basic supplies, particularly food, water, clothes or accommodation and for some people being unable to get regular medical care, prescriptions or appropriate medical supplies, such as masks;
- frustration and boredom arising from the loss of usual routine and physical contact;
- inadequate basic supplies, particularly food, water, clothes or accommodation and for some people being unable to get regular medical care, prescriptions or appropriate medical supplies, such as masks;
and
- inadequate information, particularly about the purpose of the quarantine leading to confusion and a lack of clarity about levels of risks could lead people to fear the worst.
The review also identified that quarantine could result in financial loss as a result of employment restrictions, and delays or perceived inadequate financial support from government were a cause of distress, particularly for those with lower household incomes. People who have been quarantined are also liable to be stigmatised, with others treating them differently including avoiding them, viewing them with suspicion and making critical comments.
The paper concludes by drawing out the implications for what can be done to mitigate the psychological consequences of quarantine. First, it suggest that attention needs to be paid to people with pre-existing mental health problems and providing extra support to them during quarantine. Second, the high prevalence of distress amongst quarantined health care workers means that managers need to be aware of the potential risks to their psychological health and provide additional support and early intervention. The wider steps that can be taken included:
- keeping the quarantine period as short as possible with the duration not being changed unless in extreme circumstances;
- making sure people are well informed about the reasons for the quarantine and how to manage the risks;
- providing adequate supplies to enable people to meet their basic needs and coordinating provision to ensure that supplies do not run out;
- reducing boredom and improving communication through practical advice on coping and stress management techniques; telephone support; use of social media to sustain social networks and specific phone lines or online advice for people if they start to show symptoms;
and
- support groups for people who have been quarantined.
Whilst no studies of the psychological impacts of mandatory versus voluntary quarantine were identified, the authors observe that most of the adverse effects come from the restrictions on individual freedoms. Thus, voluntary quarantine is associated with less distress and fewer long-term problems. They argue that altruism is better than compulsion and, thus promoting the message that quarantining is necessary to keep others safe can help reduce the mental health impact and promote quarantine adherence. Thus, they consider that other measures such as cancellation of mass gatherings, school closures and social distancing might be more beneficial than strictly imposed quarantine measures.
The findings from this paper and the adoption of the measures identified by the authors to mitigate the psychological impact of quarantine during the current pandemic offers some reassurance. However, it is evident that further research is needed not only on the impact of measures such as social distancing and school closures, but also the interventions to address loss of income, ensure that ‘at risk’ groups have adequate protection, the mobilisation of community action, different country responses and psychological preparedness for future pandemics. In conclusion, this review provides a foundation for much-needed research in this area and to ensure that the mental health impacts of pandemics and associated public health measures are properly considered."
Dr Karen Newbigging is a Senior Lecturer in Healthcare Policy and Management whose recent work has focused on the implementation of health and social care policy, patient and public involvement, advocacy and action to tackle health inequalities and discrimination. Karen has a particular interest in mental health, and is the Deputy Director of the Institute for Mental Health at the University of Birmingham