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Potential psychological effects of quarantine and how to mitigate them

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With the whole of the UK facing ‘lockdown’ under COVID-19, what does the evidence tell us about its likely psychological impact and how people can be supported through it? Quarantine is an effective way to prevent the transmission of infection but is potentially a source of stress from fears of infection and long isolation, frustration, boredom, inadequate information and supplies, financial loss, and stigma. However, research has shown that many of the adverse effects of quarantine can be alleviated.

Quarantine and isolation are well-established methods of dealing with infectious disease and before the modern era were frequently the only tools available to prevent disease spread. But separating people from friends, relatives and broader society can have detrimental effects on well-being and mental health.

There are many studies of the psychological impact of quarantine in the scientific literature. A recent review of existing literature found 24 studies, mostly concerned with SARS, swine flu and Ebola, of which 23 found a link between quarantine and adverse psychological impacts.[1] Most demonstrated an increase in common mental disorders (such as anxiety, depression and confusion) compared to expected levels in the general population.

But nearly all the disease outbreaks studied occurred before the widespread use of social media, or in the case of Ebola, when mobile phone use was still limited in outbreak areas. They also concerned relatively small groups rather than entire populations, which is what is now being faced in the UK and elsewhere.

There is strong evidence that an inability to contact family and friends is associated with an increase in anxiety.[2] Today most households are hyper-connected, with TV, radio, internet as well as mobile phones and social media. However, there are still groups of people, particularly older ones and those with special needs, who do not have access to these kinds of communication channels. These groups are more likely to suffer anxiety, for example due to concerns about access to food and medicines. Measures to address these issues include the support lines currently being developed in the UK that are operated by NHS volunteers.

For those who have been isolating for some time, predominantly the over 70s and those with existing medical conditions, repeated exposure to information highlighting their increased risks of dying or needing an intensive therapy unit (ITU), may heighten anxiety and depression. Public health best practice is to tell vulnerable groups what to expect should they fall ill and to provide access to a dedicated helpline or equivalent staffed by trained personnel.

Another potent source of anxiety centres around finance, with many fearing loss of jobs or, for the self-employed, a complete collapse in income. Financial loss creates long-lasting socioeconomic distress and in studies of previous disease outbreaks was found to be a risk factor for symptoms of psychological disorder, anger and anxiety several months after the period of quarantine.[3] This can be exacerbated if promised funds do not arrive in a timely way. Government action to ameliorate as much as possible financial concerns will help reduce this source of anxiety.

Healthcare workers

Of particular note are high rates of psychological impact amongst healthcare workers. Health workers who had been quarantined had more severe symptoms of post-traumatic stress than health workers who were not quarantined.[4] Some of this may be due to the work that they are being asked to do, which is exhausting, frightening and intense. But there are also additional pressures, for instance the conflict for healthcare workers between their duty to patients and being a potential source of infection to their families.

A study in the Toronto hospital at the epicentre of the 2003 SARS outbreak found that quarantined staff had concerns about their personal safety, about transmitting disease to family members, about stigmatisation and about interpersonal isolation. Working staff members were also concerned about understaffing due to quarantines and about overwork caused by colleagues calling in sick. In a second study of quarantined staff, lack of clear guidelines about how to minimise infection during quarantine added to staff fears about contaminating family members with many speaking of the conflict they felt.[5] Their anxiety continued for some time after the SARS outbreak had been contained.

COVID-19 is not precisely analogous to the SARS situation, but research relating to SARS amongst healthcare workers points strongly to the need for additional mental health support for frontline healthcare workers.

Evidence shows that quarantining a significant fraction of the population will have immediate consequences for their mental well-being such as frustration or boredom, and anxiety about becoming ill and infecting others. There is not an evidence base on the consequences of asking vulnerable groups to strictly self-isolate (shield themselves) to avoid infection, though at least some of the consequences are likely to be similar.

Experiences from previous disease epidemics point to factors that could help to reduce psychological distress for those quarantined in the time of COVID-19: clear information; rapid communication; adequate general and medical supplies; and short quarantine periods, preferably voluntary and without changes of duration. There may also be value in emphasising the altruistic nature of self-isolation and its benefit to public health.[1][6]

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References

  1. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 2020 Mar;395(10227):912-920. DOI: 10.1016/s0140-6736(20)30460-8.

  2. Jeong H, Yim HW, Song YJ, et al. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and Health. 2016 ;38:e2016048. DOI: 10.4178/epih.e2016048.

  3. Cava MA, Fay KE, Beanlands HJ, McCay EA, Wignall R. The experience of quarantine for individuals affected by SARS in Toronto. Public Health Nursing. 2005 Sep-Oct;22(5):398-406. DOI: 10.1111/j.0737-1209.2005.220504.x.

  4. Reynolds DL, Garay JR, Deamond SL, et al. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiology and Infection. 2008 Jul;136(7):997-1007. DOI: 10.1017/s0950268807009156.

  5. Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May;168(10):1245-1251.

  6. Webster RK, Brooks SK, Smith LE, et al. How to improve adherence with quarantine: rapid review of the evidence. Public Health. 2020 Mar;182:163-169. DOI: 10.1016/j.puhe.2020.03.007.

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