How We Can Mitigate the Psychological Impact of Quarantine
An evidence-based look at the stressors of quarantine and how to address them.
Posted May 30, 2020
by Hannah Sudhakar
The COVID-19 outbreak has seen many countries place their populations under mass quarantine as a measure to decrease their chances of cross-infection. Since the modes of exposure to this disease are numerous, quarantine and social distancing are seen as the only ways to truly escape it. The CDC 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 them infecting others.”
Quarantine can be an unpleasant experience for many and can lead to negative psychological impacts. In times of emergency, the WHO recommends rapid reviews as a means of evidence synthesis. The purpose of this review is to help policymakers provide guidance for the public on quarantine impacts and mitigation. This rapid review was done by Samantha Brooks, Rebecca Webster, Louise Smith, Lisa Woodland, Simon Wessely, Neil Greenberg, and Gideon Rubin of the Department of Psychological Medicine, King's College London. The research was funded by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King's College London, in partnership with Public Health England, and in collaboration with the University of East Anglia and Newcastle University. It was published in The Lancet and became available online on February 26, 2020.
Three electronic databases were used and 24 papers were studied for this review. These studies were done across 10 countries and included people quarantined due to SARS, Ebola, the 2009 and 2010 H1N1 Influenza pandemic, Middle East Respiratory Syndrome, and Equine Influenza. Among the different databases, 52 articles were narrowed down after excluding duplicates and those that did not match the inclusion criteria. Of these 52, 28 were excluded due to the nature and duration of quarantine described in those articles. Finally, 24 articles were included in this rapid review.
The results were split into two categories: stressors during quarantine and stressors post-quarantine. The stressors during quarantine were:
- Duration of quarantine. Longer durations of quarantine were associated with poorer mental health—specifically, post-traumatic stress symptoms, avoidance behaviors, and anger.
- Fear of infection. Participants were found to have high stress about being infected or infecting others, especially family members.
- Frustration and boredom. Confinement, loss of usual routine, and reduced social and physical contact with others were frequently shown to cause boredom, frustration, and a sense of isolation from the rest of the world, which was distressing to participants.
- Inadequate supplies. Having inadequate basic supplies (e.g. food, water, clothes, or accommodation) during quarantine was a source of frustration and continued to be associated with anxiety and anger 4-6 months after release.
- Inadequate information. Many participants cited poor information from public health authorities as a stressor, reporting insufficient clear guidelines about actions to take and confusion about the purpose of quarantine.
The stressors post-quarantine were:
- Finances. With people unable to work and having to interrupt their professional activities with no advanced planning the financial loss as a result of quarantine created serious socioeconomic distress and was found to be a risk factor for symptoms of psychological disorders and both anger and anxiety several months after quarantine. Participants with a combined annual household income of less than CAN$40,000 showed significantly higher amounts of post-traumatic stress and depressive symptoms.
- Stigma. Stigma from others was a major theme throughout the literature, often continuing for some time after quarantine, even after containment of the outbreak. This observation may not apply to the COVID-19 pandemic.
The results of the review suggest that while quarantine is a necessary preventative measure, it is often associated with negative psychological effects. Though these negative impacts are unsurprising, evidence suggests that many of them could be detected in participants for months or even years after quarantine. All of the during quarantine and post-quarantine stressors suggest an intense need to have effective mitigation measures put in place for quarantines.
In response to these stressors, the review also had some suggestions for mitigation:
- Keep it as short as possible. Restricting the length of quarantine to what is scientifically reasonable given the known duration of incubation periods, and not adopting an overly precautionary approach to this, would minimize the effect on people.
- Give people as much information as possible. Ensuring that those under quarantine have a good understanding of the disease in question, and the reasons for quarantine, should be a priority.
- Provide adequate supplies. Officials also need to ensure that quarantined households have enough supplies for their basic needs and, importantly, these must be provided as rapidly as possible.
- Reduce boredom and improve communication. Boredom and isolation will cause distress; people who are quarantined should be advised about what they can do to stave off boredom and provided with practical advice on coping and stress management techniques. The ability to communicate with one's family and friends is also essential. In regard to the communication of officials to the affected people, the review suggests:
“It is also important that public health officials maintain clear lines of communication with people quarantined about what to do if they experience any symptoms. A phone line or online service specifically set up for those in quarantine and staffed by health-care workers who can provide instructions about what to do in the event of developing illness symptoms, would help reassure people that they will be cared for if they become ill. This service would show those who are quarantined that they have not been forgotten and that their health needs are just as important as those of the wider public.”
In summary, these stressors and their methods of mitigation are aimed at providing policymakers with the adequate tools needed to convey information to the public. This review is also essential as it consolidates information gained from previous epidemics to inform future situations with similar effects to help in the formulation of disaster response plans. While physical impacts are usually the only considered factor in emergency situations, this review shows the connectedness of mental health and physical factors as well.
Hannah Sudhakar is a student of the M.A. in Humanitarian and Disaster Leadership program at Wheaton College. She has a background in Electrical Engineering and Biblical studies. She is passionate about ministering to children and has served in that capacity at various organizations. She has worked with children with special needs in her home country, India.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395(10227), 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8