We are experiencing an unprecedented global response to the COVID-19 pandemic. Self-isolation is a favoured tool public health officials are using to help prevent community transmission of the virus, in attempt “flatten the curve”. In February the Department of Psychological Medicine, King’s College London, completed a rapid review of the research examining the impact of quarantine (self-isolation) on wellbeing and mental health. The review strongly indicates that quarantine can have significant and long-lasting impacts on individuals. Restricting people’s liberty is therefore not a decision to be made lightly. The government has made a decision that the negative impact of exponential COVID-19 spread is greater than potential psychological risks, we must therefore use this research to ensure we optimise the mental health and wellbeing outcomes for people that will need to quarantine.
The rapid review identified 3166 papers that investigated the impact of quarantine on wellbeing and mental health. From this pool, 24 papers met criteria centering on individuals quarantined during the outbreaks of SARS, Ebola, H1N1 (“swine flu”) and an equine influenza outbreak. Findings from this review identified that quarantine can have significant and long-lasting psychological impact on individuals, including but not restricted to: fatigue, stress, depression, insomnia, irritability, concentration difficulties, detachment from others and symptoms akin with post-traumatic stress. For example, in a study of 903 individuals quarantined in Hong Kong during the SARS outbreak, 73% of individuals experienced low mood and 57% experienced irritability. In a separate study, focused on hospital staff in Taiwan during the SARS outbreak, quarantine was the highest predictor of acute stress disorder.
As a cohort, health workers appear at highest risk of psychological harm following quarantine, with stigma, shame, fear and avoidance of work identified as precipitators and outcomes. Conclusions have been drawn that those with pre-existing mental illnesses may also be at risk and require extra care during quarantine. No other clear demographic differentials have been identified.
What appears critically important from this review is understanding the risk factors during and after quarantine, and subsequently ensuring our practice as a nation proactively reflects these findings.
During quarantine : Risk factors and protective actions
Length of Duration – quarantine periods should be kept as short as possible and all effort should be taken to prevent the extension of quarantine
Fear of spread to close contacts- clear information to those in quarantine regarding how they keep their family members / house mates safe can significantly reduce individuals’ worry and anxiety. This has been shown as particularly important for pregnant women and those with young children.
Inconsistent and inadequate communication- including with loved ones and public health officials. Consistent and frequent messaging from our Director General of Health, Government and public health workers is protective. Ensuring those in quarantine have a good understanding of the disease in question, and the reasons for quarantine, should be a priority.
Boredom and Frustration – Lack of routine, social interactions and inability to participate in usual daily activities are stressors. Providing clear stress management techniques is deemed helpful. Engaging in activities that provide a sense of purpose, employers enabling flexible work from home and staying connected via social media and video apps is encouraged.
Lack of supplies – Whilst urged to resist ‘panic buying’ it is important all households have a quarantine plan in place. Either by ensuring the provision of general household and medical supplies, or establishing a network of supporters. This is especially important if you are located in a region without home delivery or medical supplies are required. In fact, a backup network is also recommended. For example, if your household is quarantined who can deliver your groceries. If they become unwell, who is your second in line?
An individual’s mindset during quarantine also impacts on wellbeing and mental health. Those that can take an altruistic approach, focusing on how their self-isolation is protecting vulnerable members of their community, fare psychologically better.
Financial stress- financial loss during quarantine periods has been linked to significant socio economic distress, and can lead to persistent anger and anxiety. Low income households and those with vulnerable job positions (for example, casual workers or those in the tourism sector) are at particular risk. Whilst we wait for the government’s economic relief package to be announced tomorrow, there is opportunity for the community to support those impacted. Ensuring you have your neighbour’s phone number and checking in on them is a good starting position. Delivering cooked meals and general household supplies at the front door of a house in quarantine is also helpful.
For employers with a business that has been financially impacted, there is compounded financial stress. Worry about their own business and the welfare of their staff. It is a time for close peers, family and friends to regularly check ‘Are you OK?’.
Stigma – Following quarantine individuals across several studies reported that others were treating them differently: “avoiding them, withdrawing social invitations, treating them with fear and suspicion, and making critical comments”. Reduction of stigma will require a multi-pronged approach:
- Continuation of general education about covid-19 for the general public
- Clear information and support for employers
- Reduction (and monitoring) of fear mongering in the media and on social networks
- Education and support for leaders with team members who are re-integrating into the workforce
- Support for individuals re-integrating into the workforce/community
When in unchartered waters, it is important our decisions and behaviours are underpinned with the available evidence base. Whilst government and public health have clear requirements to reduce the psychological impact of quarantine (clear messaging, constant contact, reduction of quarantine extensions where possible, financial aid) we also have a community responsibility. Appropriately preparing for a 14-day quarantine (having a household plan, stocking reasonable provisions and medical supplies), educating ourselves with available information from reputable sources, employing stress management techniques, self-isolating if unwell, frequent handwashing, restrain from physical contact with others and halting the spread of fear mongering propaganda is within our control. Employers also have a responsibility to, where possible, employ flexi working and positive reintegration into the workforce.
N If we can be prepared and calm, we can work together to protect the wellbeing and mental health of those that need to quarantine.
Stress Management Tools:
- Diagrammatic breathing
- Progressive Muscle Relaxation
- Keeping a gratitude journal
- Connection with others – facetime, skype, instant message