Quarantine produces negative psychological effects including post-traumatic stress symptoms, confusion and anger, according to researchers from King’s College London.
The study, published in The Lancet, finds that these psychological impacts can be long-lasting. In the light of this, the researchers provide key messages on mitigation, particularly around the provision of information and the duration of quarantine.
As a means to control the current COVID-19 outbreak, many countries have asked people to isolate themselves at home or in a dedicated quarantine facility.
UK politicians and policymakers have stated that quarantine decisions must be based on scientific evidence about the virus itself, but also the possible social and economic impacts of quarantine.
Funded by the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Emergency Preparedness and Response, the new study has reviewed research on the psychological impact of previous disease outbreaks.
Researchers analysed 24 studies, which were done across 10 countries and included people with Severe Acute Respiratory Syndrome (SARS), Ebola, H1N1 influenza, Middle East Respiratory Syndrome (MERS) and equine influenza.
The study showed a wide range of psychological impacts from quarantine, including post-traumatic stress symptoms, depression, feelings of anger and fear, and substance misuse.
Some of these, particularly post-traumatic stress symptoms, were shown to be long-standing.
Those with a history of psychiatric disorder and health-care workers suffered greater psychological impacts due to quarantine, according to the research.
Lead author, Dr Samantha Brooks from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London said: ‘Going into quarantine is an isolating and often fearful experience and our study found that it has negative psychological effects.
The finding that these effects can still be detected months or years down the line – albeit from a small number of studies – is of particular concern and indicates that measures should be put in place during the quarantine planning process to minimise these psychological impacts.
Our research suggests that health-care workers deserve special attention from their managers and colleagues and those with pre-existing poor mental health would need extra support during quarantine.’
The research investigated the factors or stressors that were instrumental in the level of psychological impact experienced from quarantine with the aim of recommendations on minimising the effects.
The study identified that longer quarantines were associated with poorer mental health.
Other influential factors in psychological effects were lack of basic supplies such as food, water and clothes and poor information from public health authorities around the purpose of quarantine and guidelines of actions to take.
In terms of the post-quarantine period financial loss due to inability to work and stigma around the disease itself were also linked to mental health problems.
Contributing author, Professor Neil Greenberg from the IoPPN said: ‘People who are quarantined are already experiencing a high level of fear around being infected and the possibility of infecting others.
When in quarantine they are often prone to catastrophic interpretations of events and an absence of accurate information can exacerbate this.
Our research showed that it is important that those in quarantine have access to up-to-date, accurate information that clearly and consistently communicates the reasons for quarantine and any changes in the quarantine plan, especially around its duration.
The period of quarantine should be as short as possible and the duration should not be changed unless in extreme circumstances as such changes can lead to significant impacts on mental health.’
No previous research has compared the psychological effects of mandatory vs. voluntary quarantine but studies do indicate that highlighting the altruistic aspect of quarantine in terms of keeping others safe could make the stress and frustration of the situation easier to bear.
As a means to control the current COVID-19 outbreak, many countries have asked people to isolate themselves at home or in a dedicated quarantine facility
Contributing author Professor Sir Simon Wessely from the IoPPN and Director of the NIHR HPRU in Emergency Preparedness and Response said: ‘Health officials charged with implementing quarantine should remember that not everyone is in the same situation and people can have very different experiences of the same quarantine plan.
If the quarantine experience is negative the results of our study suggest there could be long-term consequences on mental health.
‘Everyone is by now aware of the potential social and economic consequences of COVID-19, but what our research highlights are the possible unintended consequences of attempts to control the spread of the virus. We must be aware of these and put in place measures to lessen their impacts.
Communication and transparency are key and voluntary quarantine, performed as an altruistic act to protect others, is always going to be associated with less severe consequences than imposed quarantine.’
The researchers highlight that the recommendations made in the review apply primarily to small groups of people in dedicated facilities and to some extent self-isolation.
Funding: This research was funded by the National Institute for Health Research (NIHR) HPRU in Emergency Preparedness and Response and in collaboration/partnership with King’s College London. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care or Public Health England.
Persons placed in quarantine have their freedom restricted to contain transmissible diseases. This takes a considerable toll on the person. In relation to the recent global outbreak of SARS, considerable time has been spent discussing the specifics of quarantine and how to promote adherence to infection control measures.
Little, if any, analysis has focused on the effect of quarantine on the well-being of the quarantined person. The objective of the study survey was to capture a range of experiences of quarantined persons to better understand their needs and concerns.
This knowledge is critical if modern quarantine is to be an effective disease-containment strategy. To our knowledge, a consideration of the adverse effects of quarantine, including psychological effects, has not previously been systematically attempted.
Our results show that a substantial proportion of quarantined persons are distressed, as evidenced by the proportion that display symptoms of PTSD and depression as measured by validated scales.
Although quarantined persons experienced symptoms suggestive of both PTSD and depression, the scales that were used to measure these symptoms are not sufficient to confirm these diagnoses.
To confirm the diagnoses of PTSD and depression, structured diagnostic interviews are required. Because the survey was anonymous, this was not possible.
A score of >20 on the IES-R was used to estimate the prevalence of PTSD symptoms in our study population. This corresponds to the mean score measured on the IES-R in a study of journalists working in war zones that used diagnostic psychiatric interviews to confirm the presence of this disorder (11).
Since most respondents to our survey were healthcare workers, we chose a work-related traumatic event for the comparison group. While other cutoff points may have been used to estimate the prevalence of PTSD symptoms in our population, the risk factors that we identified for increased PTSD symptoms, rather than the absolute prevalence of PTSD in our study participants, are the important findings of this study.
This also applies to the risk factors that we identified for increased depressive symptoms in the respondents. Quarantined persons with risk factors for either PTSD or depressive symptoms may benefit from increased support from public health officials.
In this population, the presence of PTSD symptoms was highly correlated with the presence of depressive symptoms even though different clinical symptoms characterize the two disorders. Kessler’s National Comorbidity Study indicated a 48.2% occurrence of depression in patients with PTSD (15).
PTSD is an anxiety disorder characterized by avoiding stimuli associated with a traumatic event, reexperiencing the trauma, and hyperarousal, such as increased vigilance (16). This disorder may develop after exposure to traumatic events that involve a life-threatening component, and a person’s vulnerability to the development of PTSD can be increased if the trauma is perceived to be a personal assault (17).
Increased length of time spent in quarantine was associated with increased symptoms of PTSD. This finding might suggest that quarantine itself, independent of acquaintance with or exposure to someone with SARS, may be perceived as a personalized trauma.
The presence of more PTSD symptoms in persons with an acquaintance or exposure to someone with a diagnosis of SARS compared to persons who did not have this personal connection may indicate a greater perceived self-risk
. The small number of respondents who were acquainted with or exposed to someone who died of SARS may explain the lack of correlation between this group and greater PTSD and depressive symptoms (44 persons died of SARS in the greater Toronto area).
This study also notes the trend toward increasing symptoms of both PTSD and depression as the combined annual income of the respondent household fell from CAD >$75,000 to CAD <$40,000.
Quarantined persons with a lower combined annual household income may require additional levels of support. Since the survey was Web-based and required that respondents have access to a computer, the survey was likely answered by a more affluent and educated subgroup of persons.
Since respondents with a lower combined annual household income experienced increased symptoms of PTSD and depression, and since those with lower combined annual household incomes were not as likely to have access to a computer, the results of this survey may underestimate the prevalence of psychological distress in the overall group of quarantined persons.
Overall, most respondents did not report financial hardship as a result of quarantine. This finding is likely explained by the fact that >50% of the respondents reported a combined annual household income of CAD >$75,000.
As many as 50% of respondents felt that they had not received adequate information regarding at least one aspect of home infection control, and not all of the respondents adhered to recommendations.
Why some infection control measures were adhered to while others were not is unclear. A combination of lack of knowledge, an incomplete understanding of the rationale for these measures, and a lack of reinforcement from an overwhelmed public health system were likely contributors to this problem.
Of particular interest, strictly adhering to infection control measures, including wearing masks more frequently than recommended, was associated with increased levels of distress. Whether persons with higher baseline levels of distress were more likely to strictly adhere to infection-control measures or whether adherence to recommended infection-control strategies resulted in developing higher levels of distress cannot be clarified without interviewing the respondents.
Regardless of the cause, this distress may have been lessened with enhanced education and continued reinforcement of the rationale for these measures and outreach efforts to optimize coping with the stressful event.
This study has several limitations. The actual number of respondents is low compared to the total number of persons who were placed into quarantine and therefore may not be representative of the entire group of quarantined persons.
However, lack of funding, confidentiality of public health records, and an overloaded public health response system limited sampling in this study. Furthermore, a self-selection effect may have occurred with those persons who were experiencing the greatest or least levels of distress responding to the survey.
In addition, respondents required access to a computer to respond, which suggests that they may be more educated and have higher socioeconomic status than the overall group who were quarantined.
They also had to be English speaking. Recognizing these limitations, however, an anonymous Web-based method was chosen because concerns about persons’ confidentiality precluded us from access to their public health records.
A Web-based format was chosen over random-digit dialing for both cost considerations and time constraints. The project was initiated and completed without a funding source soon after the outbreak period at a time when concerns about SARS were still a part of daily life in Toronto.
Obtaining as much information about the adverse effects of quarantine as close to the event as possible was important because a study conducted several months later would have been subject to the limitations of substantial recall bias.
If this study were to be repeated, a study design ensuring a more representative selection of the population that used a combination of quantitative and qualitative methods, including structured diagnostic interviews, would be recommended to overcome these concerns.
In the event of future outbreaks, a matched control group of persons who were not quarantined should be considered because it would allow an assessment of the distress experienced by the community at large.
Finally, we determined only the prevalence of symptoms of PTSD and depression in our study population because these were the predominant psychological distresses that were observed to be emerging in our SARS patient population (W.L.G., pers. comm.).
We also focused on symptoms of PTSD and depression because we believed that they would be the most likely to cause illness and interfere with long-term functioning. Future studies should assess persons for other psychological responses, including fear, anger, guilt, and stigmatization.
A standardized survey instrument that considers the full spectrum of psychological responses to quarantine should be developed. In the event of future outbreaks in which quarantine measures are implemented, a standardized instrument would enable a comparison between the psychological responses to outbreaks of different infectious causes and could be used to monitor symptoms over time.
Despite these limitations, the results of this survey allow for the generation of hypotheses that require further exploration. Our data show that quarantine can result in considerable psychological distress in the forms of PTSD and depressive symptoms.
Public health officials, infectious diseases physicians, and psychiatrists and psychologists need to be made aware of this issue. They must work to define the factors that influence the success of quarantine and infection control practices for both disease containment and community recovery and must be prepared to offer additional support to persons who are at increased risk for the adverse psychological and social consequences of quarantine.
King’s College London