The spread and impact of the novel coronavirus has seen the implementation of various forms of managed isolation and / or quarantine arrangements (MIQ) around the world. This blogpost is all about the different psychological impacts that being in quarantine can have on people, what the causes might be, and what we can do to help minimise those impacts.
And I think it’s important to re-emphasise this now, as we in New Zealand experience a rise in overseas citizens and residents trying to come back in to New Zealand and having to enter managed isolation or quarantine, a new lockdown takes effect in Melbourne, Australia, and many other places in the world are either easing lockdown and / or experiencing rapid increases in numbers of cases of COVID -19 again.
You may have noticed I mentioned two different terms just then – quarantine, and managed isolation. Let me explain what I mean. Quarantine is the separation and restriction of movement of people who have potentially been exposed to a contagious disease to see if they become unwell, so reducing the risk of them infecting others. This definition differs from isolation, which is the separation of people who have been diagnosed with a contagious disease from people who are not sick. However, the two terms are often used interchangeably, especially in communication with the public. It should be understood that this could be a possible point of confusion for those entering managed isolation or quarantine, and for the general public. So it’s important that we’re clear when we are talking about this.
And actually, we don’t know very much about the exact psychological impacts of managed isolation (as compared with quarantine) from a research point of view. What I’m talking about here are the psychological consequences that may follow for people entering into quarantine.
What are the sorts of psychological experiences that people go through when having to go into quarantine like this?
Well, it’s often unpleasant, as you’d expect. Separation from loved ones, the loss of freedom, uncertainty over disease status, and boredom can, sometimes, have big impacts. Suicide has been reported in the research, people experience substantial anger, and legal action has been taken following the imposition of quarantine in previous outbreaks. And the evidence seems to point to the imposition of a restriction of liberty being at the root of this; because voluntary quarantine is associated with less distress and fewer long-term complications.
In the specific case of COVID-19 in New Zealand, this may have be made worse by possibly difficult circumstances leading up to return to New Zealand, including; financial distress, multiple cancellations of flights and uncertain long waits for further availability, immigration and visa issues in the country from which they were returning to New Zealand, and negative New Zealand media coverage, including social media – producing a feeling that returnees are unwelcome in their own country.
If we look at the experiences of people quarantined during previous SARS outbreaks: over 20% reported fear, 18% reported nervousness, 18% reported sadness, and 10% reported guilt. They also had experiences like confusion, anger, grief, numbness, and anxiety-induced insomnia.
During the equine influenza outbreak in Australia people were quarantined for several weeks because of that disease outbreak – and 34% of horse owners that were quarantined reported high levels of psychological distress, compared with around 12% in the general Australian population.
So, quarantine is stressful, and it is linked to people experiencing a number of different and difficult worries and emotions, with sometimes serious consequences.
What in particular about quarantine is it that people find difficult? This looks like it falls into 5 different categories:
1. Duration of quarantine
Some studies have shown that longer durations of quarantine were associated with poorer mental health specifically, post-traumatic stress symptoms, avoidance behaviours, and anger. Although the duration of the quarantine was not always clear, one study showed that those quarantined for more than 10 days showed significantly higher post-traumatic stress symptoms than those quarantined for less than 10 days.
2. Fears of infection
Participants in many studies reported fears about their own health or fears of infecting others and were more likely to fear infecting family members than those not quarantined. They also became particularly worried if they experienced any physical symptoms potentially related to the infection and fear that the symptoms could reflect having the infection continued to be related to psychological outcomes several months later.
3. 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. This frustration was made worse by not being able to take part in usual day-to-day activities, such as shopping for basic necessities or taking part in social networking activities via the telephone or internet. The ability to get outdoors to exercise and exposure to natural light and surroundings also possibly falls into this category too.
4. Inadequate supplies
Having inadequate basic supplies (eg, 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. Being unable to get regular medical care and prescriptions also appeared to be a problem for some participants. Four studies found that supplies from public health authorities were insufficient. Participants reported receiving their masks and thermometers late or not at all; food, water, and other items were only intermittently distributed; and food supplies took a long time to arrive.
5. 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. After the Toronto SARS epidemic, participants perceived that confusion stemmed from the differences in style, approach, and content of various public health messages because of poor coordination between the multiple jurisdictions and levels of government involved. Lack of clarity about the different levels of risk, in particular, led to participants fearing the worst.
What about when people leave quarantine? What’s likely to make things worse after they complete their required time?
Financial loss can be a problem during quarantine, with people unable to work and having to interrupt their professional activities with no advanced planning – and perhaps having been in limbo for weeks or months before entering quarantine when they cross an international border; and the effects appear to be long lasting. The evidence is that 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.
Stigma from others, often continuing for some time after quarantine, even after containment of the outbreak is a major issue. In a comparison of health-care workers quarantined versus those not quarantined, quarantined participants were significantly more likely to report stigmatisation and rejection from people in their local neighbourhoods, suggesting that there is stigma specifically surrounding people who had been quarantined. General education about the disease and the reasons for quarantine and public health information provided to the general public can help to reduce stigmatisation – and that includes through the media too. Because it is certainly possible that media reporting contributes to stigmatising attitudes in the general public; the media is a powerful influence on public attitudes and dramatic headlines and fear-mongering have been shown to contribute to stigmatising attitudes in the past (eg, during the SARS outbreak).
What can be done to protect people from the most psychologically damaging aspects of being in quarantine, and what happens afterwards?
1. Keep it as short as possible
Longer quarantine is associated with worse psychological outcomes; the longer the stressor was experienced, the bigger effect they seem to have. Evidence from elsewhere also emphasises the importance of authorities adhering to their own recommended length of quarantine, and not extending it. For people already in quarantine, an extension, no matter how small, is likely to make any sense of frustration or demoralisation worse.
2. Give people as much information as possible
People who are quarantined often fear being infected or infecting others. They also often have catastrophic ideas about any physical symptoms experienced during the quarantine period. This fear is a common occurrence for people exposed to a worrying infectious disease, and might be made worse by the often inadequate information people have reported receiving from public health officials leaving them unclear about the risks they faced and why they were being quarantined at all. Ensuring that those under quarantine have a good understanding of the disease in question, and the reasons for quarantine, should be a priority.
3. Reduce the boredom and improve the communication
Boredom and isolation will cause distress; people who are quarantined should be advised about what they can do to ward off boredom and provided with practical advice on coping and stress management techniques. 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, including mental health concerns. A phone line or online service specifically set up for those in quarantine and sta!ed 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.
Reassurance like this could decrease feelings such as fear, worry, and anger. An active outreach strategy, that is health services reaching out to those quarantined proactively rather than reactively waiting to be contacted can ensure safety and to create a sense of being cared for. Don’t leave it to the people who are being quarantined to make the first move. Daily check-ins should be the thing.
The psychological impacts of quarantine are wide-ranging, can be large, and can be long lasting too. I’m not suggesting that quarantine shouldn’t be used; the psychological effects of not using quarantine and allowing disease to spread would be worse. However, depriving people of their liberty for the wider public good is contentious and needs to be handled very carefully. If quarantine is essential, then the research suggests that officials should take every measure to ensure that this experience is as tolerable as possible for people.
This can be achieved by: telling people what is happening and why, explaining how long it will continue, providing meaningful activities for them to do while in quarantine, providing clear communication, ensuring basic supplies (such as food, water, and medical supplies) are available, and reinforcing the sense of altruism that people should be experiencing. And that goes for letting the general public know about this sacrifice too – yes, the public may have already gone through deprivations and sacrifice too – so that message needs to be carefully calibrated – but it’s a necessary step to help to ensure that people feel included and not so stigmatised once they emerge from quarantine.
There is a responsibility for those entering a country to comply with quarantine regulations, no doubt. But we also need to make sure that we prepare to support them through that process – and, if necessary, to ensure the balance of risks to the individual and to wider society are fairly weighed. We all need to play our parts.
This blog post draws from a rapid review of relevant evidence conducted by a team based at the Department of Psychological Medicine at King’s College, London (published in The Lancet; Brooks et. al., 14 March 2020; Vol. 395, 912-920), as well as my own review paper published in the NZ Medical Journal in 2009.