The Mental Health Impact of Quarantine – Psychological Consequences and Management Strategies
Quarantine was first used in Venice in response to plague and prevented the movement of people, animals, and goods [Tognotti E., 2013].
The Rector of Ragusa (currently Dubrovnik, Croatia), an outstanding rival sea potency of Venice, enacted in 1377 a decree officially establishing the so-called ‘trentina’ (an Italian word derived from ‘trenta,’ the number thirty), a period of isolation of 30 days for ships coming from infected, or even only suspected to be infected, places. The 30-day period became 40 days for land travellers. [Conti A., 2008]
Ships arriving in Venice from infected ports were required to sit at anchor for 40 days before landing. This practice, called quarantine, was derived from the Italian words Quaranta Giorni which mean 40 days.
Throughout history, quarantine has been the cornerstone of disease-control to limit the spread of infectious diseases including the plague, cholera, influenza, and more recently, coronavirus.
- In the 21st century, quarantine measures were used to contain SARS, which originated in Guangdong Province, China, in 2003.
- Modern containment strategies are now vastly different mainly because of how fast the contagion can spread along air-travel routes and thus cause a global public health emergency.
The recent coronavirus (COVID-19) pandemic, which originated in Wuhan, China has seen mass quarantine being effectively used, first in Wuhan and then in several towns in Veneto and Lombardy in northern Italy where it became the epicentre for COVID-19 in Europe. Furthermore, returning travellers must self-isolate while those infected also must be separated to stop further infection.
In Australia, Victoria is the only state in Stage 4 lockdown as of the time of initial publication of this article.
There are three general strategic policy responses to the challenge of coronavirus disease 2019 (COVID-19): elimination, suppression, and mitigation (or herd immunity). Each response is associated with economic, social and health harms.
On 24th July, Prime Minister Scott Morrison accepted and affirmed the Australian Health Protection Principal Committee recommendation:
The goal for Australia is to have no community transmission of COVID-19.
By this time the victorian outbreak had taken hold with a 5 day average of 500 cases per day from 29th July to 5th August. A stage 4 lockdown in Victoria was implemented on 3rd August.
Modelling suggests that elimination could have been achieved if Victoria had gone into full stage 4 lockdown immediately from 9th July, indicating the possible effectiveness of a quarantine strategy when implemented at the right stage of community transmission. [Blakely T et al., 2020]
Quarantine is often an unpleasant experience due to the loss of freedom as well as separation from family and friends. Stressors included fear of disease, frustration and boredom, inadequate information and supplies, possible financial loss, and the stigma of the disease, which together generate adverse psychological effects. [Brooks S et al. 2020]
PSYCHOLOGICAL STRESSORS ASSOCIATED WITH QUARANTINE
There have been multiple studies on people that have undergone quarantine to determine the types of adverse effects it has on mental health and psychological wellbeing.
The quarantine-related symptoms of stress have been reported to be associated with several negative psychological outcomes such as low mood, irritability, insomnia, anger, and emotional exhaustion.
When surveying the symptoms of stress in 338 hospital staff placed under a 9-day quarantine during the SARS epidemic, it was shown that the act of quarantine was the most related factor to the development of acute stress disorder. [Bai et al. 2004]
Other factors that were considered related to this reaction included stigmatisation as well as uncertainty linked to inadequate information.
More recently, a review published in the Lancet synthesised the currently available evidence on the psychological impact of quarantine. [Brooks et al. 2020]
This comprehensive review aimed to determine the factors that induce psychological distress during quarantine versus those not quarantined:
- The duration of quarantine must be of sufficient length to contain the outbreak locally as well as reduce the spread beyond.
- Longer durations of lockdown are associated with poorer mental health outcomes [Hawryluck et al. 2004]; [Reynolds et al. 2008]
Fear of disease :
- The fear of disease and the fear of infecting others have previously been reported especially in pregnant women and those with young children. [Braunack-Mayer et al. 2013]; Jeong et al. 2016]
Frustration and boredom:
- The absence of routine and loss of social contact can be particularly distressing to some, which not only has an impact on mental health but can lead to greater energy intake as well as higher consumption of alcohol. [Blendon et al. 2004]
- A lack of clarity on guidelines and rationale supporting those guidelines from public health authorities and the government can cause frustration and confusion. [Braunack-Mayer et al. 2013; Desclaux et al. 2017]
Inadequate supplies :
- Limited access to essential supplies, such as food, water, and regular prescription medications, can cause considerable anxiety and anger. [Blendon et al. 2004]; [Jeong et al. 2016]
- Interruption to professional careers can have serious and long-lasting effects on the financial welfare of those in quarantine, which is a known risk factor for high levels of distress and the development of psychological disorders. [Taylor et al 2008]; [Mihashi et al 2009]
- Stigmatisation of quarantine has been reported in several studies whereby people who have been quarantined are treated with fear and suspicion [Hawryluck et al. 2004]; [Robertson et al. 2004]; [Cava et al. 2005]; [Desclaux et al. 2017].
What can be drawn from literature is that the provision of information, both quickly and clearly, from the government and public health bodies, is of paramount importance.
Although quarantine is often a necessity for the greater good, the length of time in quarantine is a strong predictor of adverse mental health outcomes both in the short term and long term.
With regards to the long-term psychological impact of quarantine, the SARS epidemic has provided valuable and clinically relevant insights.
For instance, one study showed that avoidance behaviours were still present 6-9 months after quarantine. [Cava et al. 2005]
Another study showed that alcohol abuse and symptoms of dependency were still prevalent 3-years after SARS. [Wu et al. 2008]
SOLUTIONS TO MITIGATE PSYCHOLOGICAL CONSEQUENCES OF QUARANTINE
1. Keep it short:
It is essential that authorities adhere to their own recommended length of quarantine, and not extending it.
Imposing a cordon indefinitely on whole cities with no clear time limit (such as has been seen in Wuhan, China) might be more detrimental than strictly applied quarantine procedures limited to the period of incubation. [Brooks S et al., 2020]
2. Give as much information as possible:
Information about the disease and its impacts and the reasons for the quarantine should be provided as a matter of priority.
3.Provision of adequate supplies:
4. Reduce boredom and improve communication
5. Activate social network
- Family and friends
- Social media
- Telephone services staffed by health care workers or psychiatric nurses to provide support for vulnerable individuals
6. Specific support for healthcare workers
- Health workers are a particularly vulnerable group and are more more likely to be quarantined.
- Frontline medical staff have considerable rates of depression, anxiety, and insomnia. There are high rates of non-specific psychological distress. Read more on the mental health challenges for health care workers.
7. Tapping into altruism:
- Reinforcing the message that quarantine is helping to keep others safe, including those particularly vulnerable (such as those who are very young, old, or with pre-existing serious medical conditions), can help increase adherence to quarantine and reduce the mental health burden.
Quarantine is associated with long term psychological consequences.
A risk-benefit analysis weighing up the need for quarantine to prevent the spread of disease vs. the psychological consequences is imperative.
Individuals should be informed about the need for quarantine and should be well supported during this period.
Depriving people of their liberty for longer than is necessary has long term detrimental consequences and requires careful handling by health authorities and governments.