'The psychological impact of quarantine and how to reduce it' - The Lancet paper.

Following my last Blog 'Keep Calm ... Do Intensive Interaction ... but minimise the risks of Covid-19 transmission', this week I am summarising a very recent Lancet paper (Feb 26th) that was sent to me by one of my colleagues. This paper is: 

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

By Brooks, S., Webster, R., Smith, E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. of the Dept of Psychological, Medicine, King’s College, London. The Lancet (2020) 395, 912–20 (at -https://doi.org/10.1016/S0140-6736(20)30460-8).

The Covid-19 outbreak has seen many people being asked (or told) to isolate themselves at home or in some specific 'quarantine facility'. This review covered 24 studies of the effects of quarantine on people with SARS/MERS, Ebola, and H1N1/equine flu. The review defined 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'. 

Why is this Review needed? Quarantine is often an 'unpleasant experience for those who undergo it. Separation from loved ones, the loss of freedom, uncertainty over disease status, and boredom can, on occasion, create dramatic effects'. Therefore, using quarantine 'as a public health measure' will requires us to recognise, and then reduce, any negative effects associated with it. 

The psychological impact of quarantine: 

• All the quantitative studies covered by this review reported the psychological impacts of quarantine being generally identified as: 'emotional disturbance, depression, stress, low mood, irritability, insomnia, post-­traumatic stress symptoms, anger, and emotional exhaustion'. A number of qualitative studies also identified a range of other psychological responses to quarantine e.g. 'confusion, fear, anger, grief, numbness and anxiety ­induced insomnia'.

• One study of staff working with SARS patients found that, after 9 days of quarantine they were significantly more likely to report: 'exhaustion, detachment from others, anxiety when dealing with febrile patients, irritability, insomnia, poor concentration and indecisiveness, deteriorating work performance, and reluctance to work or consideration of resignation'. 

• A study comparing parents and children quarantined with those not quarantined found that 'the mean post-traumatic stress scores were four times higher in children who had been quarantined than in those who were not quarantined'.

Also, the review noted that there was 'mixed evidence' as to whether any individual characteristics or group 'demographics' were predictors of the effects of quarantine. However they did state that 'having a history of psychiatric illness' was associated with 'anxiety and anger 4–6 months' after quarantine.

What can be done to mitigate the consequences of quarantine? 

• Keep it as short as possible: not surprisingly the review stated that - 'Restricting the length of quarantine to what is scientifically reasonable' and not adopting 'an overly precautionary approach', would minimise the effect on people.

• Give people as much information as possible: also the review stated that - 'Ensuring that those under quarantine have a good understanding of the disease in question, and the reasons for quarantine, should be a priority'.

• 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 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'.

• The review also suggested that 'support groups specifically for people who were quarantined' could be helpful. One study found that 'having such a group and feeling connected to others who had been through the same situation could be a validating, empowering experience', and that such groups could provide people with the support they might not get from other people.

Health-care workers deserve special attention: the review also had a special section on the effects of quarantine on healthcare workers. The review pointed out that such staff 'might be concerned about causing their workplaces to be understaffed and causing extra work for their colleagues' and also that 'their colleagues’ perceptions could be particularly important'. Therefore, they state that 'it is essential that they feel supported by their immediate colleagues' (and also their managers). They state that 'organisational support has been found to be protective of mental health for healthcare staff in general and managers should take steps to ensure their staff members are supportive of their colleagues who are quarantined'.

Conclusion: Overall, this review suggests that 'the psychological impact of quarantine is wide­ranging, substantial, and can be long lasting'. If quarantine is necessary then 'officials should take every measure to ensure that this experience is as tolerable as possible for people'. 

According to the authors of this review, we should be: 

• telling people in quarantine what is happening and why, and how long it will last
• providing meaningful activities for them to do and clear communication while in quarantine 
• ensuring basic supplies (e.g. food, water, and medical supplies) are available, and 
• reinforcing the sense of altruism that people should, rightly, be feeling.

I was glad the author's identified that final point: that powerful 'sense of altruism' is and will be (and in fact always has been) the societal glue that gets us through our most difficult times. It is something that can't be quantified (there aren't any 'units' of human goodwill) but we know it when we see it, and we know just how vital it is to all our general well-being. Keep well and keep safe!