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

Duration of quarantine

Three studies showed that longer durations of quarantine were associated with poorer mental health specifically, post-traumatic stress symptoms,16, 25 avoidance behaviours, and anger.²⁰ Although the duration of the quarantine was not always clear, one study¹⁶ showed that those quarantined for more than 10 days showed significantly higher post-traumatic stress symptoms than those quarantined for less than 10 days.

Fears of infection

Participants in eight studies reported fears about their own health or fears of infecting others9, 13, 14, 16, 17, 21, 25, 26 and were more likely to fear infecting family members than those not quarantined.⁹ They also became particularly worried if they experienced any physical symptoms potentially related to the infection¹⁴ and fear that the symptoms could reflect having the infection continued to be related to psychological outcomes several months later.¹⁷ Conversely, one study¹¹ found that although very few participants were extremely concerned about becoming infected or transmitting the virus to others, those who were concerned tended to be pregnant women and those with young children.

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.10, 11, 13, 14, 15, 16, 25, 26, 31 This frustration was exacerbated by not being able to take part in usual day-to-day activities, such as shopping for basic necessities¹⁶ or taking part in social networking activities via the telephone or internet.¹⁷

Inadequate supplies

Having inadequate basic supplies (eg, food, water, clothes, or accommodation) during quarantine was a source of frustration10, 31 and continued to be associated with anxiety and anger 4–6 months after release.¹⁷ Being unable to get regular medical care and prescriptions also appeared to be a problem for some participants.¹⁰

Four studies found that supplies from public health authorities were insufficient. Participants reported receiving their masks and thermometers late or not at all;¹³food, water, and other items were only intermittently distributed;²⁴ and food supplies took a long time to arrive.¹² Although those quarantined during the Toronto SARS outbreak praised public health authorities for delivering kits of medical supplies at the beginning of the quarantine period, they did not receive groceries or other routine supplies needed for daily living.¹⁵

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.11, 12, 13, 15, 24, 26 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.¹⁵ Lack of clarity about the different levels of risk, in particular, led to participants fearing the worst.¹⁴ Participants also reported a perceived lack of transparency from health and government officials about the severity of the pandemic.¹¹ Perhaps related to the lack of clear guidelines or rationale, perceived difficulty with complying with quarantine protocols was a significant predictor of post-traumatic stress symptoms in one study.²⁵

Finances

Financial loss can be a problem during quarantine, with people unable to work and having to interrupt their professional activities with no advanced planning; the effects appear to be long lasting. In the reviewed studies, the financial loss as a result of quarantine created serious socioeconomic distress²⁴ and was found to be a risk factor for symptoms of psychological disorders²² and both anger and anxiety several months after quarantine.¹⁷ One study²⁸ found that respondents who were quarantined because of equine influenza, whose principal source of income was from a horse-related industry, were more than twice as likely to have high distress than those whose income was not from the industry. This finding is probably linked to economic effects but could also be related to disruption of social networks and loss of leisure activities. Notably, this study is exceptional in that occupation and exposure are confounded.

A study¹⁴ of people quarantined because of potential Ebola contact found that, although participants received financial assistance, some felt that the amount was insufficient and that it came too late; many felt wronged as the assistance they received did not cover their ongoing professional expenses. Many became dependent on their families to provide for them financially during quarantine which was often hard to accept and could cause conflicts. In one study,¹³ none of those quarantined in Toronto during SARS reported much financial hardship because employers or the government compensated them, but where that reimbursement was slow to arrive it caused those less financially well-off to struggle.

Potentially related to financial loss, participants with a combined annual household income of less than CAN$40 000 showed significantly higher amounts of post-traumatic stress and depressive symptoms.¹⁶ These symptoms are probably because those with lower incomes were more likely to be affected by the temporary loss of income than those with higher incomes.

People who are quarantined and have lower household incomes might require additional levels of support, along with those who lose earnings while in quarantine (ie, self-employed people who are unable to work or salaried staff who are unable to take paid leave). Financial reimbursements should be provided where possible and programmes developed to provide financial support throughout the quarantine period. Where appropriate, employers might also wish to consider proactive approaches that allow employees to work from home if they wish to, both to avoid financial loss and to stave off boredom, while being mindful that staff in these situations might not be at their most productive and might benefit more from remote social support from their colleagues.²

Stigma

Stigma from others was a major theme throughout the literature, often continuing for some time after quarantine, even after containment of the outbreak. In a comparison of health-care workers quarantined versus those not quarantined,⁹quarantined 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. Participants in several studies reported that others were treating them differently: avoiding them, withdrawing social invitations, treating them with fear and suspicion, and making critical comments.13, 14, 15, 16, 18, 21, 23, 24, 25, 26, 30, 31

Several health-care workers involved in the Ebola outbreak in Senegal reported that quarantine had led their families to consider their jobs to be too risky, creating intra-household tension.¹⁴ In the same study, three participants reported being unable to resume their jobs after surveillance ended because their employers expressed fear of contagion.

Those quarantined during the Ebola epidemic in Liberia reported that stigma could lead to disenfranchisement of minority groups in the community as families under quarantine were often said to belong to different ethnic groups, tribes, or religions and were perceived as dangerous because they were different.²⁴ Perhaps because of this stigma, being quarantined led participants in this study to keep easily treatable, non-Ebola illnesses a secret and avoided seeking help.

General education about the disease and the rationale for quarantine and public health information provided to the general public can be beneficial to reduce stigmatisation, whereas more detailed information targeted at schools and workplaces might also be useful. It might also be 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).³⁶This issue highlights the need for public health officials to provide rapid, clear messages delivered effectively for the entire affected population to promote accurate understanding of the situation.

Keep it as short as possible

Longer quarantine is associated with poorer psychological outcomes, perhaps unsurprisingly, as it stands to reason that the stressors reported by participants could have more of an effect the longer they were experienced for. Restricting the length of quarantine to what is scientifically reasonable given the known duration of incubation periods, and not adopting an overly precautionary approach to this, would minimise the effect on people. 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 exacerbate any sense of frustration or demoralisation.⁴⁰ 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.

Give people as much information as possible

People who are quarantined often feared being infected or infecting others. They also often have catastrophic appraisals of any physical symptoms experienced during the quarantine period. This fear is a common occurrence for people exposed to a worrying infectious disease,⁴¹ and might be exacerbated by the often inadequate information participants reported receiving from public health officials leaving them unclear of the nature of 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.

Provide adequate supplies

Officials also need to ensure that quarantined households have enough supplies for their basic needs and, importantly, these must be provided as rapidly as possible. Coordination for provision of supplies should ideally occur in advance, with conservation and reallocation plans established to ensure resources do not run out, which unfortunately has been reported.²

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. Having a working mobile phone is now a necessity, not a luxury, and those stepping off a long flight to enter quarantine will probably welcome a charger or adaptor more than anything else.¹⁷Activating your social network, albeit remotely, is not just a key priority, but an inability to do so is associated not just with immediate anxiety, but longer- term distress.2, 42 One study²¹ suggested that having a telephone support line, staffed by psychiatric nurses, set up specifically for those in quarantine could be effective in terms of providing them with a social network. The ability to communicate with one’s family and friends is also essential. Particularly, social media could play an important part in communication with those far away, allowing people who are quarantined to update their loved ones about their situation and reassure them that they are well. Therefore, providing those quarantined with mobile phones, cords and outlets for charging devices, and robust WiFi networks with internet access to allow them to communicate directly with loved ones could reduce feelings of isolation, stress, and panic.² Although this is possible to achieve in enforced quarantine, it could be more difficult to do in the case of widespread home quarantine; countries imposing censors on social media and messaging applications could also present difficulties in ensuring lines of communication between those quarantined and their loved ones.

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. A phone line or online service specifically set up for those in quarantine and staffed 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. The benefits of such a resource have not been studied, but it is likely that reassurance could subsequently decrease feelings such as fear, worry, and anger.

There is evidence to suggest that support groups specifically for people who were quarantined at home during disease outbreaks can be helpful. One study²³ 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 can provide people with the support they might find they are not receiving from other people.

Health-care workers deserve special attention

Health-care workers themselves are often quarantined and this Review suggests they, like the general public, are negatively affected by stigmatising attitudes from others. None of the studies included in this Review focused on the perceptions of their colleagues, but this would be an interesting aspect to explore. It is also possible that health-care workers who are quarantined might be concerned about causing their workplaces to be understaffed and causing extra work for their colleagues²¹ and that their colleagues’ perceptions could be particularly important. Being separated from a team they are used to working in close contact with might add to feelings of isolation for health-care workers who are quarantined. Therefore, it is essential that they feel supported by their immediate colleagues. During infectious disease outbreaks, organisational support has been found to be protective of mental health for health-care staff in general³⁹ and managers should take steps to ensure their staff members are supportive of their colleagues who are quarantined.

Altruism is better than compulsion

Perhaps because of the difficulties of designing an appropriate study, no research was found which tested whether mandatory versus voluntary quarantine has a differential effect on wellbeing. In other contexts, however, feeling that others will benefit from one’s situation can make stressful situations easier to bear and it seems likely that this is also true for home-based quarantine. Reinforcing 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), and that health authorities are genuinely grateful to them, can only help to reduce the mental health effect and adherence in those quarantined.19, 33 Notably, altruism has its limits if people are being asked to quarantine without adequate information on how to keep the people they live with safe. It is unacceptable to ask people to self-quarantine for the benefit of the community’s health, when while doing so they might be putting their loved ones at risk.