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 Table of Contents  
INVITED REVIEW
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 112-119

Social and psychological consequences of “Quarantine”: A systematic review and application to India


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Submission28-Jul-2020
Date of Acceptance28-Jul-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_241_20

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  Abstract 


Background: Quarantine has been used as a public health measure to contain the spread of communicable diseases. Its use in the current COVID-19 pandemic is based on experience from the past while handling other coronavirus infections. Objectives: The aim of this study is to synthesize the available literature focusing on the psychological and social consequences of quarantine. Materials and Methods: PubMed search for original research articles published in peer-reviewed journals in the English language was done. Studies focusing on psychological or social impact on quarantine were included. In view of the current pandemic being caused by coronavirus, studies were limited to the outbreak causing coronavirus diseases. Results: Psychological problems most commonly reported were anxiety, depression, acute, and posttraumatic stress disorder. Various other emotional problems, loneliness, anger, frustration, and psychosomatic problems were also reported. Quarantined individuals experience stigma and isolation. The literature on the purpose of quarantine, and referral pathways to obtain help and care seemed lacking. Literature from India and other low- and middle-income countries was scarce. Conclusion: There is a need to address the psychosocial issues emerging from the experience of quarantine. Mental health workers can play an important role in managing them, but it would require collaboration and good organizational support. More studies from developing countries can be planned in future.

Keywords: COVID-19, Middle East Respiratory Syndrome, psychological, quarantine, severe acute respiratory syndrome, social


How to cite this article:
Sharan P, Rajhans P. Social and psychological consequences of “Quarantine”: A systematic review and application to India. Indian J Soc Psychiatry 2020;36, Suppl S1:112-9

How to cite this URL:
Sharan P, Rajhans P. Social and psychological consequences of “Quarantine”: A systematic review and application to India. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 31];36, Suppl S1:112-9. Available from: https://www.indjsp.org/text.asp?2020/36/5/112/297143




  Introduction Top


The world today is facing a global health crisis. In December 2019, the Wuhan city of China witnessed the initial outbreak of COVID-19 disease. The outbreak was declared a public health emergency of international concern in January 2020, and a pandemic in March 2020, by the World Health Organization.[1] Preventive measures such as frequent hand washing, maintaining good cough hygiene practices, and physical distancing have been stressed upon.[2] The government of India responded to the pandemic by announcing a nationwide lockdown, which was implemented in four phases extending from March 25 to May 31, 2020. Currently, the country is in the Unlock phase extending from June 1, 2020 to July 31, 2020, where restrictions are being lifted in a graded manner, and re-initiation of activities outside the containment zones in phased manner has begun.[3] The pandemic has significantly impacted the mental health of people, as well as of those working at the front line, like health-care workers.[4],[5]

Coronaviruses are a large family of viruses, which cause respiratory and intestinal infections in humans and animals.[6] Illness caused in humans can range from mild flu-like symptoms to deadly outbreaks, including severe acute respiratory syndrome (SARS, 2002-2003) and middle east respiratory syndrome (MERS, 2012).[7] The strategy of quarantine is centuries old, and with the continuous re-emergence of infectious diseases, it has emerged as a powerful public health response. Quarantine measures focus on restricting movements and separating people, potentially exposed to a contagious disease, to ensure that the risk of these people infecting others gets reduced.[8] The strategy is beneficial for containing the infection, but the benefits need to be weighed against the impact it has on the psychological and social well-being of individuals. It leads to negative psychological impact, including anger and post-traumatic stress symptoms, and thus, adequate support and care need to be provided.[9] Looking at the other side of it, if strict quarantine measures are not followed, and infection is allowed to spread, people may feel stressed.

This review was planned with the objective of evaluating the available literature on the social and psychological impact of quarantine. This public health measure has been previously used in a wide range of communicable diseases, including plague, measles, and Ebola virus disease.[9],[10] To restrict our focus on diseases with a similar causative agent, we have reviewed the available literature on coronavirus disease outbreaks.


  Materials and Methods Top


Search strategy

The search strategy for this review was designed, and an electronic search for published literature was done using PubMed. Search items used were related to psychosocial impact (”psych*” OR “anxiety” OR “depression” OR “emotion” OR “substance abuse” OR “alcohol” OR “tobacco” OR “social stigma”), quarantine (”quarantine” OR “social isolation”) and coronavirus infection (”SARS” OR “MERS” OR “COVID-19”). The search items were used in combinations (”psych*” OR “anxiety” OR “depression” OR “emotion” OR “substance abuse” OR “alcohol” OR “tobacco” OR “social stigma”), quarantine (”quarantine” OR “social isolation”) AND (”quarantine” OR “social isolation”) AND (”SARS” OR “MERS” OR “COVID-19”).

Study selection

Studies were included using the following selection criteria.

Inclusion criteria for selecting studies for this review:

  • Studies that assess the psychological and/or social impact (including problems such as anxiety, depression, substance use, emotional problems or social stigma) of quarantine due to any outbreak causing coronavirus disease including SARS, MERS, and COVID-19
  • Primary research studies, published in the English language and in peer-reviewed journals from November 2002 to June 6, 2020, were included.


Exclusion criteria:

  • Studies evaluating the psychological or social impact of lockdown or isolation (separation of sick infected people from others)[8]
  • Studies that included coronavirus infected patients as participants
  • Studies assessing the psychological or social impact of other communicable diseases requiring quarantine such as Plague, H1N1 influenza, or Ebola virus disease
  • Studies that evaluate outcomes other than psychosocial issues like quality of life
  • Case studies, opinion papers, editorials and review articles.


The initial search yielded 131 papers. Four additional studies were obtained from references of included studies. Of these 117 were full-text articles and 107 were in the English language. Titles and abstracts of all the selected articles were screened. A total of 107 titles and abstracts were screened, of which 73 were excluded as they did not meet the selection criteria. Out of the 34 full-text articles screened, 13 were further excluded because psychological parameters were not assessed (n = 7), quarantine was not actually implemented (n = 5) and the articles were not primary research articles (n = 2). [Figure 1] shows the screening process. Finally, a total of 20 articles were selected for the current review.
Figure 1: Screening process

Click here to view



  Results Top


Thirteen studies were focused on SARS outbreak, 4 on MERS and 3 on COVID-19. Details of studies are provided in [Table 1].
Table 1: Studies included in the systematic review

Click here to view


Only one study was conducted in India (on children and adolescents).[25] Participants in the majority of the studies were country residents or health-care workers. Two studies included patients on hemodialysis as participants, who were quarantined after a patient or staff working in the hospital became positive for MERS.[14],[18] Some studies did not specify the exact quarantine duration.[12],[19],[21],[22],[24],[29],[30] The quarantine period ranged from a minimum of 2 days to a maximum of 1 month.[16],[18],[25] Participants were either home or hospital quarantined. Some studies also assessed the factors which contributed to the development of psychosocial issues in quarantined participants. Some of these factors have been mentioned, but have not been fully covered as it was not part of the objective of the current review. One is directed to another recent review, which specifies the various factors contributing to psychological distress.[9] Three studies compared quarantined participants with those who did not experience quarantine.[21],[27],[29]

Psychological and social impact of quarantine

The qualitative studies were conducted to identify the common themes based on experiences of quarantined individuals.[13],[19],[23],[26],[30]

Adaptation issues and stigma

Emotional difficulties and difficulty in communicating with family members were reported by the majority of the participants in a telephonic survey.[12] In a descriptive study conducted to study the impact of quarantine on residents of Toronto, Canada, after the SARS outbreak, 21 residents were interviewed using a semi-structured interview.[16] All of them described four sequential stages in their narrative. Life prior to quarantine, getting to know about it, experiencing it and life post quarantine. Uncertainty (fear of health of self or loved ones, unpredictable course of the disease and its impact on daily life), isolation (feeling stigmatized, separated, lonely and bored) and coping (support from others and self-reliance) were the three sub-themes described by participants that intersected the data.[13] Psychological difficulties experienced by people quarantined during MERS outbreak was assessed in another study.[27] The two key questions asked were about feeling depressed/hopeless or losing interest in life. Around 19.3% of the people reported of feeling depressed and having other emotional problems, and about 350 participants required continued services.[27] In another study, around 50% of the participants attributed their symptoms to strict quarantine. Shorter quarantine period predicted lesser avoidance behaviour (β = 0.23, P < 0.001) and lesser anger (β = 0.14, P < 0.008) but did not predict emotional distress.[11]

In Hong Kong, residents reported feeling stigmatized in various forms like being rejected, marginalized, or insulted in various domains of their life's including occupational and social functioning.[24] Psychological distress due to stigma was noted with respondents reporting high levels of irritability, sleep problems, and somatic complaints like chest pain.[24]

HCW reported a constant conflict between their professional, altruistic roles and the negative emotions associated with the risk of them transmitting the infection to family members.[11] They felt stigmatized, which highlights the need of providing them with stress management and coping strategies by experts.[15]

A study, which assessed both residents and HCW using qualitative methods found that stigmatization and social distancing were major contributors for perceived psychological distress experienced in the form of emotional problems including fear, sense of isolation, depression, anxiety, and boredom.[13] Five percent of the HCW thought of violating quarantine measures due to increased stress levels. Among the other HCW, 34% were “pretty stressed” but were not tempted to violate quarantine measures, and 11% were not stressed at all. The remaining reported psychological discomfort but were not overtly stressed. The presence of other members in the same household added to the stress. Coping measures reported by HCW were reading, watching television, and connecting with near and dear ones. The residents from the population survey reported of experiencing stigmatization, such that they avoided social events and gatherings.[13]

In the only study conducted in India, 121 children and adolescents in the age group of 9–18 years, placed in either home (30.57%) or community facility (77.68%) quarantine along with their parents formed the study group and about 131 children and adolescents from the neighborhood with same family background, who did not experience quarantine formed the comparison group.[25] Most of the participants did not comply with strict quarantine measures advised and the inability to go out to meet friends was the most common difficulty reported by majority (65.26%). Greater psychological distress was reported by quarantined participants with feelings of helplessness (66.11%), worry (68.59%), and fear (61.98%) being the most common.[25]

Impact of event

Most studies on quarantine have used the IES-R to measure traumatic stress. It is a self-report instrument and consists of 22 items, yielding a maximum score of 88. It has three subscale domains (intrusion, hyperarousal, and avoidance). Many studies have reported significant psychological distress in participants who were quarantined.[14],[16],[18],[25],[28]

In a study with the majority of HCW respondents (68%), with a median quarantine period of 10 days and 90% experiencing quarantine only once, mean IES-R scores were 15.2 (±17.8).[14] About 29% of the participants had an IES-R score greater than the cutoff of 20. However, no significant difference was noted between those in the home and work quarantine. HCW were more compliant with the quarantine measures.[14] Another study on HCW who experienced quarantine showed high total IES scores and avoidance dimension scores.[23] Quarantine experience was significantly associated with IES avoidance (Z = −2.674, P = 0.008), arousal (Z = −1.826, P = 0.068) and total IES scores (Z = −2.033, P = 0.042). The relationship between quarantine and IES score remained statistically significant in multivariate analysis (β = −4.958, standard error [SE] = 2.149, t = −2.308, P = 0.021).[23]

A study on hospital employees who were exposed to SARS in 2003 but were recruited in 2006,[20] showed that ten percent of employees had experienced post-traumatic symptoms at some point in the past 3 years with an IES-R score >20. A strong association was found between any quarantine and PTS symptoms with adjusted odds ratio (AOR) being (2.09 [1.00–4.37], P < 0.05).[29] Participants quarantined for longer durations had greater mean IES-R scores, and the most common symptoms reported were anxiety, boredom, and anger.[14] Regression analysis showed that HCW status (β = 3.38, P = 0.002) and duration of quarantine (β = 0.40, P = 0.012) contributed to greater IES-R scores.[18]

The impact of quarantine was not restricted to HCW but affected the common people and patients with comorbidities as well.[14],[18],[25] A study in Canada recruited more than a thousand participants, who reported that they had experienced a quarantine period ranging from 2 to 30 days (median of 8.3 days) and were found to have a mean IES score of 8.9 (standard deviation 13.7).[18] Approximately 15% of the participants scored at least 20 on IES-R. Boredom (62.2%, n = 638, 95% confidence interval [CI] 59.2–65.2), isolation (60.6%, n = 622, 95% CI 57.6–63.6), and frustration (58.5%, n = 600, 95% CI 55.5–61.5) were the common feelings reported by participants.

Two studies assessed psychological distress in patients with prior comorbid kidney problems, undergoing hemodialysis when MERS outbreak occurred.[14],[18] One of the studies used IES-R-K to assess posttraumatic stress symptoms 12 months after the experience. In total, 17.9% of participants (n = 12) reported posttraumatic stress symptoms exceeding the IES-R-K's cutoff point (≥18). Quarantine duration was linearly associated with the IES-R-K score (standardized β coefficient= −0.272, P = 0.026). Scores in Avoidance, Emotional numbing and Dissociation subscale were higher in patients with longer isolation period.[29] In the other study conducted at the artificial kidney unit, university hospital at Gangdong, total IES-R scores were higher in HCW (T = 3.894, P < 0.001) who performed MERS task when outbreak occurred.[28] The staff had greater risk for posttraumatic stress disorder (PTSD) symptoms, and the sleep and numbness sub-scores were higher in HCW who were sent on home quarantine as compared to those who were not. Thus, the risk continued to rise even after the home quarantine.[28]

Stress reactions questionnaire was used to study the impact of quarantine due to the SARS outbreak in Taiwan.[30] The questionnaire was based on acute stress disorder criteria of DSM IV. Five percent of the staff out of 338 surveyed met the acute stress disorder criteria, and the most common factor related to it was being quarantined (β = 1.405, standard error [SE] = 0.647, OR = 4.077, 95% [CI] = 1.148–14.48) on multiple logistic regression.[30]

Psychological distress, depression, and anxiety

Various tools have been used to study distress due to quarantine, for example, CES-D, a self-report, 20-item questionnaire was used to screen for depressive symptoms.[16],[21] State anger was assessed using STAXI-2, and the emotional exhaustion subscale of MBI-GS was used to assess emotional exhaustion.[17],[22] Self-rated, 20-item, screener SAS, was used in conjunction with self-rated 20-item SDS to discriminate anxiety from mood disorders in one study.[22] GHQ-30 was used to identify participants with psychological distress.[19]

A study utilizing GHQ-30 was conducted on 187 printing company workers after 7–8 months of the end of the SARS outbreak (in the recovery period).[19] Around 25% of respondents reported a score of >7 (suggesting psychological distress) during the quarantine period and about 26% also reported a score of >7 during the recovery period. Suggesting that for some, psychological distress improved in the recovery period, whereas in some new symptoms developed. About 16.6% (95% CI, 14.8%–18.4%) of the quarantined residents expressed feelings of anger on STAXI-2 and even after 4–6 months post quarantine, feelings of anger were still present in 6.4% of respondents (95% CI, 5.2%–7.6%).[26]

In a study on hospital employees in China, three groups were formed based on CES-D scores.[21] About 8.8% of respondents had a score >25, indicative of greater depressive symptoms. The high CES-D score group had a greater percentage of quarantined individuals (60%) as compared to the low score group (~15%). When other factors were controlled for, being in quarantine was associated with higher odds of having a greater level of symptoms of depression (AOR) of 4.90 (95% CI, 2.19–10.99; P = 0.0001) on multinomial logistic regression analysis even after 3 years. Greater symptom level for PTSD was significantly associated with greater symptom level of depression (AOR, 7.40; 95% CI, 2.83–19.36; P < 0.0001).[21] Quarantine negatively impacted the psychological well-being with mean CES-D scores being (13.0 ± 11.6) and about 31% of participants having a CES-D score > 16.[14] In the study on nurses, a significant positive correlation was found between emotional exhaustion and duration of quarantine, anger, and avoidance behavior.[17]

A study compared participants who had experienced quarantine themselves and an unaffected group (whose friends/family member/neighbor/colleagues had experienced quarantine).[22] Anxiety (8.3%) and depression (14.6%) were prevalent in the entire sample. The prevalence rates of anxiety and depression (12.9%, 22.4%) was higher in the affected group as compared to the unaffected group (6.7%, 11.9%). Certain factors, like poor psychological support and frequent worries about acquiring the infection contributed to increased anxiety and depression.

GAD-7, a self-administered test, was used to assess participants for generalized anxiety disorder in a study conducted at South Korea. About 7.6% (95% CI, 6.3%–8.9%) of the residents showed anxiety symptoms on GAD-7, which persisted in about 3.0% (95% CI, 2.2%–3.9%) of the residents even after 4–6 months of quarantine.[26]

Diagnoses

A study conducted during MERS outbreak developed a short, self-rated Korean version of MINI to screen for anxiety and depressive disorders. Depression and generalized anxiety disorder were reported, but the adjustment improved as the duration of hospital quarantine increased, probably because those admitted received more care and help from psychiatrists.[28]


  Discussion Top


This systematic review evaluates the psychological and social impact of quarantine. Emergence and re-emergence of infectious and communicable diseases have become global health problems, imposing challenges on the world in dealing with them. As these recurrences continue to occur, the public health sector has developed strategies such as isolation, quarantine, and contact tracing to control its spread. Undoubtedly, these measures are required for effective infection control and prevention of transmission and spread in the community. However quarantine can be taxing in terms of the psychological and social impact. It is, therefore, essential that the risks and benefits of the process are explored systematically to help prepare for eventualities.

Many studies conducted focused group discussions, surveys, semi-structured and structured interviews to identify common themes that emerged from conversations with those who experienced quarantine. The residents reported emotional difficulties such as feeling anxious, irritable, and depressed.[12],[15],[19],[30] Lack of proper communication, frustration, fear, boredom, sleep difficulties, somatic complaints, feeling helpless, and worried were the other common themes that emerged.[12],[15],[19],[23],[27] Some studies suggested that distress may be related to lack of adequate knowledge about disease,[12] and inconsistency in the case definitions (e.g., “suspect cases,” “probable cases”).[13] The study from India reported significantly greater psychological distress in the quarantined group as compared to the other group.[25]

HCW experienced more frustration, anger, and fear.[23],[26] Additional problems reported by HCW were the unpredictable nature of the disease, not being provided with adequate knowledge and a strict working schedule.[20] The most common fear the HCW reported was that of infecting others in the family and close friends.[30] The findings are consistent with that of a recent review, which assessed for the psychological impact of quarantine.[9]

Stigma and a sense of feeling isolated were seen in both residents as well as HCW.[13],[15],[19],[26] Stigma negatively impacts various domains of functioning, including academic, occupational, and social life leading to loss of social relationships.[24] Return to normalcy was delayed, and participants felt stigmatized and depressed even after the quarantine was over.[13],[20]

Greater psychological distress in quarantined participants was evident on quantitative assessment as well, with most of the studies reporting greater IES-R scores for those experiencing quarantine.[14],[16],[18],[25],[28],[29] HCW also reported stress symptoms, but an altruistic approach toward work helped the staff in dealing with these psychological symptoms.[20] HCW who performed tasks during acute stages of the infection were prone to develop PTSD symptoms that persisted.[18],[25] Longer duration of quarantine had a greater impact on psychosocial adjustment.[16],[25] The risk of developing PTSD was also found to be high in patients with comorbid kidney problems who were on dialysis and got exposed to MERS during the hospital stay.[28] A study reported the presence of acute stress disorder.[11],[16],[29]

The five studies which used different screening tools to assess psychological impact found that quarantined participants experience more anxiety, depression, anger, and emotional exhaustion.[17],[20],[21],[22],[24] Very few studies used structured diagnostic interviews.

Results of this review are consistent with studies conducted to assess the psychological impact of quarantine for other communicable diseases like Plague, Ebola, and H1N1 Influenza.[9] Those involved in direct management of infected cases exhibited higher levels of stress, anxiety, and sleep difficulties.[30]

Common limitations of the studies were selection bias due to the voluntary nature of surveys and variability in time of assessment and the duration of quarantine across studies.[11],[12],[13],[18] Studies using a retrospective design would have recall bias as a limitation along with a lack of assessment of relevant psychological and medical problems that could have contributed to stress due to quarantine.[14],[19] While some studies used validated scales for assessment, confirmatory diagnosis making requires the use of structured diagnostic interviews.[14] Lack of generalizability of findings and the possibility of the presence of preexisting psychiatric issues were also not reported.[18],[29]

Research from India on the psychosocial impact of quarantine is limited. Experience from other countries that have faced and addressed the emerging psychosocial issues of quarantine can be capitalized, and further knowledge needs to be built up. In India, there is a diversity of communities and disparity in the educational and socioeconomic status across the country. This makes the implementation of public health measures like quarantine a challenging task. To add to the complexity is the finite nature of resources and the different types of problems faced by people in different sections of the society. Its imperative to address the concerns of people and provide them with adequate and evidence-based knowledge. Knowledge about the modes of transmission, nature of disease, effective preventive measures, and absence of a definite curative treatment can be provided in simple language.[9] It is equally important to make people aware about the purpose of quarantine as it helps in reducing unnecessary anxiety and in improving adherence. Addressing the issues of job loss and income loss can also help in reducing stress. Assurance and information about steps being taken by the government should also be easily accessible and available to people living even in remote areas of the country. There should be an effective collaboration between the hospitals, government, and public health, media, and communities at stake, with better team cohesion resulting from effective leadership.[11] Further studies can be planned to address these issues, keeping the socio-economic and cultural disparities prevailing in the country in mind.

Quarantine significantly impacts the psychosocial well-being of an individual, and so adequate support, needs to be provided to people to help them deal with it. People can be made aware of such problems arising as a consequence of quarantine and when they need to seek help. Mental health and psychosocial support should be made available and easily accessible. Telepsychiatry can be used in these times of crisis, when compliance with strict quarantine measures may lead to immobility.[31] Frontline workers often encounter additional psychological problems and are often subjected to discrimination and stigmatization. Adequate support needs to be provided to them as well. People and HCW also need to be informed about the available referral pathways.[32] Training on improving coping strategies and techniques to handle stress are warranted.

In the current review, we did not come across studies on the impact of quarantine on people with problematic use of alcohol and drugs. Supplies may get affected during quarantine and can lead to withdrawals and occasional overdose.[33] Also, there were very few studies on the psychosocial impact of quarantine on children. Separation from parents and lack of companionship can be traumatic and can lead to a plethora of psychological problems.[34] Further studies can be planned to address these issues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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