Maintaining mental well-being must be a focus during quarantine

As the novel coronavirus continues to spread rapidly across the world, countries worldwide have imposed entry restrictions and travel bans to curb the spread of the infectious disease. This includes quarantine requirements for people who have potentially been exposed to COVID-19 due to overseas travel or who have come into contact with a person diagnosed with COVID-19. People affected may be asked to isolate themselves at home or stay in a dedicated quarantine facility for the duration of the quarantine period. Regardless of the conditions and circumstances under which people find themselves quarantined or isolated, it tends to be an unpleasant experience that involves the separation from loved ones and the loss of freedom. A rapid review by Lancet of the evidence on the psychological impact of being quarantined reported negative psychological effects, including post-traumatic stress symptoms, confusion and anger. Factors that contributed to heightened stress during and following the quarantine include a longer or extended duration of quarantine, fears about becoming infected or infecting others, frustration, and boredom due to reduced social and physical contact, plus inadequate basic supplies, insufficient clear information, financial hardship, and stigma.

The review included 24 studies, of which 11 were related to the outbreak of SARS in 2003. A study in Taiwan found having been quarantined was the factor most predictive of symptoms of acute stress disorder in hospital employees. Another study on the mainland reported a positive association between quarantine and alcohol abuse or dependency symptoms. Moreover, being quarantined was a predictor of post-traumatic stress symptoms even after three years. A study of healthcare workers in Canada found being quarantined was significantly and positively associated with avoidance behavior, such as minimizing direct contact with patients and not reporting to work. Another study in Canada found that healthcare workers who had been quarantined displayed more severe symptoms of post-traumatic stress than members of the general public who had been quarantined. Healthcare workers also reported greater stigmatization and substantially more anger, annoyance, fear, frustration, guilt, helplessness, isolation, loneliness, nervousness, sadness and worry. They were more likely to think they had SARS and were concerned about infecting others. The negative psychological impact of quarantine is not limited, however, to the healthcare profession.

The psychological impact of quarantine can be wide-ranging and long-lasting, and it can also have a spillover effect upon other vulnerable populations such as older adults. A study of the impact of SARS in Hong Kong found that social disengagement, mental stress and anxiety at the time of the SARS epidemic resulted in an exceptionally high rate of suicide among older adults. These suicides were motivated by stress over fears of being a burden to their families during the epidemic, as well as fears of contracting the disease and fears of disconnection. Elderly people avoided being admitted or visiting a hospital during that period because quarantine policies in hospitals prohibited them from family visits. Even without being quarantined, reduced social contact during this period led to increased isolation and loneliness for the older adults who were visited less often by their family and friends, and they themselves were discouraged from leaving their place of residence.

The studies in the review suggest that a longer quarantine is associated with poorer psychological outcomes. The period of quarantine should be limited to what is scientifically reasonable given the known duration of incubation periods. For COVID-19, the estimates range from one to 14 days. Any extension to the quarantine period is discouraged unless absolutely necessary.

People with lower household incomes may experience financial hardship, while some may lose their earnings during the quarantine period and require financial assistance. The government can look into setting up assistance programs to provide financial support to those in need. Employers should also be encouraged to allow employees to work from home wherever possible.

Stigma is a major problem, especially for healthcare workers and occupants inhabiting an outbreak site. The government and media can help to educate the public by disseminating accurate information about the disease. The media should refrain from alarmist and fearmongering headlines that amplify the stigma and panic.

Having inadequate basic supplies needed for daily living is associated with frustration, anxiety and anger. If the procuring of household and food supplies in advance of quarantine is not possible, the government should ensure that quarantined households have enough supplies and provide timely assistance to those who need help acquiring those supplies.

It is important that people understand the rationale, conditions and requirements of a quarantine, including the consequences of breaching it. Given the rapidly evolving situation, people who are under quarantine should be informed of the latest updates to the local situation and those regarding their health status. Confusion can stem from poor coordination between different departments, so it is important to maintain clear lines of communication with people in quarantine; for example, a dedicated phone and online service to support people under quarantine can help reassure and improve communication. Confinement and reduced social contact, and not being able to take part in social activities can lead to boredom and frustration, which might be distressing for some people. In today’s society, mobile devices with reliable Wi-Fi and internet access have become a necessity. People who are quarantined at their own homes are likely to have existing access to their devices and the internet, but this may be more difficult for those who are quarantined outside their homes. Providing them with chargers and Wi-Fi access may help reduce their boredom and frustration.

It is crucial that we do not forget the mental well-being of the community, in particular healthcare workers, older adults and other vulnerable populations. With the government encouraging people to practice social distancing, it is important to reassure the elderly that even if physical contact is reduced, there are alternative means for them to maintain social contacts. Equally important is building greater community networks and resources to connect with these vulnerable members and the provision of outreach medical services. With the available evidence we have, it is hoped that we can make the quarantine experience less stressful for those involved. Ultimately, the aim of quarantine is to help reduce the risk of spreading the infection to others, and by adhering to it, people under quarantine are helping to keep others safe.

If we have learned anything from the pandemic, it is that the world and the people living in it are intertwined, and the way we act and behave has repercussions for everyone else. We should take care of our own health but not let our fears and self-interests get the better of us. Even when we find ourselves in circumstances not of our own making, we still have the choice to do good and be kind. In the face of the pandemic, each person can make a huge difference if we do our part to slow the spread. Fear, anxiety and panic in the midst of any epidemic are not uncommon. The important thing is to be able to receive accurate information and try to be a gatekeeper to one another. Sharing is caring. If we have an additional mask, give it to someone who needs to line up for it.

Paul Yip is the founding director of the Centre for Suicide Research and Prevention at the University of Hong Kong. Yulin Cheng is a doctorate student at the Social Work and Social Administration Department of HKU. The views do not necessarily reflect those of China Daily.