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The Psychological Impact of Quarantine

The Psychological Impact of Quarantine



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People separated from loved ones and work due to potential illness report negative psychological impact even 3 years later.

Quarantine is the removal from contact with the general population of a person who may have been exposed to an infectious disease like the coronavirus. When people who actually have the disease are separated it is called isolation.

A study published this week in The Lancet summarizes a number of research reports which investigated populations who were quarantined. For many, it was a bad experience with mental health impact lasting long after the quarantine ended.

In the 3-year period following quarantine, incidence of PTSD in the quarantined population was 4 times that of people who were not affected. As many as 60% of those who experienced quarantine reported symptoms of depression.

Only 5% of those impacted remember a positive experience when quarantined.

The isolation and boredom of the experience led to increased rates of fear and anxiety. Quarantines that approached or exceeded 10 days were the most damaging.

For people in quarantine an extension of the quarantine period, no matter how long, exacerbated any sense of frustration or demoralization.

Ironically, two of the key negative impacts of quarantine were the inability to receive proper medical care and the inability to refill prescription medication.

Inability to acquire basic supplies such as food and water, and poor information from authorities also drove high rates of psychological distress among those surveyed.

While many individuals suspected of being exposed to a pathogen were negatively impacted, the most serious psychological effects of quarantine were found in healthcare workers removed from their jobs due to exposure.

While many negative factors were experienced during the quarantine period, the most significant negative experiences occurred following the quarantine period.

Loss of income led many into severe financial stress. Also, a stigma against those who were removed from the population was attached to people as they returned from quarantine.

Healthcare workers who were quarantined faced increased absenteeism, substance abuse and high levels of anxiety about contact with patients. Job satisfaction plummeted.

More positive experiences with quarantine were reported when the quarantine period was clearly stated and limited to the incubation period of the disease.

Complete and timely communication from health officials about the reasons for the quarantine and its likely outcome were crucial. And of course, availability of supplies and the ability to communicate with loved ones significantly determined feelings of well-being.

Altruism is powerful, and when quarantine was positioned as positive with broad societal impact, individuals fared better. The best outcome was reported by healthcare workers who were given the option to enter quarantine voluntarily.

As quarantines are enforced as we face the coronavirus, people should be carefully and positively told what is happening and why, and how long the quarantine will last. They should be provided with meaningful activities and given clear and unlimited lines of communication with their families. And of course, basic supplies should be arranged for.

We should also consider financial assistance for those who have to sacrifice so the disease does not spread, especially the healthcare workers who will have to quickly and without prejudice return to work and lend their skills to the job of defeating the virus.

George Hofmann’s book Resilience: Handling Anxiety in a Time for Crisis is available now. To help independent bookstores working to stay open during the shutdown find the book here.

Psych Central has closed its blog network to new content. Find more atPracticing Mental Illness


What months of lockdown does to your body and brain


Psychological and Behavioral Impact of Lockdown and Quarantine Measures for COVID-19 Pandemic on Children, Adolescents and Caregivers: A Systematic Review and Meta-Analysis

Background: During the current ongoing COVID-19 pandemic, psychological problems like anxiety, depression, irritability, mood swings, inattention and sleep disturbance are fairly common among quarantined children in several studies. A systematic review of these publications to provide an accurate burden of these psychiatric/behavioral problems is needed for planning mitigating measures by the health authorities.

Methods: Different electronic databases (MEDLINE, EMBASE, Web of Science, CENTRAL, medRxiv and bioRxiv) were searched for articles describing psychological/behavioral complications in children/adolescents with/without pre-existing behavioral abnormalities and their caregivers related to the COVID-19 pandemic. Only original articles with/without comparator arms and a minimum sample size of 50 were included in the analysis. The pooled estimate of various psychological/behavioral problems was calculated using a random-effect meta-analysis.

Results: Fifteen studies describing 22 996 children/adolescents fulfilled the eligibility criteria from a total of 219 records. Overall, 34.5%, 41.7%, 42.3% and 30.8% of children were found to be suffering from anxiety, depression, irritability and inattention. Although the behavior/psychological state of a total of 79.4% of children was affected negatively by the pandemic and quarantine, at least 22.5% of children had a significant fear of COVID-19, and 35.2% and 21.3% of children had boredom and sleep disturbance. Similarly, 52.3% and 27.4% of caregivers developed anxiety and depression, respectively, while being in isolation with children.

Conclusion: Anxiety, depression, irritability, boredom, inattention and fear of COVID-19 are predominant new-onset psychological problems in children during the COVID-19 pandemic. Children with pre-existing behavioral problems like autism and attention deficit hyperactivity disorder have a high probability of worsening of their behavioral symptoms.

Keywords: COVID-19 SARS-CoV-2 behavioral problems child psychology neuropsychiatric features.


Introduction

The outbreak of the 2019 coronavirus disease (COVID-19) emerged in the city of Wuhan (China) in December 2019. Motivated by its rapid spreading, the World Health Organization (WHO) declared it a pandemic on March 11, 2020 (World Health Organization (WHO), 2020). Italy and Spain are two of the most affected countries worldwide, with, respectively, more than 29,000 and 25,000 reported deaths as of May 1 (European Centre for Disease Prevention and Control, 2020) since its spread. Spain has the world’s second-highest number of deaths in relation to the number of inhabitants, with 544 deaths per million inhabitants, followed by Italy, with 481 deaths per million inhabitants, as of May 5 (European Centre for Disease Prevention and Control, 2020). Following the Chinese government’s retarding the spread of COVID-19, quarantine was implemented in Italy and Spain, among other countries, starting on March 10 in Italy and 6 days later in Spain. School closure was mandatory, and gathering in public spaces, with certain exceptions, was prohibited. During school closures, children’s routines change, and healthy behaviors, such as physical activity, adequate diet, or good sleep habits, could be less probable to happen (Brazendale et al., 2017). Also, as a recent review of studies concludes, the limited social interaction increases loneliness, which is associated with mental health problems in children and adolescents (Loades et al., 2020). However, the effect of closing schools as a measure to decrease virus transmission is inconclusive. According to a systematic review of studies focused on other previous coronavirus outbreaks, school closure did not seem to have a very determining effect compared to other social distancing measures, and following some COVID-19 modeling studies, school closure may only reduce between 2 and 4% of deaths (Viner et al., 2020). Esposito and Principi (2020) highlighted alternative strategies, such as reducing class size or physical distancing, considering the adverse effects of school closure on children and their families (e.g., the economic consequences for parents who remain at home to take care of their children, or problems in implementing distance learning in the poorest areas of some countries). However, a recent study examining parents of Czechia children show that families tend to cope well with education at home during the COVID-19 confinement, although they consider that children would need more time for learning activities (Brom et al., 2020).

This is the first time that a quarantine to control a pandemic has been implemented in Italy and Spain, as well as in most countries worldwide. Therefore, there is a lack of conclusive studies providing data on how this measure can affect children and adolescents. Regarding the specific psychological consequences of COVID-19 and the measures to cope with them, few studies have been published. The psychological impact on the Chinese population after 2 weeks of quarantine was rated as moderate or brief by 53.8% of the 1,210 participants in a study with adults from 194 cities in China (Wang C. et al., 2020). Depression symptoms of moderate to severe severity were reported by 16.5% of participants, anxiety by 28.8%, and stress by 8.1%. The results of a study with 4,607 adults aged 17 to 90 years from 31 regions of China, however, reported slight changes in the frequency with which participants experienced negative and positive emotions before and after the COVID-19 imposed quarantine. Rather, some benefits were found, with reports of fewer sleep problems, fewer aggressive behaviors, and less alcohol and tobacco use during the quarantine. As the authors of the study point out, among other reasons, the quarantine was imposed just before the Chinese New Year holidays, when the majority of the population were at home with their families, thus having social support to reduce stress (Li et al., 2020). Concerning the specific stressors affecting the population during the quarantine, a review of 24 studies highlights as main stressors the duration of the quarantine, the fear of infection, frustration and boredom, and not having adequate information or clear guidelines from public authorities as main stressors after the quarantine, having financial problems and the stigma for people who were infected or exposed to the disease were reported (Brooks et al., 2020).

To date, no studies have examined how the quarantine declared due to COVID-19 may affect children’s and adolescents’ emotional or behavioral well-being within Western countries. Some previous studies suggest that the effects may be troublesome. In a recently published study, 23% of Chinese school-age children reported depressive symptoms, and 19% reported anxiety symptoms after 34 days of COVID-19 confinement (Xie et al., 2020). A review of 190 studies with an American population concluded that, compared to vacation periods and weekends, by being more structured, class days give children more opportunities to be physically active, spend less time in front of screens, and regulate their sleep schedules (Brazendale et al., 2017). Post-traumatic stress is estimated to be four times higher in children who have been in quarantine compared to those who have not, and their likelihood of presenting acute stress disorder, adjustment disorder, and grief is also higher (Sprang and Silman, 2013). Among the possible consequences of the COVID-19 emergency, a main concern is suicidal ideation, as stressful life events are considered a psychosocial risk factor for suicidality (Carballo et al., 2020). Some authors have reflected on the possible effects of the COVID-19 quarantine on children and adolescents. Wang G. et al. (2020) highlight the need for awareness of the quarantine’s potential effects on children’s mental health and the importance for governments, non-governmental organizations, the community, schools, and parents to act to reduce the possible effects of this situation. Special attention should be paid to children and adolescents who are separated from their caregivers who are infected or suspected of being infected and those whose caregivers are infected or have died, because they are more vulnerable to psychological problems (Liu et al., 2020). It is very important to identify childhood mental health problems as soon as possible, differentiating normal and pathological reactions through the use of screening tools that may indicate the need for intervention (Espada et al., 2020 Liu et al., 2020).

COVID-19 confinement changed the lives of most children and adolescents. Social relationships and academic routines were changed by virtual friends and distance learning leisure was restricted to indoors as public spaces were closed. Italy and Spain had one of the most restrictive home confinement rules, not allowing children to go outside until 3 and 6 weeks, respectively, after the start of confinement. Although confinement was necessary to break the pandemic, the interruption of all social contact and the prohibition from going outside home could have had immediate effects in children and adolescents. Controversy in both countries arose over whether confinement would affect children or whether they could adapt to the new situation without being emotionally affected. Knowing if confinement has effects on the well-being of children would help professionals to implement preventive measures and governments, less strict confinement rules. Despite that, so far, we have not found any study that examines the effect in children and adolescents of the quarantine imposed by COVID-19 within Western countries. The available studies have been carried out with adult populations—hence, the results cannot be extrapolated to child populations𠅊nd with Chinese populations, whose cultural differences with the West make it difficult to generalize their findings. This study is the first to determine the immediate psychological responses in children and adolescents of the West to the quarantine imposed to put an end to COVID-19. The main objective of the study is to examine the emotional well-being of Italian and Spanish children aged between 3 and 18 who are in quarantine as a measure imposed by governments to prevent the transmission of COVID-19. Specifically, the aim is to know: (a) the immediate psychological responses in children and adolescents during the quarantine perceived by parents, (b) the emotional impact of the quarantine on children’s primary caregivers, (c) the relationship between the parents’ emotional state and their children’s immediate psychological responses, (d) the change in childrens, habits, and (e) the relationship between the parents’ emotional state and the change in their children’s habits. According to the only study carried out to date to examine the immediate effects of COVID-19 in children (Xie et al., 2020), and to findings with adult samples (e.g., Wang C. et al., 2020), it is expected that confinement affects the well-being of Italian and Spanish children, as it affected the Chinese population.


COVID-19 and At-Risk Populations: Psychological and Social Impact of the Quarantine

Studies of pandemics faced over time, such as SARS, Ebola, H1N1, Equine Flu, and the current COVID-19, show that the psychological effects of contagion and quarantine is not limited on the fear of contracting the virus (Barbisch et al., 2015). There are some elements related to the pandemic that affect more the population, such as separation from loved ones, loss of freedom, uncertainty about the advancement of the disease, and the feeling of helplessness (Li and Wang, 2020 Cao et al., 2020). These aspects might lead to dramatic consequences (Weir, 2020), such as the rise of suicides (Kawohl and Nordt, 2020). Suicidal behaviors are often related to the feeling of anger associated with the stressful condition widely spread among people who lived/live in the most affected areas (Miles, 2014 Suicide Awareness Voices of Education, 2020 Mamun and Griffiths, 2020). In light of these consequences, a carefully evaluation of the potential benefits of the quarantine is needed, taking into account the high psychological costs (Day et al., 2006 Mazza et al., 2020).

As reported in a recent survey administered during the Covid-19 pandemic, children and young adults are particularly at risk of developing anxious symptoms (Orgilés et al., 2020). The research involved a sample of 1,143 parents of Italian and Spanish children (range 3�). In general, parents observed emotional and behavioral changes in their children during the quarantine: symptoms related to difficulty concentrating (76.6%), boredom (52%), irritability (39%), restlessness (38.8%), nervousness (38%), sense of loneliness (31.3%), uneasiness (30.4%), and worries (30.1%). From the comparison between the two groups—Spanish and Italian parents—it emerged that the Italian parents reported more symptoms in their children than the Spanish parents. Further data collected on a sample of college students at the time of the spread of the epidemic in China showed how anxiety levels in young adults are mediated by certain protective factors, such as living in urban areas, the economic stability of the family, and cohabitation with parents (Cao et al., 2020). On the contrary, having infected relatives or acquaintances leads to a worsening in anxiety symptoms. Furthermore, the economic problems and the slowdown in academic activities are related with anxious symptoms (Alvarez et al., 2020). In addition, an online survey conducted on the general population in China found that college students are more likely to experiencing stress, anxiety, and depression than others during the pandemic (Li et al., 2020). These results suggest monitoring and promoting mental health of youths in order to reduce the negative impact of the quarantine (CSTS, 2020 Fessell and Goleman, 2020 Li et al., 2020).

Health-care workers (HCWs) are another segment of population particularly affected by stress (Garcia-Castrillo et al., 2020 Lai et al., 2020). HCWs are at risk to develop symptoms common in catastrophic situations, such as post-traumatic stress disorder, burnout syndrome, physical and emotional exhaustion, depersonalization, and dissociation (Grassi and Magnani, 2000 Mache et al., 2012 Øyane et al., 2013). However, an epidemic presents different peculiarities compared to a catastrophic event, for instance, the stigmatizing attitudes in particular toward health professionals, who are in daily contact with the risk of infection (Brooks et al., 2020). During SARS, up to 50% of health-care professionals suffered from acute psychological stress, exhaustion, and post-traumatic stress, caused by the fear of contagion of their family members and the prolonged social isolation (Tam et al., 2004 Maunder et al., 2006).

As a consequence of the pandemic, the health professionals who were overworked suffered high level of psychophysical stress (Mohindra et al., 2020). Health professionals also lived/live in daily life a traumatic condition called secondary traumatic stress disorder (Zaffina et al., 2014), which describes the feeling of discomfort experienced in the helping relationship when treatments are not available for all patients and the professional must select who can access them and who cannot (Roden-Foreman et al., 2017 Rana et al., 2020). Data from a survey on 1,257 HCWs who assisted patients in Covid-19 wards and in second- and third-line wards showed high percentages of depression (50%), anxiety (44.6%), insomnia (34%), and distress (71.5%) (Lai et al., 2020). Also, the constant fear of contagion leads to obsessive thoughts (Brooks et al., 2020), increasing the progressive closure of the person and reducing social relationships. In line with these results, Rossi et al. (2020) evaluated mental health outcomes among HCWs in Italy during the pandemic, confirming a high score of mental health issues, particularly among young women and front-line workers. Furthermore, Spoorthy et al. (2020) conducted a review on the gendered impact of Covid-19 and found that 68.7�.5% of medical staff is composed of women, and the mean age ranged between 26 and 40 years. Also, women are more likely to be affect by anxiety, depression, and distress (Lai et al., 2020 Zanardo et al., 2020). Liang et al. (2020) also found a relation between age and depressive symptoms associated with the pandemic. Indeed, the medical staff at younger ages (㰰 years) reports higher self-rated depression scores and more concern about infecting their families than those of older age. Staff > 50 years of age reported increased stress due to patient’s death, the prolonged work hours, and the lack of personal protective equipment. Cai et al. (2020) also found that nurses felt more nervous compared to doctors.

As emerged by the recent literature, the promotion of psychological interventions on the specific population who is more likely to develop pathologies and suffering is needed. The Lancet Global Mental Health Commission’s observation (Patel, 2018) reported that the use of digital technologies can provide mental health interventions in order to reduce anxiety and stress levels and increase self-efficacy (Kang et al., 2020 Xiao et al., 2020).


Associated Data

Quarantine played an important role in the coronavirus disease 2019 (COVID-19) outbreak and can also cause mental disorders. Dr Brooks and her colleagues conducted a rapid review ( Brooks਎tਊl., 2020 ) about the psychological impact of quarantine in 2020. However, their review did not include any articles related to the ongoing COVID-19 outbreak.

We conducted a rapid review about psychological impact of quarantine during the COVID-19 outbreak. We systematically searched the following databases from their inception until 30 March 2020: Medline, CNKI (China National Knowledge Infrastructure), WANFANG Data, CBM (SinoMed), and Google Scholar with the combination terms relating to COVID-19 (eg, 𠇌OVID-19″ OR “SARS-CoV-2″ OR � novel coronavirus” OR �-nCoV” OR “novel coronavirus”) AND quarantine (eg, “quarantine” and “patient isolation”) AND psychological outcomes (eg, “psych” and “stigma”). The inclusion criteria are original studies published in peer-reviewed journals in Chinese or English. The literature focuses on the psychological state of patients and physicians in quarantine. We used Endnote X9 for literature screening. Two trained researchers (XL, QW) screened first by title and abstract, then the third researcher (YC) checked the results. Full text screening was done by one researcher (XL) and checked by another (ML).

Table. 1

StudyCountryDesignParticipantsAge of participants (in years range or mean ± SD)Quarantine periodEvaluation methods
Cheng etਊl., 2020ChinaCross-sectional60 patients with COVID-19 and 60 patients suspected with COVID-19 (all quarantined)NRLength unclear COVID-19 exposureSelf-developed questionnaire via online system (https://www.wjx.cn/)
Dong etਊl., 2020ChinaCross-sectional40 suspected COVID-19 patients being quarantined, and 38 residents not quarantined21�Length unclear COVID-19 exposureGAD-7 and PHQ-9 to assess psychological disorders
Ju etਊl., 2020ChinaCase report2 residents suspected with COVID-1946 and 7811 days and 12 daysInterview
Ma etਊl., 2020ChinaCross-sectional13 quarantined in hospital and 110 at homeGroup 1: 35.38 ±ਅ.17Group 2: 38.24 ±ꀑ.01Length unclear COVID-19 exposureSF-36 health survey, PSQI to evaluate the sleep quality and DASS-21 to evaluate general mental health
Wang etਊl., 2020ChinaCross-sectional396 children12.8 ±ਂ.6Length unclear COVID-19 exposure home quarantineDSRS to assess depressive symptoms
Li etਊl., 2020aChinaCross-sectional396 children and adolescents aged 8� years12.8 ±ਂ.6Length unclear COVID-19 exposure home quarantineSCARED to assess anxiety symptoms
Li etਊl., 2020bChinaCross-sectional76 quarantined in hospital36 ±ꀕLength unclear COVID-19 exposure hospital quarantineHAMA to assess anxiety symptoms
Zhong etਊl., 2020ChinaCross-sectional20 quarantined in hospital21�Length unclear COVID-19 exposure hospital quarantineSelf-developed questionnaire

NR: Not Report GAD-7: Generalized Anxiety Disorder-7 PHQ-9: Patient Health Questionnaire SF-36: Short-Form Health Survey-36 items PSQI: Pittsburgh sleep quality index DASS-21: Depression Anxiety Stress Scale 21 DSRS: Depression Self-rating Scale for Children SCARED: Screen for Child Anxiety Related Emotional Disorders HAMA: Hamilton Anxiety Scale SD: standard deviation.

Two studies ( Wang਎tਊl., 2020 Li਎tਊl., 2020a ) evaluated the symptoms of depression and anxiety in children (8� years) after quarantine. One study ( Dong਎tਊl., 2020 ) compared the psychological outcomes for people quarantined with those not quarantined. One ( Cheng਎tਊl., 2020 ) compared the psychological outcomes for people quarantined in hospital and at home. One ( Ma਎tਊl., 2020 ) compared the quality of sleep and state of mental health between patients quarantined in hospital and at home. One (Li, X. etਊl., 2020) explored the risk factors of anxiety and depression in patients with suspected COVID-19. One ( Zhong਎tਊl., 2020 ) conducted a psychological health survey for front-line medical staffs. The case report ( Ju਎tਊl., 2020 ) analyzed two patients with COVID-19 who developed the acute stress disorder (ASD) during the quarantine.

Based on these studies, a great amount of psychologic symptoms or problems developed during the quarantine period, including anxiety (228/649, 35.1%), depression (110/649, 16.9%), loneliness (37/649, 5.7%) and despair (6/649, 0.9%). One study ( Dong਎tਊl., 2020 ) reported that people quarantined had suicidal tendencies or ideas than those not quarantined.

We also examined the factors influencing the development of psychologic symptoms. Two studies ( Wang਎tਊl., 2020 Li etਊl., 2020b ) showed that the mental health status of COVID-19 patients and people under medical observation differed across gender, age, marital status, education, occupational status, monthly income per capita, and place of residence. However, according to another study ( Ma਎tਊl., 2020 ), no significant associations between age, gender, marital status, and education level with psychological problems in patients quarantined in hospital and at home. For children, age, gender, place of residence, and awareness of the epidemic were the main factors affecting mental health ( Wang਎tਊl., 2020 Li਎tਊl., 2020a ).

Three studies ( Cheng਎tਊl., 2020 Dong਎tਊl., 2020 Ma਎tਊl., 2020 ) explored the stressors during quarantine. One study ( Cheng਎tਊl., 2020 ) indicated that not being able to reunite with family members, not being able to complete work, and having only limited possibility for activities in the isolation room were the main sources of psychological stress. Another article ( Dong਎tਊl., 2020 ) reported that concerns about infection, disorder of life, isolation of the surrounding environment, and stigma were the main stressors during quarantine. A cross-sectional study ( Ma਎tਊl., 2020 ) showed that worrying about own and families' illness, disruptions in normal life, and too small isolation space were the main sources of psychological health problems. In contrast to the review by Brooke etਊl., however, problems in insufficient supplies or insufficient information were rarely mentioned. Included studies did not report the presence of stressors affecting the mental health of COVID-19 patients after the end of the quarantine.

In China, two main types of quarantine are being used during the COVID-19 epidemic. Those who have no symptoms but had contact with people with confirmed cases are usually required to stay at home for about 14 days. Suspected patients and patients discharged after treatment need to stay in collective quarantine in a hospital or other facility. For people quarantined at home, the social media such as WeChat and Weibo have become the main sources of information. But the information from such sources is mixed including some fake news ( Shimizu, K., 2020 ), which may cause public panic. In hospitals medical assistance is the first priority, but the mental health of people quarantined is an equally important matter and should not be ignored. Considering the huge number of people with mental illness in China ( Huang਎tਊl., 2019 ), psychological interventions are urgently needed. However, the lack of psychiatrists has become a major challenge for effective psychological care in China ( Que਎tਊl., 2019 Shi, S., 2019 Wu, J., and Pan, J., 2019 ).

In conclusion, we systematically analyzed eight studies and found that the main psychological problems of patients with COVID-19 were anxiety, depression and loneliness. The main source of the problems seems to be the small isolation space and the surrounding environment, but the stress may also be related to concerns about delayed work or infecting family members. Professional psychological care and the access to reliable information are essential for minimizing the mental health problems during quarantine.


DISCUSSION

The current systematic review provides a quantitative estimate of the psychological and behavioral impact of the current ongoing COVID-19 pandemic in children. Since many countries are now attempting unlocking measures, child psychiatrists/psychologists need to intervene at this point to minimize long term consequences. In the countries where lockdown measures have not been completely removed, the psychiatrists and behavioral pediatricians need to identify these children with behavioral problems and provide proper behavioral/psychological intervention through telephonic consultation [18, 19].

Because of this unprecedented situation, schools of the children are closed, examinations have been postponed, children have been confined to the home and they can’t plan outdoor play activities with their peers due to social distancing norms, places for recreation like parks, shopping malls and theaters are closed. There is a large number of COVID-related deaths occurring in the community and a feeling of uncertainty and fear has loomed over everybody. All these adverse conditions in the immediate family environment could probably predispose a lot of children to develop behavioral problems. The review identified that anxiety stress, sadness, boredom, depressive symptoms, sleep disturbance and fear for the situation are the predominant behavioral/emotional problems.

Having said that, it seems currently impossible as health authorities are now mainly concerned about handling the critically sick patient and containing the wildfire spread. Moreover, a large number of people have lost their job and regular earnings due to the pandemic, thereby disrupting their healthy financial family environment [20].

Anger, post-traumatic stress disorder and emotional exhaustion are also found to be very common in our review in various studies. At least 70�% of children were found to have worsened in at least some aspects of their behavior, which is worrisome for the clinicians. Notably, Saurabh and Ranjan [12] have shown that although the children who are quarantined showed more psychological co-morbidities, even the non-quarantined children had a relatively higher incidence of these problems, as compared with the studies in children in the pre-COVID era. Thus, it seems, the COVID-19 pandemic as such has a definite adverse impact on the psychological profile of children, which is further aggravated by quarantine measures.

One interesting aspect is that smartphones and social media, which was previously despised by most parents, have now become the only media for entertainment, information and education for children. Although many authors are favoring their use in mitigating the stress and depression of children, the parents need to have control over the judicious and reasonable use of electronic media and content of the programs their children are viewing [21, 22]. Online classes have been initiated in many schools and innovative measures to make online learning interesting can help many children. Indoor games, which are enjoyable and educational at the same time, are also welcome [23]. Positive reinforcement and healthy emotional interaction between family members is another simple yet effective step to relieve the stress of children. Despite all these measures, many children would need structured psychological intervention in the upcoming days [20, 23]. Our review will most probably give a reasonable estimate towards the target psychological disorders and their relative burden in these children the clinicians are going to come across in the next few months. The demand for psychotropic medications and sessions for behavioral/psychiatric counseling is likely to increase in the future [1].

Our review showed some geographical and temporal differences in the relative prevalence of various psychological problems in children. Most studies from Asia showed a higher prevalence of psychological morbidities as compared with other developed countries like Italy and Spain [8, 11]. The studies were done in the earlier stage of the pandemic also included a high proportion of participants with uncertainty and fear [8, 21].

The proposed interventions to mitigate these effects can be divided into few subdivisions like educational interventions (effective online learning, provision of psychosocial support and healthy lifestyle motivation through educational portals), information dissemination (accurate information, limited but adequate exposure with news, discussion with children about what they heard or saw), behavioral therapy complemented with sleep hygiene, exercise and healthy eating, utilizing telehealth to provide counseling/support to children at risk and to help parents coping with family issues, ensure positive parenting and social connectivity and seeking the help of professional when needed. Schools and teachers also need to be actively involved in achieving all these targets [22]. Education and public health officials need to work together to decide on the content of effective online learning, minimizing exposure to social crowding and ensuring a safe return to school at the earliest possible [22].

Children tend to worry more when they are kept in dark about what is happening in the community and often vent out their worry in form of anger, distraction and temper tantrums. Thus, making them understand about the pandemic and lockdown norms using age-appropriate language and understanding is a challenge to the parents. It is highly essential to acknowledge and validate the thought, feelings and reactions of children and provide them with the appropriate emotional scaffolding they need during the quarantine period [24]. Cognitive-behavioral therapy incorporating culturally sensitive interventions, enjoyable activities, problem-solving skills and tasks to address avoidance behaviors are also required in a proportion of severe cases [24].

In many low-medium income countries schools are the only feasible mental health strategy to reach out to a large number of children during this pandemic and thus WHO is encouraging the ‘health-promoting school’ global strategy to mitigate the long-term adverse mental health consequences in the post-quarantine period. On the other hand, positive parenting and problem-focused coping strategies can convert this crisis into an opportunity. Parents can use this period as a novel opportunity to spend quality time with their children, improve positive interaction between parents, children and siblings and strengthen family bonds. Consistent with the above facts the ADHD children found the home environment less challenging and many of them had improvement in symptom profile [2].

However, almost all parents of autistic children found it a challenging situation, and the majority of these children had worsening of behavioral abnormalities. A significant proportion of their parents needed the help of professionals as compared with the parents of children with ADHD. Overall, the need for the help of psychiatric professionals was relatively higher for children with prior behavioral co-morbidities as compared with the general community [25].

Imran et al. [26] performed a systematic review in this regard in the early stage of the pandemic and included only three studies on COVID19 in a descriptive review. This review raised the same issues of various psychological problems that were addressed more objectively with exact information on their public health burden. However, many issues like the perception of students and the perception of parents were not addressed in that review [27]. Thus our review is the first global perspective including 㸠򠀀 children across various countries revealing the real-world impact of the on the behavior and psychiatry of children. This review is likely to help the regulating authorities in deciding the future strategy as many countries are in different phases of the unlocking process, breaking the misery of home confinement, even allowing small to moderate social gatherings and reopening schools and public places. Although these measures carry a definitive risk of the second wave of the pandemic, the public health authorities need to take a tough but reasonable decision considering the benefits and harms of discontinuing quarantine measures [27]. Last, the results of our review also indicate the requirement for a structural stress management helpline for parents and secondary school students as a novel finding. At the same time, the children who had family members suffering from COVID-19 or who had lost their near and dear ones to the pandemic need more intensive behavioral and psychological support [27�].

Recommendations based on findings of our systematic review

Most of the above-mentioned problems can be taken care of by audio/video counseling, hence, an urgent need for public health authorities to provide appropriate educational and recreational measures as well as psychological interventions through telephonic review. Psychologists, psychiatrists, pediatricians and community health practitioners need to join hands at this challenging time, to reach the children at every corner of the community, without violating the lockdown and social distancing norms. In many countries, the lockdown measures have been made liberal and are being replaced by unlocking measures as in India. This could help the key health care stakeholders to expedite their effort in identifying the children who require counseling/psychotropic medications and institute mitigating measures at the earliest possible. At the same time, in some countries, the second and third wave of new COVID-19 cases have forced governments to impose lockdown measures again. Thus, child health practitioners and psychiatrists will probably face an uphill task to normalize the psychological impact of this pandemic on children in upcoming days.

Limitations

Our review has several limitations. First, the reliability of pooled estimates might be compromised due to different study designs of included articles, separate measurement tools in different studies for a particular psychiatric symptom, variable study outcomes and subjectivity of interpretation of the behavior of children by parents. Second, even after careful interpretation, we could not differentiate what proportions of these disorders are due to the effect of disaster, disease or disaster containment measures, or synergistic effects of both. Third, the parents themselves are found to be suffering from stress and psychological problems and thus their perception might not be the true reflection of the situation. Some of the studies included were not of good quality and the heterogeneity of the studies was high. Direct assessment by child psychiatrists was not part of most of the studies, so the problem burden projected in this review might be the tip of the iceberg only and the real picture of psychological stress might be more pervasive and worrisome.


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 21 st 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]

Inadequate information:

  • 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]

Financial problems:

  • 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.
SUMMARY

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.


Introduction

The entire world is facing a crisis today with the pandemic associated with the coronavirus disease (COVID-19). Unprecedented policies and strategies are being implement to contain the spread of this disease, that have resulted in around a third of global population being subjected to COVID-19 lockdown. In scientific terminology the word ‘Lockdown’ means ‘Restrictive Mass Quarantine’. Historically in 2003 citywide quarantines were imposed in areas of China and Canada during the outbreak of severe acute respiratory syndrome (SARS). Entire villages in many west African countries were quarantined during the 2014 Ebola outbreak [1]. However, current COVID-19 seems to be the largest and most restrictive quarantine till date.

Quarantine often is an unpleasant experience. On one hand for those who earn their living on daily wages, it is a question of their survival. On the other hand, the loss of freedom, separation from the loved ones, and the uncertainty over the disease status, may pose immense psychological turbulence, even in the more affluent population. These unnatural circumstances have been hypothesized to lead to extreme risk-taking behaviours–including suicidal tendencies. Social isolation and loneliness are recognised risk factors for suicidal attempts [2]. It is imperative to carefully weigh and strategically implement the potential benefits of mandatory mass quarantine against the possible odds of psychological distress in the society [3]. A recent textual analysis of 5780 publications enforces the need of global research collaborations, during this pandemic, in order to address the knowledge gaps in a country to country based approach [4].

The aim of this study is to explore the degree of psychological distress in terms of–Depression, Anxiety and Stress among the adult population in India during the strict 21 days mandatory lockdown. We hypothesize that quantification of psychological impact of current situation will help us to modify the policies and implementation strategies. This assessment might also help in future to keep targeted services in place, to cope up with the psychological distress of the quarantined population.


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Keywords: psychological impact, COVID-19, psychological support, tele-psychotherapy, vulnerability factors

Citation: Dagnino P, Anguita V, Escobar K and Cifuentes S (2020) Psychological Effects of Social Isolation Due to Quarantine in Chile: An Exploratory Study. Front. Psychiatry 11:591142. doi: 10.3389/fpsyt.2020.591142

Received: 03 August 2020 Accepted: 19 October 2020
Published: 17 November 2020.

Dinesh Kumar Bhugra, Institute of Psychiatry, Psychology and Neuroscience, United Kingdom

Luigi Janiri, Catholic University of the Sacred Heart, Italy
M. Mahbub Hossain, Texas A&M University, United States
Maria Casagrande, Sapienza University of Rome, Italy

Copyright © 2020 Dagnino, Anguita, Escobar and Cifuentes. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.


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