Mar 31, 2020
Psychology of Coping with Quarantine
The latest psychological research unearths some surprising mental effects of quarantine
By Dr Raj Persaud
Three years after you have been released from quarantine, you can still suffer from profound psychological effects.
Elevated rates of mental health problems, such as post-traumatic stress, depression and alcoholism, can all be traced back to the stress of confinement, three years earlier.
These are the conclusions of a group of mental health experts based in the UK (including a psychiatrist who had also served in the army, and who had been deployed to various hostile environments including Afghanistan and Iraq), which has just published an investigation into the psychological impact of quarantine. Their study was published in one of the oldest and most prestigious medical journals in the world, The Lancet, and attempted comprehensively to review the body of previous published scientific research into psychological survival of quarantine.
Titled, ‘The psychological impact of quarantine and how to reduce it: rapid review of the evidence’, this investigation also found profound impacts on lives beyond the issue of mental health, long after the quarantine was over. For example, weeks after being released from quarantine, avoidance behaviour in health care workers persisted, such as minimising direct contact with patients and not reporting to work. Other research this study cited found 54% of people who had been quarantined avoided those who were coughing or sneezing, 26% avoided crowded enclosed places, and 21% avoided all public spaces in the weeks following the quarantine period. For some, the return to normality was delayed by many months.
This investigation also reviewed evidence that Governments should be cautious about introducing quarantine given some of the effects can be counter-productive. For example, one study argued that travel bans and other ‘lock-down’ measures may inadvertently spread disease, because the economic hardship induces an unintentional consequence of increasing the migration of potentially infected people from affected areas.
One of the studies quoted examined the enforced quarantine of a hospital in Taiwan following a SARS outbreak there in 2003. All 930 staff were ordered into a two-week quarantine, yet expected to perform duties as usual. All 240 patients staying at the hospital were banned from leaving, as were 129 visitors and outpatients. Everyone was imprisoned in the hospital for at least 14 days while the police cordoned off the building. After watching some health care workers die from SARS, some medical staff tried to escape, while others refused to provide care for the ill. Telephone lines and television cables were cut by the authorities citing security reasons, adding to the terror and mental strain of their ‘lock-down’.
The authors of this particular investigation into the Taipei Municipal Hoping Hospital SARS quarantine of 2003, Donna Barbisch, Kristi Koenig and Fuh-Yuan Shih, point out that the full psychological impact was revealed when on just the third day of confinement a depressed man who was suspected of having SARS, hanged himself in the hospital. This was despite psychiatric counselling. The following day, another suicide attempt was halted when another was prevented from jumping out a window.
The Lancet study quoted an investigation into the strain of quarantine following a 2007 outbreak of highly infectious equine influenza in Australia, which found that those with one child had a 1.2 times higher risk of high psychological distress than those with no children. Yet this study, titled, ‘Factors influencing psychological distress during a disease epidemic: Data from Australia's first outbreak of equine influenza’, also found that having three or more children appeared protective against high psychological distress.
Perhaps having more children represents a distraction from the monotony of quarantine, though it’s hard to get one’s head around the idea that having more children in this circumstance would not be a nightmare whatever the context. One meme doing the rounds on the internet right now is that if the doctors don’t develop a vaccine soon, the parents will step in and do it for them.
Another possible explanation for this intriguing finding is that having three children simply might be a marker for being older. This study found one of the primary factors associated with high psychological distress during an epidemic was age. Those in the 16–24 age category reported highest levels of psychological distress.
It could therefore be that in post-quarantine it is the young who appear to need the most psychological support. Thus we might lose a whole generation, psychologically, not virally, to this pandemic. The elderly may be most vulnerable to physical attack from Covid-19 but it is the young who might be least immune to the longer-term mental effects, once quarantine is over.
Another possible explanation for this fascinating finding is suggested by some other research conducted in Pittsburgh USA where the precise opposite procedure to the usual quarantine study being reported here, occurred – people were quarantined because attempts were being made to infect them deliberately.
Titled, ‘Parenthood and Host Resistance to the Common Cold’, this study investigated immune resistance to viruses, by quarantining subjects, then administering nasal drops containing one of four common cold viruses. They were then monitored for the development of a clinical cold. Published in the academic journal Psychosomatic Medicine the intriguing finding is that the more children you have as a parent, the more resistant you are to getting the common cold. One possible explanation is that you have built up immunity over time because of having more children who constantly exposed you to bugs they got.
Another reason this might be an important link with psychological resilience during quarantine is that The Lancet review found a major cause of psychological strain was becoming worried if physical symptoms potentially related to the infection were experienced. This fear that the symptoms could reflect having the infection, continued to be related to future mental health difficulties several months later. It might be parents with lots of children having been through the mill with infections being brought home, are better set up for quarantine, because they are already more resigned or resilient or immune, and therefore either shrug off ambiguous or irrelevant symptoms, or just don’t get them.
We all get physical symptoms quite a lot of the time but usually these just go away of their own accord, and so we give them little attention. During quarantine, in contrast, perhaps we become hypervigilant for signs we have got the very thing we were being quarantined against, and this constant worrying about what the latest symptoms mean, might take a more significant toll on our mental health than previously appreciated.
As the physical symptoms of anxiety can look very similar to a viral infection, for example, headache, difficulty breathing or hyperventilation and also a cough, it is possible to enter a panic cycle. Your anxiety makes you believe you have the viral infection you dread, as you detect physical symptoms attributable to rising panic, but mistake them for the flu, you get more panicky and descend into a spiral of ever increasing mental and physical distress.
The conclusion of the just published academic investigation in The Lancet into the stress of quarantine, argues that ‘altruism is better than compulsion’. The authors contend that superior coping with the mental strain of such confinement could also hinge on whether those quarantined are motivated to comply because of a sense of volunteering, and free choice, seeing meaning in their sacrifice, by assisting others. However, if we are being compelled instead, to endure the many different sacrifices of quarantine, without it being clear exactly why it’s necessary, then poorer coping and worse mental health becomes more likely.
The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Samantha K Brooks, Rebecca K Webster, Louise Smith, Lisa Woodland, Simon Wessely, Neil Greenberg, Gideon James Rubin. The Lancet, Published: February 26, 2020 DOI:https://doi.org/10.1016/S0140-6736(20)30460-8
Is There a Case for Quarantine? Perspectives from SARS to Ebola. Donna Barbisch, Kristi Koenig and Fuh-Yuan Shih. Disaster medicine and public health preparedness, Volume 9, Issue 5 October 2015 , pp. 547-553.
Factors influencing psychological distress during a disease epidemic: Data from Australia's first outbreak of equine influenza. Melanie Taylor, Kingsley Agho, Garry Stevens & Beverley Raphael. BMC Public Health volume 8, Article number: 347 (2008)
Parenthood and Host Resistance to the Common Cold. Rodlescia Sneed, Sheldon Cohen, Donald Turner and William Doyle. Psychosomatic Medicine. 2012 Jul-Aug; 74(6): 567–573.doi: 10.1097/PSY.0b013e31825941ff
Professor Neil Greenberg, Professor of Defence Mental Health
BM, BSc, MMedSc, FHEA, MFMLM, DOccMed, MInstLM, MEWI, MFFLM, MD, FRCPsych
Professor Neil Greenberg is an academic psychiatrist based at King’s College London UK and is a consultant occupational and forensic psychiatrist. Neil served in the United Kingdom Armed Forces for more than 23 years and has deployed, as a psychiatrist and researcher, to a number of hostile environments including Afghanistan and Iraq. At King’s College London, Neil is one of the senior members of the military mental health research team and is a principal investigator within a nationally funded Health Protection Research unit which researches the psychological impacts of disasters on organisations. Neil also runs March on Stress (www.marchonstress.com) which is a psychological health consultancy and also Chairs the Royal College of Psychiatrists (RCP) Special Interest Group in Occupational Psychiatry.
Neil studied medicine at Southampton University and graduated in 1993. He served as a general duties doctor in a variety of Warships, Submarines and with two Royal Marines Commando units. Whilst serving with the Royal Marines he completed his arctic warfare qualification and the All Arms Commando Course, earning the coveted Green Beret.
Neil provided psychological input for Foreign Office personnel after the events of September 11th 2001 and in Bali after 12th October 2002 bombings. He has also assisted with the aftermath management of number of other significant incidents including assisting the London Ambulance Service in the wake of the London Bombings in 2005.
In 2008 he was awarded the Gilbert Blane Medal by the Royal Navy for his work in supporting the health of Naval personnel through his research work. He also led the team that won a military-civilian partnership award in 2013 for carrying out research into the psychological health of troops who were deployed and was shortlisted for The RCP Psychiatrist of the Year in 2015. He was awarded an RCP Presidential Medal for his work with trauma and veterans in 2017.
Neil has published more than 250 scientific papers and book chapters. He has presented to national and international audiences on matters concerning the psychological health of the UK Armed Forces, organisational management of traumatic stress and occupational mental health. He has been the Secretary of the European Society for Traumatic Stress Studies, the President of the UK Psychological Trauma Society and Specialist Advisor to the House of Commons Defence Select Committee. He is the current Royal College of Psychiatrists’ Lead for Military and Veterans Health, a trustee with Walking with the Wounded, an independent director of the Forces in Mind Trust and a principal advisor for Hostage International.
Neil has extensive experience of conducting research in military and veteran populations and successfully led the first two ever randomised controlled trials on the effectiveness of psychological health interventions in the UK Armed Forces. He, working with the team at King’s College London, is one of the UK’s leading military health researchers and has published very widely on a broad spectrum of military health and traumatic stress related topics (www.kcl.ac.uk/kcmhr) and advises the Armed Forces, media organisations (including the BBC and News UK) and UK government regularly about mental health issues.