Psychological states of COVID-19 quarantine

The psychological effects of a national lockdown to prevent the spread of the novel SARS-coronavirus-2 (COVID-19) as a public health measure are yet to be realised. However, there are known negative psychological effects of quarantine. The terms ‘quarantine’ and ‘isolation’ are not the same.¹ Quarantine is the separation and restriction of movement of people who have been potentially exposed to infection, whereas isolation is the separation of people diagnosed with infection from people who are not ill. Quarantine is associated with symptoms of acute stress disorder, with reports of feeling exhausted, confused, detached, fearful, angry and numb with associated grief, insomnia, indecisiveness and impaired work performance.^2–4

Primary care health professionals can anticipate emergent and negative psychological effects of a mandatory mass quarantine as a consequence of the COVID-19 pandemic.⁵ Some adverse effects in the interim result from perceptions of imposed restriction of liberty and feelings of boredom and frustration. During quarantine, people feel particularly stressed by fears of infection, not having basic supplies such as food and inadequate access to information. Depending on the duration of the lockdown and beyond the end of mass quarantine, financial hardship and losses reverberate and general practitioners (GPs) can expect to see patients with symptoms of post-traumatic stress and depression. Not everyone will develop symptoms of a mental illness. The COVID-19 pandemic’s effect on individuals’ psychological and social wellbeing may be mild or severe, short-term or long-lasting.⁶ People with vulnerable psychological states and severe mental illness will need more support as they are at risk of poorer psychological outcomes.⁷

Physical distancing, cancellation of large gatherings and closing schools and churches also have negative psychological effects. Limiting contact to social bubbles is socially isolating and considered to be a risk factor for morbidity and death.⁸ Perceived social isolation is akin to loneliness,⁹ described itself as a contagious condition and a signal of pain that connections to others are weakening.¹⁰ Loneliness is a psychological state of chronic distress associated with irritability, depression and inward-focus.¹⁰ There is an added dimension to loneliness associated with COVID-19 in Italy where family members who are critically ill have been separated from loved ones and die alone in hospital.¹¹ Some families have felt the pain of grief in isolation, impeded by restrictions on large gatherings. Negative effects of isolation are mitigated by social connection, access to accurate information, adequate supplies and the ability to communicate with others.¹ The situation for lonely older adults is exacerbated by conditions of quarantine if they usually rely on community programmes and behavioural interventions and have less access to online resources.

Mass quarantine offers a unique opportunity for psychological interventions to boost public mental health literacy for people affected by the COVID-19 pandemic.¹² People exposed to potentially traumatic events often display a high degree of resilience and are helped by practical, pragmatic support delivered with empathy.⁶ Emotions drive behaviour in the threat of infection and the uncertain future. We have observed a surge in anxiety manifest in panic buying at supermarkets, anger in response to observing members of the public breaking rules of self-isolation and behaviour driven by disgust, the part of our nature that deals with repulsion. The disgust of mucous, spittle, droplets, coughing and contaminated fomites is harnessed as a defence against infection¹³ and an impetus to copious use of hand sanitiser and scrupulous 20-s handwashing.

Health professionals need to fight panic with timely, verified information for this immediate and significant public health threat.¹⁴ This may be in the form of psychological first aid, by communicating simple and effective ways of supporting others.¹⁴ Psychological first aid is a set of practical, early interventions that can be used by clinicians and others to address emotional distress caused by traumatic events, to stabilise and support psychological and behavioural functioning and help people to access further care.⁶ Evidence for psychological first aid has not been sufficiently evaluated for effectiveness,^15,16 but it is an intuitive, common sense approach that many GPs will use in normalising emotions such as fear and acknowledging its usefulness as the body’s alarm system, to be alert and ready for action.⁶ Psychological first aid may be used to empower our patients to respond to someone in mental distress or with suicidal thoughts. Health professionals in primary care can encourage colleagues and family members within their social bubbles to learn the principles of psychological first aid. These principles are look, listen and link: to look to establish contact through a calm, comforting and compassionate presence, to protect people from further harm (meet their basic physical needs); to listen to people, help them feel calm and to express their needs and concerns (meet their basic psychological needs); and link them to information, loved ones and support.^6,17

Humans have capacity to adapt positively to adversity and change. GPs have a role in enabling social connectedness in spite of isolation and linking people to essential resources to keep pace with evolving news amidst a pandemic. Different groups with specific needs include patients with confirmed and suspected infections; health-care and essential workers; people who have close contacts with confirmed cases; people who refuse medical treatment; vulnerable groups such as people with underlying health conditions; and the general public.¹⁴ The New Zealand Ministry of Health’s advice on wellbeing in self-isolation includes advice to use technology to stay connected, exercise, keep a routine, seek out accurate information, find ways to relax and to give to others.¹⁷

The World Health Organization’s (WHO) document on mental health and psychosocial responses during the COVID-19 pandemic¹⁸ targets six groups for advice: the general population; health-care workers; team leaders and managers in health-care facilities; care providers for children; older adults, care providers and people with underlying health conditions; and people in isolation. The WHO’s advice to the general population is to minimise watching, reading or listening to news that causes anxiety or distress and to seek information from trusted sources ‘to take practical steps to prepare your plans and protect yourself and loved ones.’ GPs may note this guidance for themselves as they face unique challenges in the changing health-care landscape and respond to the multiple threats posed by COVID-19. They are having to rapidly adapt to the way they do business in their workplaces: minimising face-to-face contact with patients; optimising telehealth; taking extra precautions to reduce contamination and spread of infection to others; using personal protective equipment; and considering beyond-scope practice and activities.

GPs, an essential health-care workforce, deserve special attention and support, especially when the quarantine of infected workers leads to understaffing and extra work.¹ They may be required to test the limits of ethical decision-making. They can expect to treat members of the health workforce who fall critically ill or experience psychological distress. They may have felt the conflict in being a health-care worker and a parent in weighing professional responsibility against fear and guilt about potentially exposing their family to infection.⁵ They may be negatively affected by the stigma of risk of infection to others¹ or in seeking support for themselves. Experiencing anxiety and preoccupation is understandable as a response to extraordinary life circumstances.¹⁹ As businesses struggle to survive in the wake of a pandemic, GPs themselves may experience high mental and emotional distress. In the face of avoiding feeling overwhelmed in the months to come, primary care providers need support to maintain a psychological state of equilibrium. In current survival mode, they may need to receive psychological first aid themselves, seek restorative sleep, take particular care of their own health, find information and support, control what they can and know they are not alone.

The author declares no competing interests.

This viewpoint article did not receive any specific funding.