Addressing Mental Health to Increase Isolation Compliance: We Are All in this Together

As the COVID-19 pandemic progresses, people around the world are being asked to self-isolate for at least a period of 14 days, and socially distance from one another. A rapid review by Brooks et al examined mental health impacts during five recent outbreaks in 11 countries, and found that those under quarantine or in isolation experienced higher levels of stress, post-traumatic stress disorder, anxiety, and symptoms of depression [1]. Several studies have shown that those experiencing greater psychological distress are more likely to be non-compliant with restriction protocols [1,2,3,4,5,6].  In order to increase compliance to isolation procedures, governments, communities and individuals need to address causes of mental health distress. 

As entire cities go into lockdown, and industries shut down, many may feel a financial strain from income loss, layoffs, and inadequate insurance coverages. These financial stressors can lead to increased psychological distress, and non-compliance of isolation measures [7,8,1,4]. Those who are unable to work from home, are self-employed, working part-time, or in affected industries are impacted the most [1,9]. As of April 6, in Canada and the US, over 1 million claims for employment insurance had been made, and many workers are experiencing temporary or permanent layoffs [10,11].  During this time, and for a period of time after, governments and employers could mitigate anxiety by allowing for payment deferrals, offer income compensation for those affected, provide medical insurance coverage and/or waive healthcare costs [1].  

The media, public health units, organizations, friends/family and the internet provide information on isolation protocols [5]. Having these fragmented voices led to confusion, anger and non-compliance among those quarantined during the 2003 SARS and 2014 Ebola outbreaks [4,5,6]. Similarly, each day during COVID-19, new guidelines are put forth regarding the use of personal protective equipment, hygiene, lockdown procedures, and business closures [12]. Despite these protocols, many continue to gather in groups, panic and stockpile food and medical supplies, and misuse personal protective equipment for fear of infection [13,14,15,16]. During this incredibly fluid and complicated situation, public health officials can continue to provide cohesive and centralized information that is understandable in order to increase compliance and lessen panic and anxiety [1,4,6,17,18,19].

Long and indefinite quarantine periods can result in boredom. Many under quarantine experienced fear, isolation, and depression, however being bored and frustrated were major reasons for breaking quarantine [4,20]. To help ease these feelings, the World Health Organization recommends that individuals create and stick to routines, virtually keep in touch with loved ones, limit consumption of the constant stream of information and exercise in your home or neighbourhood [21]. 

In times like these, it is more important than ever to take care of each other and of ourselves. Everyone, from the government to organizations to community members and individuals have a duty to ensure compliance by providing mental health support and easing psychological distress among the general public.  

References

[1] Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395(10227), 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8.

[2] Barbera, J., Macintyre, A., Gostin, L., Inglesby, T., O’Toole, T., DeAtley, C., Tonat, K., & Layton, M. (2001). Large-scale quarantine following biological terrorism in the united states: Scientific examination, logistic and legal limits, and possible consequences. JAMA, 286(21), 2711. https://doi.org/10.1001/jama.286.21.2711.

[3] Courbot-Georges, M. C., Leroy, E. & Zeller, H. (2002). Ebola: a virus endemic to central Africa? Med Trop 62, 295-300.

[4] DiGiovanni, C., Conley, J., Chiu, D., & Zaborski, J. (2004). Factors influencing compliance with quarantine in toronto during the 2003 sars outbreak. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 2(4), 265–272. https://doi.org/10.1089/bsp.2004.2.265.

[5] Hawryluck, L., Gold, W. L., Robinson, S., Pogorski, S., Galea, S., & Styra, R. (2004). Sars control and psychological effects of quarantine, toronto, canada. Emerging Infectious Diseases, 10(7), 1206–1212. https://doi.org/10.3201/eid1007.030703.

[6] Caleo, G., Duncombe, J., Jephcott, F., Lokuge, K., Mills, C., Looijen, E., Theoharaki, F., Kremer, R., Kleijer, K., Squire, J., Lamin, M., Stringer, B., Weiss, H. A., Culli, D., Di Tanna, G. L., & Greig, J. (2018). The factors affecting household transmission dynamics and community compliance with Ebola control measures: A mixed-methods study in a rural village in Sierra Leone. BMC Public Health, 18(1), 248. https://doi.org/10.1186/s12889-018-5158-6.

[7] Mihashi, M., Otsubo, Y., Yinjuan, X., Nagatomi, K., Hoshiko, M., & Ishitake, T. (2009). Predictive factors of psychological disorder development during recovery following SARS outbreak. Health Psychology, 28(1), 91–100. https://doi.org/10.1037/a0013674.

[8] Jeong, H., Yim, H. W., Song, Y.-J., Ki, M., Min, J.-A., Cho, J., & Chae, J.-H. (2016). Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and Health, 38, e2016048. https://doi.org/10.4178/epih.e2016048.

[9] Taylor, M. R., Agho, K. E., Stevens, G. J., & Raphael, B. (2008). Factors influencing psychological distress during a disease epidemic: Data from Australia’s first outbreak of equine influenza. BMC Public Health, 8(1), 347. https://doi.org/10.1186/1471-2458-8-347.

[10] Morath, S. C. and E. (2020, March 24). Surge in unemployment claims sparks delayed checks amid coronavirus crisis. Wall Street Journal. https://www.wsj.com/articles/surge-in-unemployment-claims-sparks-delayed-checks-amid-coronavirus-crisis-11585059384.

[11] Alini, E. (2020, March 24). Coronavirus: Nearly 1 million Canadians applied for EI last week. Global News. Retrieved from https://globalnews.ca/news/6726111/coronavirus-ei-claims-1-million/

[12] World Health Organization. (2020, March 25). Country & technical guidance – coronavirus disease (COVID-19). Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance. 

[13] Dittrich, V. (2020, March 23). #COVIDIOTS gather in large groups despite public health warnings to keep social distance. National Post. Retrieved from https://nationalpost.com/news/covidiots-continue-to-gather-in-large-groups-despite-public-health-officials-urging-social-distancing.

[14] Hay, A., & Resnick-Ault J. (2020, March 18). Meet the Americans still going out and gathering in large groups. The Reuters. Retrieved from https://www.reuters.com/article/us-health-coronavirus-usa-groups/meet-the-americans-still-going-out-and-gathering-in-large-groups-idUSKBN2153QT.

[15] Sagan, A. (2020, March 13). Bare store shelves, long lines at grocers amid coronavirus stockpiling. The Toronto Star. Retrieved from https://www.thestar.com/business/2020/03/13/bare-store-shelves-long-lines-at-grocers-amid-coronavirus-stockpiling.html.

[16] Nguyen, T. (2020, March 20). Health care workers are running out of face masks. They’re asking people to donate. Vox. Retrieved from https://www.vox.com/the-goods/2020/3/20/21188369/face-masks-short-supply-coronavirus-donations.

[17] Robertson, E., Hershenfield, K., Grace, S. L., & Stewart, D. E. (2004). The psychosocial effects of being quarantined following exposure to sars: A qualitative study of toronto health care workers. The Canadian Journal of Psychiatry, 49(6), 403–407. https://doi.org/10.1177/070674370404900612.

[18] Desclaux, A., Badji, D., Ndione, A. G., & Sow, K. (2017). Accepted monitoring or endured quarantine? Ebola contacts’ perceptions in Senegal. Social Science & Medicine, 178, 38–45. https://doi.org/10.1016/j.socscimed.2017.02.009.

[19] Blendon, R. J., Benson, J. M., DesRoches, C. M., Raleigh, E., & Taylor‐Clark, K. (2004). The public’s response to severe acute respiratory syndrome in toronto and the united states. Clinical Infectious Diseases, 38(7), 925–931. https://doi.org/10.1086/382355.

[20] Reynolds, D. L., Garay, J. R., Deamond, S. L., Moran, M. K., Gold, W., & Styra, R. (2008). Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiology and Infection, 136(7), 997–1007. https://doi.org/10.1017/S0950268807009156.

[21] World Health Organization. (2020).  Mental health and psychosocial considerations during COVID-19 outbreak. Retrieved from https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf. (Accessed 25th March 2020).