Dr Alexandra Pitman (@DrAPitman), joint lead of the Loneliness & Social Isolation in Mental Health research network and trauma specialist Dr Michael Bloomfield (@docbloomfield) reflect on the findings of a recent rapid review.
The review has been blogged about by Dr Andrew McIntosh for the Mental Elf and to complement that, we wanted to set out our own thoughts from the perspective of the Loneliness and Social Isolation in Mental Health Network. For this, we invited a trauma specialist, Dr Michael Bloomfield, to contribute.
How does quarantine effect people’s mental health? How long do these effects last? And what can be done to reduce their impact?
Increased psychological distress
First, let’s summarise the findings of the review itself. The team at KCL conducted a rapid review of studies investigating the psychological impact of quarantine using three electronic databases. They identified 24 eligible papers from 3166 potentially relevant citations. The evidence they summarised reported on the psychological impact of outbreaks of SARS, Ebola, the 2009 and 2010 H1N1 influenza pandemic, MERS, and equine influenza.
The evidence from these studies indicated that quarantine was associated with an increased risk of psychological distress, often manifesting as post-traumatic stress symptoms, confusion, and anger, with some studies suggesting that these effects were long-standing. Only one study measured loneliness (Reynolds, et al. 2008). It found that 39% of a sample of people quarantined in Canada following the SARS outbreak reported feeling lonely. The proportion reporting loneliness was significantly higher for healthcare workers than for non-healthcare workers (54% versus 33%). Other findings were that the quarantine restriction that people most commonly expressed finding difficult was not being able to leave the house to visit friends, family or attend other social activities. The most common psychological impacts of quarantine were reported as boredom (62%), isolation (61%) and frustration (59%). Other psychological concerns included fears about infecting others, and being infected themselves. However, no details were provided on which measures were used to capture loneliness, social isolation, boredom, or frustration, and we have not been able to clarify this further with the authors. It is therefore hard to interpret the clinical importance of these findings, and highlights the importance of using and specifying validated measures in epidemiological research.
How loneliness interacts with mental health is an important research area and is the focus of the Loneliness and Social Isolation in Mental Health Research Network. It is important to understand potential impacts of quarantine on loneliness, however many surveys use a single question to measure loneliness. This approach is poorly validated and cannot measure change or distinguish between social and emotional dimensions of loneliness. Validated alternatives are the De Jong Gierveld Loneliness Scale, and the UCLA (University of California, Los Angeles) Loneliness Scale, which have full or shorter versions. The De Jong Gierveld Loneliness Scale measures both emotional and social aspects of loneliness (De Jong Gierved J. and van Tilburg, 2006) and the UCLA Loneliness Scale captures the frequency and intensity of people’s current experience of loneliness (Hays R.D and Di Matteo M.R., 1987). Researchers planning future work should note that the 3-question UCLA Loneliness Scale is recommended by the United Kingdom Office for National Statistics (ONS) for use in surveys (ONS, 2018).
Generally, the stressors identified across the studies in the Lancet review included longer quarantine duration, infection fears, frustration, boredom, inadequate basic supplies, inadequate information, financial loss, and stigma of being quarantined. Many of these factors apply to the current Covid-19 outbreak. Policy suggestions arising from this review include the recommendation that where quarantine is deemed necessary, officials should quarantine individuals for no longer than required. It is also recommended that governments provide a clear rationale for quarantine, clear information about protocols for reducing transmission, and ensure that sufficient supplies of food, water, medicines and accommodation are provided. It further suggests that appealing to the public’s sense of altruism in reminding them of the wider social benefits of quarantine may buffer the psychological impact.
Appealing to the public’s sense of altruism by reminding them of the wider social benefits of quarantine may buffer the psychological impact.
Clarity, communication and altruism
The key messages of this review were as follows:
- Providing clear information is key. People who are quarantined need to understand the situation, what they are and are not allowed to do, and the rationale for this.
- Effective and rapid communication is essential.
- Supplies (both general and medical) need to be provided, and this information needs to be communicated to the population clearly.
- The quarantine period should be short and the duration should not be changed unless in extreme circumstances.
- Most of the adverse effects come from the imposition of a restriction of liberty: voluntary quarantine is associated with less distress and fewer long-term complications.
- Public health officials should emphasise that self-isolating is altruistic, despite the lack of immediate tangible benefits to the individual.
Insights from social marketing theory
The key messages suggest ways in which the Department of Health and Social Care, Public Health England, and all departments involved in policy-making on social distancing currently can reduce the potential impacts by communicating clearly and consistently, and providing a clear rationale for decisions. We suggest that careful “social marketing” of messages about altruism, informed by behavioural science, may also help in behaviour . The key assumption of social marketing is that everyone is not the same, and therefore a blanket message is not going to work for all groups. People understand things in different ways, and have different priorities. Only by segmenting out these groups of people and providing a targeted message for each one can we expect people to respond with behaviour change. So far government agencies have missed an opportunity to position key messages to specific sub-groups.
We suggest that key considerations when defining those sub-groups include people who are struggling with , people in different age groups, and people in different socio-economic circumstances. Each group will need a tailored approach, positioning messages carefully to help them see how important their sacrifices are in lifting the burden on the NHS. By helping each group understand the rationale for the behaviour they are being expected to adopt, in a way that resonates for them, the government can do much to help people cope psychologically with the strict limitations imposed on them.
Encouraging the media to report responsibly could also help in the way policy changes are interpreted by the public. If we are to learn from implementing media guidelines on responsible reporting of suicides, then punitive measures appear to be less effective than collaborating closely with editors and journalists (Michel, et al. 2000) . That is, carrots can be more effective than sticks. If government departments’ press liaison officers could work closely with editors to identify their specific reach, and match this to the specific groups of people identified for targeting of messages, we could encourage editors to report on policies in line with the above suggestions. Reporting could highlight the tangible benefits of self-isolating to each group, matched to tips on how to cope with this situation. This strategic social marketing approach could be a way to increase a sense of empowerment and reduce anxiety in a range of people across the UK. The commercial world is well versed in targeting messages to reach specific groups and this knowledge could be harnessed to achieve attitude and behaviour change (Albrecht and Bryant 1996).
Encouraging the media to report responsibly could also help in the way policy changes are interpreted by the public.
Collaborative response needed
We believe that the best way in which the mental health research community can contribute at the moment is by producing rapid evidence syntheses such as the recent review by the KCL team. A review collating evidence for interventions effective at reducing adverse mental health outcomes of quarantine is particularly needed right now. Realistically, such evidence may be thin on the ground, but researchers and practitioners can help identify promising interventions. Such interventions are likely to be those that connect people socially and help buffer some of the harmful effects of social isolation and loneliness on mental health. Digital interventions will obviously be critical at this time, and will require the rapid collaboration of a number of disciplines to ensure their acceptability and efficacy. The government will also need to work with internet providers to ensure that broadband capacity can meet these new demands.
Observational work will also be vital to understand the impact of the outbreak on loneliness and social isolation and mental health problems. Researchers will be working hard throughout this pandemic to understand and mitigate its impact, and use their findings to benefit people at risk of new onset or worsening mental health problems. Given the increased risk of psychological traumatisation associated with the quarantine (aside from the anxiety arising from experiencing symptoms of the coronavirus or caring for those with the coronavirus), there is a pressing need for informed responses to the current crisis in terms of both research and clinical interventions.
Albrecht, TL, and C. Bryant. 1996. “Advances in segmentation modeling for health communication and social marketing campaigns.” J Health Commun.
Brooks, Samatntha K, Rebecca K Webster, Louise E Smith, Lisa Woodland, Simon Wessely, and Neil Greenberg. 2020. “The psychological impact of quarantine and how to reduce it: rapid review of the evidence.” The Lancet.
De Jong Gierved J. & van Tilburg, T. G. 2006. “A 6-Item Scale for Overall, Emotional, and Social Loneliness: Confirmatory Tests on Survey Data.” Res. Aging 28, 582-598.
Hays R.D & Di Matteo M.R. 1987. “A short-form measure of loneliness.” J Pers Assess 51, 69-81.
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ONS 2018. “Measuring loneliness: guidance for use of the national indicators on surveys.” In (Anonymous), HMSO: London.
Reynolds, D, J. R. Garay, S.L. Deamond, M.K. Moran, W Gold, and R Strya. 2008. “Understanding, compliance and psychological impact of the SARS quarantine experience.” Epidemiol Infect.