Introduction

I remember March 11th, 2020 vividly: schools in my area announced they would go online for the next three weeks. I was relieved that things slowed down. I could finally catch up on my sleep, schoolwork, and responsibilities. And after the quick break, I would finish the school year in person. But the three weeks closure turned into a month and a half closure, and soon after, the rest of the school year was cancelled. Governor Inslee announced all schools would not return in person and the state of Washington, accompanied by the majority of the US, effectively shut down as SARS-CoV-2, more commonly referred to as COVID-19, took countless lives.

The nationwide lockdowns turned everyone’s life upside down. We lost the privilege of activities we took for granted like being able to travel, play sports, or attend graduations. But possibly the most serious of these losses was the loss of our ability to see one another while in quarantine.

After the emergence of COVID-19 in Wuhan, China in December 2019 and the disease’s spread to the United States in late February 2020, the US went into a nationwide quarantine, with Americans compelled to comply with their respective states' stay-at-home orders [1]. This quarantine was intended to separate and restrict the movement of individuals who may have been exposed to the disease in an effort to decrease infection rate after case counts spiked in the US [2]. After these lockdown policies went into place, the average rates of increase in cases per day dropped from 12% to 5% [3].  Clearly, quarantine flattened the curve, but it came with detrimental effects, both biological and psychological, from the stress of living through a pandemic as well as from being so isolated. Various methods of alleviating the effects of these changes have arisen, primarily in online form, but symptoms of loneliness and anxiety remain prevalent.

Neurological Effects of Quarantine

In long-term social isolation scenarios like quarantine, parts of our nervous system normally involved in stress responses are activated for prolonged periods of time [4]. In animals, social isolation invokes stress responses like the disruption of cardiac function and anxiety-like behaviors [4]. Certain animals can model human behavior well, which may explain why we can observe similar phenomena in humans within situations with less social interaction. During quarantine, the nucleus ambiguus, a group of neurons that regulates heart function and ensures that the heart does not overwork itself, demonstrates a decrease in activity, disrupting bodily processes like cardiorespiratory function. This disruption can destabilize other bodily functions such as emotional regulation  [5].

Another huge implication of the weakened activity in the nucleus ambiguus is the imbalance between the sympathetic and parasympathetic nervous system. The parasympathetic nervous system, or the “rest and digest” system, slows down certain functions within our body in an attempt to conserve energy. On the flip side, the sympathetic nervous system, or the “fight or flight” system, does the opposite: it aims to energize our body and increase certain functions in case of a threat. The nucleus ambiguus plays a huge role in the parasympathetic system as it helps slow the heart down to a steady rate [6]. Its dampened activity in quarantine elevates heart rate, allowing the fight or flight response to take over more often [5]. While these stress responses are good when your body is under an immediate threat, stress activation for long periods of time takes a toll on the body. This can result in a weakened immune system as the body uses energy for stress responses rather than for immune function. Eventually, the body decreases antibody production, which increases the chance of viral infections [5]. While also restricting the movement and therefore the transmission of a disease, the lack of social interaction may actually lower the ability to fight off the disease if contracted [7].

Psychological Effects of Quarantine

Many studies conducted on past pandemics have found quarantine to have both acute and long-term psychological effects [8]. During the SARS outbreak in the early 2000s, hospital staff were subject to increased workload and donning airtight PPE (much like for COVID-19 today), which added to the staff’s exhaustion. Exposure to SARS patients forced some workers into quarantine. Additionally, health care workers were discouraged from interacting with fellow workers to prevent the spread of SARS, which increased feelings of isolation [9]. A study investigating the stress reactions among 338 hospital employees in Taiwan during the SARS outbreak showed that having been quarantined was the most predictive factor for development of acute stress disorder [9]. Moreover, a significantly greater percentage of quarantined workers reported exhaustion, detachment from others, anxiety when dealing with febrile patients, irritability, and insomnia. They also reported higher rates of poor concentration, deteriorating work performance, feeling stigmatized because of their work, and reluctance to work or even consideration of resignation.

Depressive symptoms were also found in quarantined individuals. A study in a major Beijing hospital surveyed a sample of 549 employees to examine the relationship between the SARS outbreak and depression [10]. To measure levels of depressive symptoms, researchers asked hospital employees to fill out a questionnaire that included questions such as whether participants had crying spells, if they had been feeling happy, and how much hope they felt for the future. Researchers found that three years after the outbreak, individuals reported high levels of depressive symptoms such as loss of appetite, crying spells, and sadness. These depressive symptoms were suggested to have been linked to three factors: having quarantined during the outbreak, having worked in places with potential exposure to SARS, and having been exposed to a violent incident before the outbreak [10]. Additionally, there was a positive association between individuals with post-traumatic stress disorder (PTSD) and alcohol abuse [11]. Researchers found that individuals exhibiting alcohol abuse three years after the outbreak were more likely to have been quarantined and have worked in a high-risk environment during the outbreak.

The lockdowns during the COVID-19 pandemic halted a lot of face-to-face interactions, and feelings of loneliness spiked during this time. A study conducted by Stanford University and the University of Cambridge used a sample of 15,530 individuals in the United Kingdom, and assessed participants for symptoms of loneliness and potential causes of such feelings [17]. Researchers discovered that young adults (18-30 years old) were more likely to experience loneliness and psychiatric disorders. This could be explained as young adults are experiencing the “rush hour of life,” where many major life decisions are being made: starting a family, continuing education, and developing a career. Thus, younger people may feel that quarantine caused a bigger disruption in their life compared to older demographics.

Quarantine can leave a significant impact on people’s lives. For some individuals, the return to normalcy is a long one. After isolation, quarantine-related behaviors may persist. Individuals may still engage in “avoidance behaviors” such as abandoning the practice of handshakes, as well as avoiding public, crowded, or enclosed spaces [12].

In addition to healthcare workers, civilian populations also faced quarantine. The H1N1 pandemic of 2009 infected between 43.3 to 89.3 million people in the United States [13]. The University of Kentucky conducted a study in a group of parents and children who were affected by pandemic illnesses to determine the impact of quarantine on PTSD symptoms [14]. Children who were quarantined had an average PTSD score four times higher than children who were not quarantined. Moreover, interview responses from the participants showed general anxiety among parents and children resulting from separation and the possibility of death. For example, some parents had stated “My children were scared. There was no time for goodbyes,” and “...they can't crawl into bed with you. That was tough, that was the toughest, the hardest part.” Some children asked their parents tough questions, like, “Mommy, are you going to die?” The responses showed themes of perceived threat, disruption, and isolation. In the same study, 44% of parents who quarantined reported that their children did not receive mental health services whereas 33% of parents reported that their children began to use these services either during or after the pandemic. This shows that in both healthcare workers and civilians, quarantine is correlated with heightened fear and distress. Thus, it is important to explore ways we can mitigate these consequences while we quarantine during our current pandemic, and prepare for the possible pandemics to come.

Potential Ways to Mitigate Negative Impacts of Quarantine

Determining which mental health resources are the most useful in quarantine relies on the way in which these resources can be delivered. Research shows that audio, visual, and body cues matter in interpersonal communication [16]. In a study of 29 pairs of friends, face-to-face communication was found to provide the most self-reported bonding when communicating. This was followed by video chat, audio chat, and finally, texting. This may be because face-to-face communication allowed for more non-verbal cues such as smiling, head nods, leaning, and hand gestures, which fostered better human connection. Texting provided the lowest connection between friends because non-verbal cues are not as easily conveyed. While online communication may not be a perfect substitute for face-to-face interactions, it is a substitute nonetheless, and may lessen the negative psychological effects of isolation.

One study has shown that counseling, even via an online platform, can be beneficial to people who are isolating [15]. In the early stages of the COVID-19 outbreak, quarantined patients in China with anxiety and depression were given consultation with nurses over WeChat, which significantly lowered their anxiety and depression levels. This may suggest that an increase in online mental health resources would be extremely beneficial during a pandemic.

Another study suggested that economic support during the pandemic may also alleviate the consequences of quarantine [18]. A longitudinal sample of 3,983 individuals from the Netherlands showed that depressive and anxiety symptoms did not increase. In addition, self-perception of emotional support did not decrease over the course of the pandemic. Researchers conjectured that the actions of the Dutch government potentially minimized the psychological impact. Politicalization of the pandemic was kept to a minimum and economic benefits were given to both the unemployed and businesses [18]. Emotional support–even delivered online–together with economic safety nets, may alleviate the stress of quarantine and lead to improved health outcomes.

Conclusion

The COVID-19 pandemic is one of the worst outbreaks in modern times, and it certainly won't be the last one. In determining how to approach future outbreaks, neurological and psychological impacts of quarantine should be considered to ensure successful application of quarantine as a measure to prevent the spread of diseases. Quarantining can take a toll on many individuals, leaving long-term consequences in some cases. Thus, further research is also needed to provide the general population with emotional support and alleviate negative effects of isolation.

References

1. Burke, R. M., Midgley, C. M., Dratch, A., Fenstersheib, M., Haupt, T., Holshue, M., . . . Rolfes, M. A. (2020). Active Monitoring of Persons Exposed to Patients with Confirmed COVID-19 — United States, January–February 2020. MMWR. Morbidity and Mortality Weekly Report, 69(9), 245-246. doi:10.15585/mmwr.mm6909e1
2. Centers for Disease Control and Prevention. (2017, September 29). Quarantine and Isolation. https://www.cdc.gov/quarantine/index.html.
3. Castillo, R. C., Staguhn, E. D., & Weston-Farber, E. (2020). The effect of state-level stay-at-home orders on COVID-19 infection rates. American Journal of Infection Control, 48(8), 958-960. doi:10.1016/j.ajic.2020.05.017
4. Grippo, A. J., Lamb, D. G., Carter, C. S., and Porges, S. W. (2007). Social Isolation Disrupts Autonomic Regulation Biological Psychiatry 62, 1162–1170. doi:10.1016/j.biopsych.2007.04.011.
5. Poli, Andrea & Gemignani, Angelo & Conversano, Ciro. (2020). The psychological impact of SARS-CoV-2 quarantine: observations through the lens of the polyvagal theory. Clinical Neuropsychiatry. 17. 112-114. doi:10.36131/CN20200216.
6. Petko, B. (2020, July 31). Neuroanatomy, Nucleus Ambiguus. National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK547744/.
7. Hawkley, l. c., and Capitanio, J. p. (2015). Perceived social isolation, evolutionary fitness and health outcomes: a lifes- pan approach. Philosophical Transactions of the Royal So- ciety B: Biological Sciences, 370, 20140114. doi:10.1098/rstb.2014.0114.
8. 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. doi:10.1016/s0140-6736(20)30460-8
9. Bai, Y., Lin, C., Lin, C., Chen, J., Chue, C., & Chou, P. (2004). Survey of Stress Reactions Among Health Care Workers Involved With the SARS Outbreak. Psychiatric Services, 55(9), 1055-1057. doi:10.1176/appi.ps.55.9.1055
10. Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, Guan Z, Wu P. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry. 2012 Jan;53(1):15-23. doi:10.1016/j.comppsych.2011.02.003.
11. Wu, P., Liu, X., Fang, Y., Fan, B., Fuller, C. J., Guan, Z., . . . Litvak, I. J. (2008). Alcohol Abuse/Dependence Symptoms Among Hospital Employees Exposed to a SARS Outbreak: Table 1. Alcohol and Alcoholism, 43(6), 706-712. doi:10.1093/alcalc/agn073
12. Reynolds, D., Garay, J., Deamond, S., Moran, M., Gold, W., & Styra, R. (2007). Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiology and Infection, 136(7), 997-1007. doi:10.1017/s0950268807009156
13. Centers for Disease Control and Prevention. (2019, June 11). 2009 H1N1 Pandemic (H1N1pdm09 virus). https://www.cdc.gov/flu/pandemic-resources/2009-h1n1-pandemic.html.
14. Sprang, G., & Silman, M. (2013). Posttraumatic Stress Disorder in Parents and Youth After Health-Related Disasters. Disaster Medicine and Public Health Preparedness, 7(1), 105-110. doi:10.1017/dmp.2013.22
15. Zhou, L., Xie, R., Yang, X., Zhang, S., Li, D., Zhang, Y., . . . Wen, S. W. (2020). Feasibility and Preliminary Results of Effectiveness of Social Media-based Intervention on the Psychological Well-being of Suspected COVID-19 Cases during Quarantine. The Canadian Journal of Psychiatry, 65(10), 736-738. doi:10.1177/0706743720932041
16. Sherman, L. E., Michikyan, M., & Greenfield, P. M. (2013). The effects of text, audio, video, and in-person communication on bonding between friends. Cyberpsychology: Journal of Psychosocial Research on Cyberspace,7(2). doi:10.5817/cp2013-2-3
17. Li, L. Z., & Wang, S. (2020). Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. Psychiatry Research, 291, 113267. doi:10.1016/j.psychres.2020.113267
18. Velden, P. G., Contino, C., Das, M., Loon, P. V., & Bosmans, M. W. (2020). Anxiety and depression symptoms, and lack of emotional support among the general population before and during the COVID-19 pandemic. A prospective national study on prevalence and risk factors. Journal of Affective Disorders, 277, 540-548. doi:10.1016/j.jad.2020.08.026