Severe acute respiratory syndrome

Five studies identified short-term repercussions following SARS outbreaks [15,28,36,39,44]. Bai et al found that 17% (7 of 41) of Taiwanese HCWs suffered from an acute stress disorder up to ten days following quarantine compared with 4% (10 of 297) of those not quarantined [15]. Moreover, 20% of quarantined HCWs were reluctant to work compared to 5% not experiencing these measures and were more likely to consider resigning or observed a significant deterioration in their work performance [15]. In contrast, Chen et al described improved physical, social, and emotional well-being in HCWs after two weeks of self-quarantine and a further two weeks of off-duty shifts in comparison to those surveyed immediately after on-duty shifts treating SARS patients [44 ]. However, outcomes remained significantly impaired compared to controls lacking patient contact, particularly for vitality and mental health scores [44 ]. Ko et al associated higher depression symptomatology with being isolated, having poorer family or neighbourhood relationships, and negative economic effects following quarantine [28].

Social repercussions, including stigmatisation, discrimination, behavioural, and emotional reactions were short-term after effects [36,39]. Stigma or discrimination, including interpersonal and professional marginalisation, were experienced by 48∙7% (440 of 903) of individuals returning to work in Hong Kong following quarantine [36]. Canadian participants also reported stigmatisation from colleagues and detailed behavioural changes, including vigorous handwashing and avoidance of crowds [39]. Emotional reactions described by Toronto residents following quarantine comprised initial relief, however, participants expressed unease regarding the effect these measures may have on socially isolated and financially insecure populations [39].

Middle East respiratory syndrome

PTSD symptoms in HCWs were investigated by Lee et al after 24 days of hospital shutdown with 51∙5% (183 of 359) initially meeting diagnostic criteria [35]. One month later, 40∙3% (31 of 77) of survey respondents originally fulfilling criteria remained eligible for PTSD diagnoses [35]. Quarantine itself was not correlated with overall diagnostic scores, however, post-hoc analyses associated higher sleep and numbness sub-scores [ 35].

Coronavirus disease 2019

Psychiatric symptoms, stress, stigmatisation, sleep disturbance, and increased emergency department attendances with alcohol intoxication were identified following COVID-19 lockdown measures [19-21, 29,30,50-52,55].

Eight studies investigated mental health repercussions [19 -21,29,30,50,51,55]. PTSD (10∙8%, 73 of 673), depression (3∙7%, 25 of 673), and anxiety (3∙8%, 26 of 673) symptoms were identified in returning workforces, with symptom prevalence similar to that of the general population at the start of measures [19]. Strict personal and workplace hygiene and attention to employees physical and psychiatric well-being may have mitigated psychological morbidity [19 ]. Acute symptoms of anxiety and depression were identified in six studies [20,21,29,30,50,51]. Lei et al described significantly increased symptoms of anxiety (12.9%, 54 of 420), and depression (22.4%, 94 of 420), in those quarantined, compared to 6.7% (79 of 1173) and 11.9% (140 of 1173) in unaffected individuals respectively [30 ]. Identified risk factors for psychiatric symptoms included stress, loneliness, being female, worse self-perceived health, poor physical health, lower educational levels, lower household income, and those experiencing economic fallout [19-21,30,50]. In contrast, Wang at al found no significant correlation between quarantine and symptoms of PTSD, stress, anxiety, or depression in 26 Chinese residents [55]. Sleep disturbance (4.4%, 71 of 1602), and suicidal ideation (1.9%, 30 of 1602) have been detailed following quarantine and research concerning emergency department attendances found that 11.31% (25 of 221) involved severe alcohol intoxication in the three weeks after lockdown compared to 0.88% (1 of 117) in the preceding period [29, 52].

Social repercussions, including stigma and behavioural modifications, have been investigated in HCWs [51]. Duy et al reported 34.43% (21 of 61) expressed guilt for isolating, 18.03% (11 of 61) felt unsafe in their profession, and many described discriminatory experiences [51]. However, only 1.64% (1 of 61) detailed undertaking efforts to avoid COVID-19 related work after quarantine [51].

Severe acute respiratory syndrome

Three studies investigated medium-term PTSD symptoms following the SARS outbreak [17,26,45]. Hawryluck et al and Reynolds et al found that following Toronto-based home or workplace quarantine the prevalence of significant PTSD symptomatology was 28∙9% (35 of 129) and 14∙6% (148 of 1057) respectively [17,26]. Chong et al, however, found no correlation between quarantine and PTSD or psychiatric morbidity in Taiwanese HCWs [ 45]. Symptoms of depression and suicidal ideation were associated with quarantine [ 26,56]. Hawryluck et al described significant depression symptoms in 31∙2% of their cohort [26]. Although precise time-frames are unclear, one case-note review described increased suicide rates in those aged over 65 during and in the months after the SARS outbreak in Hong Kong with measures including reduced interpersonal contact, disruptions to social support, and experiences of disconnection highlighted as contributing factors [56]. Identified risk factors for symptoms of PTSD and depression included quarantine periods longer than ten days and lower household income [26]. Despite governmental compensation, Reynolds et al associated quarantine with household income reduction [17].

Behavioural changes and emotional reactions were observed [17 ,37,40]. Reynolds et al found that 53∙7% (568 of 1057) avoided those sneezing or coughing, whilst 25∙7% (272 of 1057) refrained from entering crowded public spaces up to four months after lockdown [17]. Individuals continued performing behaviours, including frequent hand washing, and several participants reported extending their quarantine or limiting social contact beyond public guidance [17,40]. A study involving nurses associated avoidance coping behaviours, including missing work and avoiding patient contact, with home or workplace quarantine [37]. Increased anger correlated with longer lengths of quarantine, although emotional exhaustion was not associated [37].

Stigmatisation following quarantine was reported in four studies [17,36,40,41]. Experiences ranged from heightened attention to social ostracization in settings including day-care facilities, workplaces, and private social gatherings, leading some HCWs to deny their occupation or conceal they had quarantined [17, 40,41]. However, perceived discrimination reduced to 4∙0% (36 of 903) from 48∙7% (440 of 903) for residents in Hong Kong three months after lockdown measures ended compared to immediately after quarantine [36].

Middle East respiratory syndrome

Symptoms of anxiety, requirements for psychiatric support, and changes to biochemical parameters are identified medium-term consequences following the MERS outbreak in South Korea [27,33,38,57].

A study quantifying mental health service utilisation by those quarantined demonstrated that 19∙6% (1221 of 6231) experienced psychological and emotional difficulties during quarantine, with 28∙7% (350 of 1221) of these requiring follow-up after measures ended [ 57]. Jeong et al described 7∙6% (126 of 1656) of residents reporting anxiety symptoms during isolation, decreasing to 3∙0% (50 of 1656) four to six months later, similar to general population prevalence [ 27]. Factors associated with increased anxiety symptoms included insufficient supply provision, lacking access to social networking facilities, psychiatric comorbidities, and financial concerns [27].

Two studies investigated biological parameters in haemodialysis patients during and after quarantine or isolation [33,38]. One study reported impaired haemodialysis efficacy and albumin levels during isolation which significantly improved three months later [38]. Another study reported normal haemodialysis efficacy, however, detected continuously elevated stress markers in patients compared to HCWs quarantined alongside them [33].

Coronavirus disease 2019

Repercussions for psychological well-being, dietary habits, and weight have been identified medium-term outcomes following COVID-19 lockdown measures [22 -24,42].

Psychological distress, comprising symptoms of depression and anxiety disorders, was found to increase during measures for American participants with or without mental health diagnoses [ 22]. Although levels of distress returned to baseline in both cohorts after measures ended, initial distress severity was significantly higher in those with pre-existing psychiatric diagnoses [22]. Symptoms of anxiety, PTSD, and depression were identified during lockdown in the general public and HCWs by Lu et al, with HCW PTSD (16.2%, 62 of 382) and any depression (57.9%, 221 of 382) symptomatology significantly higher compared to general population prevalence, (11.7%, 121 of 1035) and (45.7%, 473 of 1035) respectively [24]. Similarly, overall symptom predominance decreased following measures lifting [24]. Conversely, symptoms of stress, anxiety, and depression in a study of Chinese students decreased during national lockdown, and subsequently increased after measures were removed [23]. Minimal changes to psychological well-being were described by Zhou et al six weeks after national lockdown ended in China [58].

Two studies described consequences to dietary behaviours and weight [34,42]. Over half of respondents in one study (n = 1994) reduced their consumption of seafood, raw food, and imported frozen food whilst increasing the frequency of home-cooking after lockdown in China [34]. Several participants also continued engaging in unhealthy dietary behaviours including drinking vinegar (9.8%, 195 of 1994) to prevent infection [34]. Zarah et al found that although most American respondents did not report dietary changes following lockdown, 38% (1191 of 3133) described weight gain, and increased consumption of sweets and salty snacks were nevertheless noted [42].

Severe acute respiratory syndrome

Three studies analysed survey responses from HCWs, 18∙8% (103 of 549) of whom were quarantined, three years following the SARS outbreak in Beijing [31,32,43]. Quarantine was significantly associated with increased alcohol abuse/dependence, PTSD, and depression symptoms [31,32,43]. Identified groups at-risk for exhibiting PTSD symptoms over six months after measures ended were HCWs who experienced prolonged contact with infectious patients or those who had close relations diagnosed with SARS [32]. Risk factors for depression symptoms included concurrent PTSD symptoms, work-related stressors, being single, and prior experiences of traumatic events [31]. Mihashi et al measured the prevalence of psychological disorders in printing company workers, university staff, and students during and after hospital isolation or home quarantine [54]. During these measures, 24∙6% (46 of 187) reported symptoms indicating psychological disorder increasing to 26∙2% (49 of 187) seven to eight months later, however, this did not achieve statistical significance [54]. Income reduction was identified as the principally associated risk factor [54].

Middle East respiratory syndrome

Significant long-term PTSD symptoms were identified in 17∙9% (12 of 67) of quarantined haemodialysis patients in South Korea, however, lengths of isolation of 16 days or more were associated with lower symptomatology [16]. Females were also at higher risk of exhibiting PTSD symptoms over six months after lockdown measures ended [ 16].

Ebola

Another study investigated PTSD, anxiety, and depression symptomatology in 3564 residents in Sierra Leone approximately 14 months after the start of the Ebola outbreak [25]. Knowing somebody who had been quarantined or having personal relations with suspicion or diagnosis of Ebola was independently associated with increased PTSD, anxiety, and depression symptoms [25]. Higher and ongoing perceived disease threat was also associated with symptom prevalence [25].

Principal findings

Lockdown measures are a venerable method to contain infectious disease outbreaks, however, profound biopsychosocial impacts, ranging from acute stress reactions to chronic psychopathology, are apparent [7]. Economic repercussions may be compounded by social obstacles in returning to work ( Table 2 ) [26-28, 39]. Certain groups, such as those lacking financial security, are therefore particularly vulnerable to continued financial hardship [22,26-28,30,39,50,54]. Enduring behavioural and social effects and adjustments to workplace practice can impede return to social and professional normalcy which may require extensive support including workplace modifications [15,17,28,37,39-41,51]. Acute alcohol intoxication, weight gain, and dietary changes have also been described [34,42 ,52]. Physical, emotional, and social well-being of HCWs during outbreaks may improve following self-quarantine compared to parameters observed during clinical work [44]. However, no differences in the degree of psychiatric symptoms in other workforces following COVID-19 measures were found [19]. National interventions to alleviate individually perceived disease threat and improve social support may reduce psychological morbidity [25,28,56]. Actively approaching vulnerable individuals and ensuring publicly accessible mental health services may reduce and prevent mental health burden [19,28]. However, comprehensive research analysing effective interventions to mitigate biopsychosocial aftereffects of lockdown is lacking.

Previous studies

Brooks et al reviewed psychological consequences of quarantine primarily focusing on interventions and outcomes during quarantine [4 ]. Acute stress reactions, PTSD, anxiety, and depression symptoms were identified [4]. Behavioural changes, reluctance to re-enter work, and deteriorating work performance were also described [4]. Financial loss consequent to quarantine was an evident stressor for psychological well-being [ 4]. Brooks et al highlighted the importance of social networking facilities in avoiding frustration, boredom and anxiety, and emphasised the importance of clear public health messages [4 ]. Recent evidence indicated that measures introduced in China, including city-wide lockdown, swift isolation of confirmed and suspected cases, effective contact tracing, and workplace adjustments likely helped improve public confidence [ 19,30]. Brooks et al additionally reported that stigmatisation following quarantine could be ameliorated through public education [4].

Previous reviews had not investigated suicidality, biological markers including biochemical parameters and weight change, dietary behaviours, or psychiatric symptoms in returning workforces after lockdown measures. The importance of social support, relationships, and their correlation with mental health well-being have also not been addressed. Social barriers compounding financial hardship, the implications of perceived disease risk, and the significance of childhood isolation from primary caregivers were similarly unexamined. This review exclusively explored repercussions once lockdown measures were lifted. To our knowledge, this is also the first review to report a possible restorative effect of quarantine in HCWs by improving emotional, physical, and social well-being.