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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 1
| Issue : 2 | Page : 59-65 |
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Psychological impact of quarantine and isolation on patients, carers, and frontline healthcare workers during COVID-19 pandemic
Ovais Wadoo1, Naveed Nazir Shah2, Mudasir M Firdosi3, Arshad Hussain2, Mehvish Mushtaq2, Aaliya Mohi-uddin Azad2, Sami Ouanes1, Zaid Khan2, Shahid Majid2, Waseem-ud Din2, Sabeena Qadri2, Shuja Reagu4
1 Mental Health Services, Hamad Medical Corporation, Doha, Qatar
2 Government Medical College, Srinagar, Kashmir, India
3 Kent and Medway NHS and Social Care Partnership Trust, Kent, United Kingdom
4 Mental Health Services, Hamad Medical Corporation, Weill Cornell Medicine, Doha, Qatar
| Date of Submission | 13-Sep-2022 |
| Date of Decision | 17-Nov-2022 |
| Date of Acceptance | 10-Dec-2022 |
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
Dr. Mudasir M Firdosi
Kent and Medway NHS and Social Care Partnership Trust, Kent
United Kingdom
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JIMPH.JIMPH_9_22
Background and Objectives: Coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the mental well-being of the general population and the impact is reported to be more in people in isolation/quarantine facilities and frontline healthcare workers managing patients in such facilities. The impact of the COVID-19 pandemic on mental health is yet to be fully understood by family carers who attend to the patient for basic nursing care in hospital settings. We set out to bridge this gap by exploring the psychological impact on patients, carers, and frontline healthcare workers. Materials and Methods: This cross-sectional study was conducted at a COVID-19 tertiary care treatment facility. Consecutive adult patients admitted for quarantine and isolation purposes, their immediate carers, and frontline workers were included in the study. Patient Health Questionnaire Anxiety-Depression Scale was used to study the psychological impact of the COVID-19 pandemic. Results: In the patient group, the prevalence of depression was 60.2% and the prevalence of anxiety was 53%. In the carer group, the prevalence of depression was 46.2% and the prevalence of anxiety was 49.2%. In the healthcare worker group, the prevalence of depression was 16.7% and the prevalence of anxiety was 33.3%. Interpretation and Conclusions: COVID-19 has led to an increasing reliance on home and hospital carers. Our study underlines an important finding that the psychological impact is significant not only on the patients who contract the infection but also on their carers. Keywords: Carers, healthcare workers, isolation, patients, psychological impact, quarantine
How to cite this article:
Wadoo O, Shah NN, Firdosi MM, Hussain A, Mushtaq M, Azad AM, Ouanes S, Khan Z, Majid S, Din Wu, Qadri S, Reagu S. Psychological impact of quarantine and isolation on patients, carers, and frontline healthcare workers during COVID-19 pandemic. J Integr Med Public Health 2022;1:59-65 |
How to cite this URL:
Wadoo O, Shah NN, Firdosi MM, Hussain A, Mushtaq M, Azad AM, Ouanes S, Khan Z, Majid S, Din Wu, Qadri S, Reagu S. Psychological impact of quarantine and isolation on patients, carers, and frontline healthcare workers during COVID-19 pandemic. J Integr Med Public Health [serial online] 2022 [cited 2023 Mar 27];1:59-65. Available from: http://www.jimph.org/text.asp?2022/1/2/59/370079 |
| Introduction | |  |
The novel coronavirus disease 2019 (COVID-19) first reported from Wuhan, China, was declared a pandemic by the World Health Organization on March 11, 2020. India reported its first COVID-19 case on January 30, 2020 from Kerala. The COVID-19 pandemic had a significant impact on the mental well-being of the general population and the impact is reported to be more in people in isolation/quarantine facilities and frontline healthcare workers managing patients in such facilities.[1],[2],[3] Quarantine and isolation are recommended by the World Health Organization to limit the spread of infectious diseases, involving restriction of movement for a period to monitor for any evolving symptoms of the disease in question. It is reported that quarantine and isolation with associated stigma have a negative impact on the mental health of the patients and their families.[1],[3],[4],[5] Moreover, working in such quarantine centers has a negative psychological impact on healthcare workers as well.[6] Healthcare workers are at risk of infection and contracting the disease and worry about passing the virus to their families. There is also emotional distress due to dealing with morbid population under stressful circumstances at times with limited recourses and manpower.[7] A higher prevalence of depression, anxiety, and insomnia symptoms has been reported in healthcare workers due to the ongoing pandemic.[8]
Commentators have drawn attention to the concern that the pandemic may have a disproportionate impact on communities in developing countries due to suboptimal socioeconomic determinants.[9],[10] The published studies on mental health aspects of the COVID-19 pandemic in India are mainly a plethora of online surveys, narrative reviews, and personal opinions. The implications of the COVID-19 pandemic for mental health are thus yet to be fully understood in India.[9] The proportional contribution of mental disorders to the total disease burden in India is estimated to have almost doubled between 1990 and 2017 and high-quality research is needed to assess the impact of the pandemic.[11] An online survey of the general population from India reported symptoms of anxiety in 38.2% and symptoms of depression in 10.5% of the participants.[12] Another study on healthcare workers from India found a very high prevalence of symptoms of depression and anxiety and low quality of life due to the COVID-19 pandemic. Forty-seven percent reported symptoms of depression, 50% reported symptoms of anxiety, and 45% had low quality of life.[13] There is a paucity of research on the mental health impact of COVID-19 in regions marred by conflict. Published research from Jammu and Kashmir, a region marred with decades of conflict shows high prevalence of anxiety and depressive symptoms, with more than 50% of respondents reporting symptoms due to the COVID-19 pandemic.[14],[15] A population-based survey published by Wani and colleagues shows 49.5% of respondents had depression, 34.8% had anxiety, and 22.3% had stress of varying severity.[16] A study by Khanum and colleagues shows a higher degree of psychological impact and stress in frontline health workers with nurses reporting higher levels of stress.[17] To our knowledge, there are no studies exploring the psychological impact of the pandemic on all the main stakeholders in healthcare delivery. These stakeholders include healthcare staff, patients affected, and carers for the patients affected directly by the SARS-CoV-2 infection. We set out to bridge this gap by exploring the psychological impact of COVID-19 quarantine and isolation not only on patients, and frontline healthcare workers but carers as well.
| Materials and Methods | | |
Study population and settings
This cross-sectional study was conducted at a COVID-19 tertiary care treatment facility, Chest Diseases Hospital, Srinagar which is one of the main hospitals receiving COVID-19 patients and was used as one of the quarantine and isolation facilities from the beginning of the pandemic in Kashmir valley. Chest Diseases Hospital Srinagar is a 110 bedded tertiary hospital associated with Government Medical College Srinagar. The study was conducted between October and December 2020. Consecutive adult patients admitted for quarantine and isolation purposes, and who were between the age of 18 and 65 were included in the study. Their immediate carers were also included. Written informed consent was obtained from those included in the study and those who did not consent or were not able to consent due to underlying severe physical or mental illness or learning disability were excluded. The frontline workers treating and looking after these patients were also invited to participate in the study and those who consented were included in the study.
Data collection
Data on demographic characteristics, duration of the hospitalization, facilities, and conditions in the facility, pre-existing mental health conditions, current or past use of mental health treatments (including medication), and COVID-19 infection testing status was recorded for all three groups, that is, patients, carers, and healthcare staff.
Study instruments
To study the psychological impact of the COVID-19 pandemic, a self-administered tool for Anxiety and Depressive symptomatology-Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS)—which combines the PHQ-9 and GAD-7 scales18 was used. The tool was offered both in Urdu and English. PHQ-ADS is well established, and validated tool used in multiple settings.[18],[19],[20],[21],[22],[23] PHQ-ADS has been validated and has demonstrated good reliability. PHQ-ADS is a participants‗ self-completed screening questionnaire and comprises questions about depression and anxiety. PHQ-9 and GAD-7 are public domain scales and do not require any fee for usage. For PHQ-9, we used scores of 5, 10, 15, and 20 as cutoff points for mild, moderate, moderately severe, and severe depression, respectively.[24] For GAD-7, we used scores of 5, 10, and 15 as cutoff points for mild, moderate, and severe anxiety, respectively.[25]
Statistical analysis
Statistical analysis was performed using SPSS, IBM, v26 for Windows. For descriptive statistics, we determined the relative and absolute frequencies for categorical variables, and the mean and the SD for continuous variables. To compare the prevalence of depression or anxiety among different groups, we used Pearson‗s Chi-square. In case of non-validity, we used Fisher‗s Exact test. To compare continuous variables (like age and hospital stay duration) between groups with/without depression/anxiety, we used Mann–Whitney‗s nonparametric test. To examine associations between scores of depression and anxiety, we used Pearson correlation after having checked the normality of the scores. For all statistical tests, the alpha value was set at 0.05.
Ethical approval
The study was approved by the ethics committee of Government Medical College, Srinagar.
| Results | | |
Patients
In our sample of 85 patients, 70.2% (n = 59) were male, and the mean age was 59 ± 12.6 years. Most (90.5%, n = 76) had positive COVID-19 PCR results. The mean duration of hospital stay was 8.0 ± 4.2 days. The prevalence of depression was 60.2% (n = 50, 95% CI [49.4%; 71.1%]). The prevalence of anxiety was 53% (n = 44; 95% CI [43.4%; 63.9%]). [Table 1] summarizes the main sociodemographic and clinical characteristics of the patients‗ sample. We found a moderate to high positive correlation between GAD-7 and PHQ-9 scores in patients (P < 0.001, r = 0.734). Patients who reported having no difficulties to cope with were less likely to have anxiety than those who reported difficulties to cope with (43.8% vs. 69.4%, P = 0.029). Patients who reported illness among the difficulties to cope were also more likely to have anxiety (87.5% vs. 13.3%, P = 0.015). However, we found no other significant associations between anxiety and other variables, including age, sex, reported worries, or reported helpful strategies during treatment. Patients who reported “finances/job” as a worry, and those who reported living with family to be helpful had a higher proportion of depression (90.9% vs. 55.6%, P = 0.026; and 74.2 vs. 51.9%, P = 0.045). Patients who reported “family health/passing infection to family members” as a worry and those who reported information about infection and quarantine to be helpful had a lower proportion of depression (38.9% vs. 66.2%, P = 0.036; and 46.9% vs. 68.6%, P = 0.049, respectively). No other significant associations were found between depression and other variables.
Carers
In our sample of 68 carers, 80.9% (n = 55) were male, and the mean age was 37.9 ± 13.7 years. The prevalence of depression was 46.2% (n = 30, 95% CI [33.8%; 58.5%]). The prevalence of anxiety was 49.2% (n = 32; 95% CI [36.9%; 61.5%]). [Table 2] summarizes the main sociodemographic and clinical characteristics of the carers‗ sample. We found a moderate to high positive correlation between GAD-7 and PHQ-9 (P < 0.001, r = 0.757). Carers who reported having no difficulties coping with and those who reported internet connectivity to be helpful.
Healthcare workers
In our sample of 44 healthcare workers, 54.5% (n = 24) were male, and the mean age was 41.9 ± 10.8 years. The prevalence of depression was 16.7% (n = 7, 95% CI [4.8%; 28.6%]). The prevalence of anxiety was 33.3% (n = 14; 95% CI [19%; 47.6%]). [Table 3] summarizes the main sociodemographic and clinical characteristics of the healthcare providers‗ sample. We found a high positive correlation between GAD-7 and PHQ-9 in healthcare providers (P < 0.001, r = 0.823). We found no significant associations between anxiety or depression in healthcare providers and other variables, including age, sex, profession, worries, and help during treatment.
| Discussion | | |
Quarantine and isolation measures are recommended by the World Health Organization to limit the spread of the COVID-19 pandemic as part of a comprehensive package of public health response. Like the rest of the world, a surge in the number of COVID-19 cases in the Kashmir valley necessitated the lockdown and establishment of quarantine and isolation centers to limit the spread of infection and management of patients infected with SARS-CoV-2. The global pandemic has affected the mental well-being of most people, including those who must stay home due to the lockdown, people who contracted the infection, their carers, and the frontline health staff.[26] Our study is the first in the region to triangulate the psychological impact of COVID-19-associated quarantine and hospitalization on patients, their carers, and frontline healthcare workers.
Our patient sample mainly comprised men (70%) and 90.5% had a positive COVID-19 test. We found a very high prevalence of depression (60.2 %) and anxiety (52%) symptoms in the study sample. This could be because Kashmir valley has higher pre-pandemic rate of depressive (41%) and anxiety symptoms (26%) in the local population attributed to the ongoing conflict over the last many decades.[27] The rates of depressive and anxiety symptoms in our study sample due to COVID-19 was higher compared to similar studies around the world. The inability to cope with COVID-19 was directly associated with higher anxiety levels. Worries about job loss and finances were associated with higher depression rates. There were no other significant associations between other variables in the sociodemographic profile and symptoms. A study of quarantined and isolated patients in Qatar showed a prevalence of depressive symptoms in 37.4% and anxiety in 25.9% of respondents.[3] An Irish study on a home-quarantined population reported anxiety rates of 20% and depression rates of 22.8%.[28] A few studies from China reported lower rates of depressive (22.4%) and anxiety symptoms (6.2–12.9%) in the home-quarantined population with COVID-19.[29],[30] A study from Italy highlights 48.6% of responders reporting psychological impact, of whom 43.4% are mild or moderate and 5.2% are severe.[31] A study on mass quarantine from India suggests a progressively detrimental effect on mental well-being with an eight to 10-fold increase in the prevalence of depression and anxiety with depression in 30.5% and anxiety in 22.4% of the study sample.[32]
Our carer sample mainly comprised men (80.9%). In resource-constrained settings, it is often the relatives who attend to the patient for basic nursing care in place of healthcare workers thus being at increased risk of infection and psychological impact. The carers or the family attendants of the patients admitted for treatment or quarantine similarly showed higher rates of anxiety (49.2%) and depression (46.2%). It is worth noting that although the rates of depression and anxiety are lower in this group, they seem to have higher rates of anxiety than depression which could be due to fear of catching the infection, worries about loved ones who are unwell due to COVID-19, stigma and financial concerns. To our knowledge, this study is the first of its kind exploring mental health impact in this group. The mental health impact is important to explore in this group as families are the main caretakers of patients in hospitals in developing countries like India. It is known that family members can suffer from fear, fatigue, withdrawal, and guilt in such situations.[33] Those who are not able to visit find it emotionally difficult and those who do visit may have feelings of helplessness.[34],[35] Sheth et al., report significantly increased caregiver stress than in pre-COVID times.[36] Another study on caregivers during COVID-19 has reported that psychological distress is much higher in them in comparison to non-caregivers.[37]
The prevalence of depressive and anxiety symptoms in healthcare workers was 16.7% and 33.3%, respectively. This is significantly lower than in the patient or carer group. This could be because healthcare workers‗ expert knowledge and position of control in healthcare matters give them some protection. The psychological impact of COVID-19 on frontline health workers has been well-reported. A meta-analysis of 13 studies by Pappa et al., in which anxiety was assessed in 12 studies and depression in 10 studies concluded a pooled prevalence of anxiety in 23.2% and depression in 22.8% of healthcare workers.[8] Another multinational study by Chew et al., in Singapore and India, reports moderate to severe depression in 5.3% of the study sample and moderate to severe anxiety in 8.7%.[38] A systematic review of 71 studies found the pooled prevalence of anxiety in healthcare workers was 25% (27% in nurses, 17% in medical doctors, and 43% in frontline healthcare workers).[39] Working under stressful conditions and having to make difficult decisions affecting people‗s lives could lead to moral injury due to the dilemmas faced in such situations. Moral injury could be significantly associated with psychological distress in healthcare workers.[40]
| Conclusion | | |
Unpaid carers who look after another member of their household are known both in the Eastern and Western cultures; however, unpaid carers in hospital settings in only known in low-income and middle-income countries. Carers are known to have poorer mental health than the general population. The COVID-19 pandemic in countries like India and places like Kashmir stretched the health infrastructure and resources to their limits. This led to an increasing reliance on home and hospital carers. Our study underlines an important finding that the psychological impact of COVID-19 is significant not only for the patients who contract the infection but also for their carers. This has far-reaching consequences given the pandemic is still in full momentum and we are witnessing further waves of infection the world over. We recommend that government and health agencies take necessary steps in supporting and managing the psychological impact on this vulnerable group.
Acknowledgment
None.
Financial support and sponsorship
None
Conflicts of interest
None.
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[Table 1], [Table 2], [Table 3]
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